Cardiac Disease

in Pregnancy

Woman’s Hospital School of

Medicine Zhejing University
He jin
 Physiological Changes in the
Cardiovascular System During
Pregnancy

• A thorough knowledge
– is essential
• In order to understand
– the additional impact of cardiac disease
 Physiological Changes

• The first cardiovascular change

associated with pregnancy
• Peripheral vasodilation (induced by
progesterone)
• leading to
• A decrease in systemic vascular
resistance
 Physiological Changes
• Cardiac output increases
• 8 weeks : 20%
• 20-28 weeks :40-50%
• Stroke volume increase 80ml/t
– ventricular end-diastolic volume
– wall muscle mass
– contractility
• Heart rate increase
– 10 to 15 beats per minute
 Physiological Changes
• Labour leads to further increases in
cardiac output
• In the first stage: 15%
• In the second stage: 50%
– blood back into the circulation with each
uterine contraction: 300-500 ml
– pain and anxiety : sympathetic
stimulation
 Physiological Changes
• After delivery
• Cardiac output increases again
immediately : 60-80%
– uterine contraction
– relief of caval compression
• Within 1 h
– rapid decline to pre-labour values
 Table 1 -- Normal Hemodynamic Changes During Pregnancy

Hemodynamic Change During Change during Change during

Parameter Normal Pregnancy labor and delivery postpartum
Blood volume ↑ 40-50% ↑ ↓ (autodiuresis)

Heart rate ↑ 10-15 beats/min ↑ ↓

Cardiac output ↑ 30-50 % ↑ additional 50% ↓

Blood pressure ↓ 10 mm Hg ↑ ↓

Stroke volume ↑ 1st and 2nd ↑ (300-500 mL per ↓

trimester; contraction)
↓ 3rd trimester
Systemic ↓ ↑ ↓
vascular
resistance
 Types of CD during pregnancy

• Congenital heart disease

• Rheumatic heart disease
• Pregnancy-induced hypertension
heart disease
• Peripartum cardiomyopathy
• Other
 Congenital heart disease
• Left → right shunt • No shunt
① pulmonary
• ① atrial septal
stenosis
defect
② coarctation of
• ② ventricular septal the aorta
defect ③ Marfan
syndrome
• ③ patent ductus
arteriosus

• right → Left shunt:f4 、 AS

 Rheumatic heart disease
• Mitral stenosis:
• Increased blood volume during pregnancy
• Intrapartum and early puerperium:
blood volume back to the heart increased
• Pulmonary circulation volume increase
• Left atrial pressure increases
• Pulmonary venous hypertension
• Acute pulmonary edema.

• Mitral incompetence: simply

• Can tolerance pregnancy, delivery and
puerperium.
 Rheumatic heart disease
• Aortic stenosis: severe
• Pulmonary edema
• Low discharge capacity heart failure
• Aortic incompetence : severe
• Left ventricular failure
• Combined with bacterial endocarditis
 PIH heart disease
• No history of heart disease and signs over
the past
• Sudden onset of systemic failure are
dominated by left ventricular failure
• Misdiagnosed as the flu and bronchitis
• Early diagnosis is important
• After eliminate the cause, most can be
restored
 PIH heart disease
• Myocardial ischemia, interstitial
edema, hemorrhage and necrosis
spots
• Blood viscosity increased to promote
myocardial ischemia
• Combined with severe anemia
• Heart failure occurs
 Peripartum Cardiomyopathy
(PPCM)
• Define: dilated cardiomyopathy
• Interval: between the last 3 month of pregnancy
up to the first 6 months postpartum
• Women : without preexisting cardiac dysfunction
• Fetal death:10~30%
• Maternal mortality is approximately 9%
– heart failure, pulmonary infarction, arrhythmia
• These women should be counseled against
subsequent pregnancies
 PPCM
• The exact etiology : unknown
• Possible causes
– infection, immunity, multiple pregnancy,
hypertension, malnutrition
– viral myocarditis
– automimmune phenomena
– specific genetic mutations
 PPCM
• Typical signs
• Fatigue
• Dyspnea on exertion, orthopnea
• Nonspecific chest pain
• Abdominal discomfort and distension
• palpitations, cough, hemoptysis,
hepatomegaly, edema and other
heart failure symptoms
 PPCM
• Saymptoms
• Heart enlarged
• Myocardial contractility reduce
• Ejection function reduced

