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Pregnancy
O&G Dept
CWM Hospital
Physiological changes
Physiology
Braunwald E et al.
Heart Disease.
2001. pg. 2173.
Physiology
Physiology
Risk assessment
Lesion assessment
Global Risk (risk Index)
Dr.M. Narayanswamy
Prof. & HOD,OBG
Sri Devaraj Urs Medical College, Kolar
Method
Retrospective cohort study
Examined 276 pregnancy in 221 women
Toronto hospital, Mt sinai hospital and
womens college hospital.
1986 to 1994
Inclusion
All pregnant women with heart disease
Congenital
Aquired
Arrhymias
Symptomatic
Sustained
Requiring treatment before pregnancy
Echo at booking or within previous 2 years
Exclusion
Patients with isolated mitral valve prolapse
23 women who underwent therapeutic
abortion
Data collection
Definition of predictors and outcome were a
consensus between cardiologist and
obstetrician
Independent review of health records by 2
coauthors
Maternal outcome
(cardiac event)
Pulmonary odema
Symptomatic tachy or brady arrythmia
Stroke or TIA
Death
Neonatal outcome
Prematurity
SGA (BWT < 10th)
RDS
Intra-ventricular hemorrhage after birth
Death
Secondary outcome
PIH
PPH
RESULTS
No Maternal Death
No Eisenmenger syndrome
4 marfan syndrome ( normal aortic root)
89% of the cardiac events occurred in Antepartum period
5.
Points system
66%
30%
3%
Sensitivity 91%
Specificity 61%
CONCLUSION
Weakness
Pulmonary HTN and prior cardiac surgery
wasnt associated with complication
Because there is a small number (8)
The need for a larger study
The need to assess specific lesion
All Marfan syndrome had normal aortic root
Need for a prospective study
The need to assessment medication use and
its effects
PROSPECTIVE
MULTICENTER STUDY OF
PREGNANCY OUTCOMES
IN WOMEN WITH HEART
Difference in Method
Prospective study
Enrolled 562
Had more pulmonary HTN ( n= 25)
Marfan syndrome ( n= 10)
There was still no Eisenmenger syndrome
RESULTS
Cardiac events
Primary
(80) 13%
Total number
cardiac events
(99) 17%
Pulmonary
edema
(38)
Arrhythmia
(40)
Stroke or TIA
(4)
cardiacDeath
(2)
Secondary
(37) 6%
Worsening of
the Fx classes
(26)
Need for
intervention
(13)
Neonatal events
Premature birth
(105)
Total number
Neonatal
events
(122)
Small for
gestational age
(22)
RDS + IVH =
(17)
Fetal
(8)
Death
NND
(7)
Obstetric events
PIH
(24)
obstetric
events
Noncardiac
deaths
(2)
PPH
(19)
PET
(12)
75%
27%
5%
CASE 1
Case 1
26 yr old Fijian primp
know case of RHD and abnormal rhythm at
form3
Was on digoxin now no meds
Defaulted clinic 2 years before
Presented with
SOB at rest & Palpitation
26 weeks of gestation (unbooked)
Case 1
On Examination
P 160 Bp 150/70 Sat- 97% ( oxygen 3L)
No Cynosis
JVP normal
Lung
Bilateral crepitation
Heart
Systolic murmur
Case 1
Abdominal
20cm fundal height
Extremities
No oedema
Investigation
ECG Show fast AF
Chest xray Enlarged heart
Enlarged LV
Enlarged LA
Case 1
Echo
was done but the result was missing from
the folder
Severe MS (<1cm)
Assesment
CCF
AF
VHD ( severe MS )
Risk assesment
1. Prior cardiac event
Prior arrhymia
2. NYHA class > II
3. Left heart obstruction
MVA <2 cm
Total points is 3 = 75%
Outcome
This patient manage to reach
35 weeks by scan
39 weeks by dates
She had a CS for obstetric reasons
The wasnt any notes availible intra op
But GA was used
She when into a coma post op
GCS of 6
CT Scan
Report: impression
Generalised ischeamic encephalopathy
Small infarct basal ganglia
Due to
? Prolonged hypotension
Post mortem
Heart
Mitral valve admit tip of finger
Impression
Heart failure as a complication of VHD in
high risk pregnancy
CASE 2
Mrs AK
23 yr old Fijian
G1P0
2/8/11 Echocardiogram
AoR 2.79cm
LA 3.74cm
IVSd 1cm
LVPWd 0.67cm
LVs 3.44cm
MVA 1.9cm2
EF 60%
Summary:
Mod MS with Mild MR
Mitral Valve
abnormal with
thickened cusps of
both leaflets.
No pulmonary HTN
Currently: 36/40
Last Seen @ 33/40
Completely Asx
Physically nil sign of failure
Impression:
NYHA 1
Mod MS and Mild MR
MVA 1.9cm
Risk Index
No Hx of Cardiac event
NHYA 1 and nil cynosis
MVA 1.9
EF 60%
Total points is 1 =
27% cardiac event
4% Neonatal or fetal death
Longterm Plan
1. Benzathine IM every 3/52
2. Weekly Reviews
3. IOL @ 38/40
Making a assesment
Risk index
Specific lesion
If there is a discordance
Take the higher Risk assesment