CARDIOVASCULAR

DISORDERS

Carla Elise M. Celino, MD

Department of OB-GYN
 INCIDENCE

• Account for significant maternal morbidity and are a leading cause of obstetrical
intensive care unit admissions (Small, 2012)

• Increasing prevalence of cardiovascular diseases complicating pregnancy is likely

due Obesity, Hypertension, and Diabetes (Fryar, 2012).
 NORMAL ADAPTATIONS IN
PREGNANCY
• Profound effect on underlying
heart disease
• Cardiac output: ↑40x
• CLINICAL FINDINGS:
• Functional systolic heart murmurs
• Respiratory efforts is accentuated
(DYSPNEA)

• Starts at 8 weeks and maximal • Edema

• Fatigue and exercise intolerance
by midpregnancy
• Increased:
• SV, EDV, HR, CO

• Decreased:
• SVR, BP
 CLINICAL
INDICATORS OF
HEART
DISEASE
 DIAGNOSTIC STUDIES
• Electrocardiograph
• Normal findings: 15-degree left axis deviation, mild ST
elevations, premature atrial and ventricular contractions are
relatively frequent
• Pregnancy DOES NOT alter voltage findings

• 2D Echocardiography
• Normal findings: significantly increased tricuspid regurgitation,
left atrial end-diastolic dimension, and left ventricular mass
 DIAGNOSTIC STUDIES

• Chest X-ray with Abdominal Shield

• Normal findings: heart silhouette is larger
• Anteroposterior and Lateral chest radiograph with Lead apron

• Plasma Brain Natriuretic Peptide

 CLASSIFICATION OF FUNCTIONAL
HEART DISEASE (NYHA, 1979)
• Class I
• Uncompromised

• Class II
• Slight limitation of physical activity

• Class III
• Marked limitation of physical activity

• Class IV
• Severely compromised
 WORLD HEALTH ORGANIZATION (WHO) RISK
CLASSIFICATION OF CARDIOVASCULAR DISEASE AND
PREGNANCY
 ANTENATAL VISITS

• Determined by severity of lesion and clinical cause

• In general
• Every month – mild disease until 28 weeks
• Every 2 weeks – moderate to severe until 28 weeks
• Weekly thereafter until delivery
• Screening for Anemia is a MUST!
 FETAL SURVEILLANCE

• Accurate dating important for possible early termination

• Congenital anomaly scan (CAS) at 18-22 weeks
• Biophysical Profile Scoring (BPS) at 28 weeks
• Doppler Studies if with poor fetal growth
 PERIPARTUM MANAGEMENT

• TEAM APPROACH with an obstetrician, cardiologist, anesthesiologist,

and other specialists as needed.

• The FOUR changes that affect management include

• Decreased vascular resistance
• Increased blood volume
• Increased cardiac output
• Hypercoagulability
 PERIPARTUM MANAGEMENT

• Valvular Heart Disease

• Avoid contact with persons who have respiratory infections, including the common cold
• Pneumococcal and influenza vaccines are recommended

• Cigarette smoking is prohibited

• Illicit drug use may be particularly harmful
• Cardiovascular effects of cocaine or amphetamines

• Intravenous drug use increases the risk of infective endocarditis

 LABOR AND DELIVERY
• Vaginal delivery is PREFERRED
• Cesarean delivery is limited to OBSTETRICAL INDICATIONS

• Simpson (2012) recommends cesarean delivery for women with the following:
• (1) dilated aortic root >4 cm or aortic aneurysm
• (2) acute severe congestive heart failure
• (3) recent myocardial infarction
• (4) severe symptomatic aortic stenosis
• (5) warfarin administration within 2 weeks of delivery
• (6) need for emergency valve replacement immediately after delivery
 LABOR AND DELIVERY

• Position during labor: semirecumbent position with lateral tilt

• Vital signs are taken frequently between contractions

• Impending Ventricular failure: HR >100 bpm or RR >24 cpm

 ANESTHESIA AND ANALGESIA
• Relief from pain and apprehension is important.