• ECG:
• Arrhythmias, left ventricular hypertrophy,
ST segment and T wave abnormalities
CD main threat to pregnant
women
• Heart failure
• Subacute infective endocarditis
• Hypoxia and cyanosis
• Venous thrombosis and pulmonary
embolism.
 The impact of CD in
pregnant women
• Gestation period:
• increased blood volume, heart burden
• Delivery period:
• uterine contractions
• blood pressure↑
• the blood flow increases
• pulmonary artery pressure increased
• sudden interruption of placental circulation
• abdominal pressure plummeted
 The impact of CD in
pregnant women
• Puerperium:
– uterine contractions
– retented Interstitial fluid returned to circulation
• The greatest change period in systemic
blood circulation and heart burden
– 32 to 34 weeks
– Intrapartum
– 3 days postpartum
• easily induced heart failure
 The impact of CD in
pregnant women
• A validated cardiac risk score
• Predict a maternal chance of having
adverse cardiac complications
Table 2 Risk factor and maternal cardiac event rates

Risk factor 0 1 >1

Maternal
cardiac 5% 27% 75%
event rates
 Table3 Predictors of Maternal Risk for Cardiac Complications

Criteria Example Poin

ts*
Prior cardiac heart failure, transient ischemic attack, 1
events stroke before present pregnancy

Prior symptomatic sustained tachyarrhythmia or 1

arrhythmia bradyarrhythmia requiring treatment

NYHA III/IV 1
or cyanosis

Valvular and aortic valve area <1.5 cm2, mitral valve 1

outflow tract area <2 cm2, or left ventricular outflow
obstruction tract peak gradient > 30 mm Hg

Myocardial LVEF <40% or restrictive cardiomyopathy 1

dysfunction or hypertrophic cardiomyopathy
 The impact of CD in Fetal
• Premature birth
• Low birth weight
• Respiratory distress
• Fetal death
• Neonatal death
• Genetic heart disease
 Maternal Cardiac Lesions and Risk
of Cardiac Complications
• Low Risk
• Atrial septal defect
• Ventricular septal defect
• Patent ductus arteriosus
• Asymptomatic aortic stenosis with low
mean gradient (<50 mm Hg) and normal
LV function (EF >50%)
• Aortic regurgitation with normal LV
function and NYHA functional class I or II
Maternal Cardiac Lesions and Risk
of Cardiac Complications
• Low Risk
• Mitral valve prolapse
– (isolated or with mild to moderate mitral regurgitation
and normal LV function)
• Mitral regurgitation with normal LV function and
NYHA class I or II
• Mild to moderate mitral stenosis
– (mitral valve area >1.5 cm2, mean gradient <5 mm Hg)
without severe pulmonary hypertension)
• Mild/moderate pulmonary stenosis
• Repaired acyanotic congenital heart disease
without residual cardiac dysfunction
Maternal Cardiac Lesions and Risk
of Cardiac Complications
• Intermediate Risk
• Large left-to-right shunt
• Coarctation of the aorta
• Marfan syndrome with a normal aortic root
• Moderate to severe mitral stenosis
• Mild to moderate aortic stenosis
• Severe pulmonary stenosis
Maternal Cardiac Lesions and Risk
of Cardiac Complications
• High Risk
• Eisenmenger's syndrome
• Severe pulmonary hypertension
• Complex cyanotic heart disease
– (tetralogy of Fallot, Ebstein's anomaly, truncus
arteriosis, transposition of the great arteries,
tricuspid atresia)
• Marfan syndrome with aortic root or valve
involvement
Maternal Cardiac Lesions and Risk
of Cardiac Complications
• High Risk
• Uncorrected severe aortic stenosis with or without
symptoms
• Uncorrected severe mitral stenosis with NYHA
functional class II-IV symptoms
• Aortic and/or mitral valve disease (stenosis or
regurgitation) with moderate to severe LV
dysfunction (EF <40%)
• NYHA class III-IV symptoms associated with any
valvular disease or with cardiomyopathy of any
etiology
• History of prior peripartum cardiomyopathy
 Diagnosis
• History:
• Palpitations, difficulty breathing
or heart failure
• Organic heart disease
• Rheumatic fever
 Diagnosis
• Signs and symptoms abnormal:
• Exertional dyspnea, Paroxysmal nocturnal
dyspnea , orthopnea, hemoptysis,
recurrent exertional chest pain
• Cyanosis, clubbing, jugular vein
engorgement continuing.
• Cardiac auscultation
– a diastolic murmur of grade Ⅲ or rough systolic
murmur over the whole
– a pericardial friction rub, diastolic gallop,
alternating pulse
Early signs of heart failure
• Chest tightness, palpitations,
shortness of breath after mild
activity
• Resting heart rate> 110 beats / min
• Respiration> 20 times / min
• Paroxysmal nocturnal dyspnea
• The end of the lung wet rales
persisted
 Diagnosis:
auxiliary examination
• Noninvasive testing of the heart may include:
• ECG: severe arrhythmias
– atrial fibrillation, atrial flutter, Ⅲ degree
atrioventricular block, ST segment and T wave
abnormalities and changes
• Chest radiograph
– the heart was significantly expanded
• Echocardiogram
– expansion of the heart chamber
– myocardial hypertrophy
– valvular motion abnormalities
– cardiac structural abnormalities
 Management