• MAJOR PROBLEMS:
• Maternal hypotension
• intracardiac shunts - flow may be reversed
• pulmonary arterial hypertension or aortic stenosis - ventricular output is dependent
on adequate preload

• For vaginal and cesarean delivery, both prefers epidural

analgesia given with intravenous sedation often suffices.
 COMPLICATIONS DURING PREGNANCY

HEART FAILURE ARRHYTHMIAS

• Admitted for bed rest • Therapeutic anticoagulation for Atrial
• Medical treatment Fibrillation , Left Arterial Thrombosis or
prior embolism
• Diuretics
• Beta blockers (to reduce afterload) • Treatment: Digoxin
• ***Do not give ACE inhibitors (↑↑FETAL
TOXICITY)
• Salt and fluid restriction
 MANNER OF DELIVERY

• Assisted Vaginal Delivery preferred under epidural anesthesia for

adequate pain relief

• Cesarean Section for obstetric indications and for women with Severe
Aortic Stenosis
 MANAGEMENT
• Routine Endocarditis Prophylaxis is NOT RECOMMENDED unless the
patient has the following:
• Prosthetic heart valves
• Previous history of endocarditis
• Complex CHD/Surgically corrected systemic-pulmonic conduit

• Treatment:
• Ampicillin 2g IV
• Gentamicin 1.5 mg/kg IV 30 minutes of CS
 PUERPERIUM

• Meticulous care should be continued

• Fluid mobilization  intravascular compartment  decreased peripheral vascular

resistance  increased demands on myocardial performance (DECOMPENSATION)

• SERIOUS COMPLICATIONS
• Postpartum hemorrhage
• Anemia POSTPARTUM HEART
• Infection FAILURE
• Thromboembolism
 STERILIZATION AND CONTRACEPTION

• Cesarean delivery can proceed with tubal sterilization, if indicated

• Vaginal delivery , sterilization can be delayed a few days once

patient is hemodynamically stable
 CONGENITAL HEART DISEASE
• Incidence: 8 in 1000 liveborn infants

• Atrial septal defect (ASD)

• Most frequently encountered adult congenital cardiac lesion
• Most recommend repair if discovered
• Pregnancy is well tolerated unless the patient develops pulmonary hypertension

• Ventricular Septal Defect (VSD)

• 90% of lesions close spontaneously during childhood

• Atrioventricular Septal Defect (AVSD)

 CYANOTIC HEART DISEASE

• Right to left shunting

• In general, women with cyanotic heart disease do poorly during
pregnancy

Tetralogy of Fallot
• Classic and most commonly encountered lesion in adults and during
pregnancy
• Large VSD, Pulmonary stenosis, RVH, Overriding of the aorta
• PREGNANCY: decreased peripheral vascular resistance  shunt
increases  cyanosis worsens
 PULMONARY
HYPERTENSION
CARDIOMYOPATHIES
 HEART FAILURE

CAUSE SYMPTOMS
• Cardiac dysfunction caused by • Persistent basilar rales
• Nocturnal cough
an obstetrical complication that
• Easy fatigability
precipitates or aggravates the
• Increased dyspnea on exertion
underlying condition • Hemoptysis
• Edema
• Tachypnea
• Hallmark Findings: • Tachycardia
• Cardiomegaly
• Pulmonary Edema
 HEART FAILURE

MANAGEMENT
• Diuretic administration
• To reduce preload

• Hydralazine or Vasodilator
• To decrease afterload

• Heparin
• Thromboembolism prophylaxis
 INFECTIVE ENDOCARDITIS
• Pathophysiology
• Bacterial infection of a heart valve involves cardiac endothelium and results in valvular
vegetation

• RISK FACTORS
• IV drug use (MC: Staphylococcus aureus)
• Intracardiac devices
• Degenerative Valve disease

• Other species:
• Streptococcus pneumoniae, Neisseria gonorrhea, Escherichia coli
 INFECTIVE ENDOCARDITIS
• Diagnosis • Management
• Findings: fever, chills, • Medical with appropriate
murmurs, anorexia, timing of surgical
fatigue (“FLULIKE”) intervetion

• Duke Criteria • Antibiotics 4-6 weeks

• Positive blood culture • Penicillin G
• Evidence of endocardial • Ceftriaxone
involvement • Vancomycin
• Gentamicin 2-4 weeks