• Before pregnancy:
– detailed examination to determine
whether she is suitable to pregnant
• access to counselling
– specialized
– multidisciplinary
– preconception
• In order to empower them to make
choices about pregnancy
 Not suitable for pregnancy ！
• Cardiac function grade Ⅲ ~ Ⅳ
• Those who previously had heart failure
• A pulmonary hypertension, severe
stenosis the main A, Ⅲ atrioventricular
block, atrial fibrillation, atrial
flutter,diastolic gallop;
• Cyanotic heart disease
• Active rheumatic or bacterial endocarditis
 The main aims of
management
• To optimize the mother's condition
during the pregnancy
– considering ß-blockers
– Thromboprophylaxis
– pulmonary arterial vasodilators
• To monitor for deterioration
• Minimize any additional load on the
cardiovascular system
 Pregnant women with CD
• Should be assessed clinically as soon as possible
• A multidisciplinary team and appropriate
investigations undertaken
• The core members of the team should include:
• Suitably experienced obstetricians
• Cardiologists
• Anaesthetists
• Midwives
• Neonatologists
• Intensivists
 Management of
gestation period
• Regular prenatal care
• Early prevention of heart failure
– adequate rest
– appropriate weight limit
– treatment the motivation of heart failure
: infection, anemia,PIH
• The treatment of heart failure
– as same as those who are not pregnant
 Mode of Delivery
• Vaginal delivery:
– cardiac function Ⅰ ~ Ⅱ grade
– not a fetal macrosomia
– cervical conditions are good
• Cesarean section:
– Marfan syndrome : expansion of the aortic
root> 45 mm
– use warfarin during delivery
– sudden hemodynamic deterioration
– severe pulmonary hypertension and severe
aortic stenosis
Management in intrapratum
• First stage of labor
• Semi-recumbent position, oxygen
masks, attention Bp, R, P, heart rate,
– cedilanid : 0.4mg +5% GS20ml iv slow
(when necessary)
– antibiotics : during labor to 1 week after
postpartum
 Vaginal delivery
• Low-dose regional analgesia:usually
recommended
• providing effective pain relief
• reduce the further increases in
– cardiac output
– myocardial oxygen demand
• Be careful not to inhibit the neonatal
breathing
Management in intrapratum
• Second stage of labor:
– episiotomy, facilitate instrumental delivery to
shorten the stage
• Third stage of labor:
– Ergot disabled to prevent venous pressure
increased
– injection of morphine or pethidine immediately
postpartum
– abdominal pressure sandbags
– control the liquid velocity
Management in puerperium
• Monitoring heart rate, blood oxygen,
blood pressure during delivery 24
hours
• She could not breast-feeding
– more than grade Ⅲ cardiac function
• Prophylactic antibiotics
• High-level maternal surveillance
Thanks four your
listening