Pregnancy and heart diseases

Pregnancy and Heart diseases

Dr.Safoin Kadi Consultant cardiologist at Al-Hayat medical center.

D.I.S. Cardiovascular diseases. D.U. Echocardiography. D.U. Vascular echodoppler. D.U. Congenital and pediatric cardiology.

PRE-PREGNANCY RISK ASSESSMENT

Many disorders can be identified by taking a careful personal andfamily history, particularly D.V.T , cardiomyopathies, the Marfan syndrome, congenital heart disease, juvenile sudden death, longQT syndrome, and catecholaminergic ventricular tachycardia(VT) or Brugada syndrome. It is important to ask specifically about possible sudden deaths in the family. The assessment of dyspnoea is important for diagnosis and prognosis of valvelesions and for heart failure.

A thorough physical examination , including auscultation for new murmurs, changes in murmurs, and looking for signs of heart failure.

When dyspnoea occurs during pregnancy or when a new pathological murmer is heard, echocardiography is indicated.

It is crucial to measure the BP, in left lateral recumbency using a standardized method, and to look for proteinuria.

Graduated compression stockings

COMPRESSION STOCKING PRESCRIPTION

1-SIZE2-PRESSURE3-LEVEL

VARICES

30-40% OF PREGNANT WOMEN . We have to determine the type the

severity and the need for treatment or preventive measures for each one of them.

Pregnancy induces a series of haemostatic changes, with an increase in concentration of coagulation factors, fibrinogen, and platelet adhesiveness, as well as diminished fibrinolysis, which leadto hypercoagulability and an increased risk of thrombo-embolic events.

In addition, obstruction to venous return by the enlarging uterus causes stasis and a further rise in risk of thrombo-embolism.

THROMBO EMBOLIC RISK

Take home message 1

CONSIDER LMWH OR

COPRESSIVE STOCKING

Hypertension

 women with a history of preeclampsia should receive low-dose aspirin started before 16 weeks, NICE guidelines say it should be started around 12 weeks. That is the first point and the most important one. The dosage should be at least 75 mg, and if possible, we should probably try to evaluate aspirin resistance.

 the effect of aspirin before conception: Most experts believe that it is not effective

 NICE recommends : Aspirin 75 mg be given to women with 2 or more of these risk factors:

- First pregnancy-Age older than 40 years- Pregnancy interval greater than 10 years-Body mass index (BMI) 35 kg/m2 or greater at first visit, -Family history of preeclampsia, or -Multiple pregnancy.

Before 16 weeks of pregnancy

Placentation :is typically completed by 20-22 weeks at the latest. That means that women could potentially take aspirin only for about 10 weeks, but no study has evaluated stopping aspirin as early as that.Some authors and experts have concluded from many trials that aspirin should be continued up to delivery, but if we use dosages greater than 100 mg, women should certainly stop aspirin therapy earlier. Others have proposed, and I agree,

that we should probably stop aspirin around 34 weeks until new studies have evaluated the effect of stopping aspirin therapy earlier or later than that.

TAKE HOME MESSAGE 2

ASSESSEMENT OF RISK OF PREECLAMPSIA FOR EVERY PATIENTIF MORE THAN 2 RISK FACTORS GIVE ASPIRINBEGIN BEFOR 16 WEEKS OF PREGNANCY (NOT BEFOR PREGNANCY)STOP AT WEEK 34

DYSPNEA

TAKE HOME MESSAGE 3

DYSPNEA ASSESSEMENT IS FOLLOWED BY BNP AND ECHOCARDIOGRAPHY.

TAKE HOME MESSAGE 4

VALVULAR HEART DISEASES HAVE A WIDE RANGE OF RISK WHICH SHOULD BE EVALUATED BEFOR PREGNANCY .TEAM WORK IS ESSENTIAL WITH THE CARDIOLOGIST.WARFARINE CAN BE GIVEN IN THE FIRST TRIMESTER IF DOSE IS LESS THAN 5 MG AND IN THE SECOND AND THIRD TRIMESTRE IN ANY DOSE.

The heart is rotated towards the left and on thesurface ECG there is a 15–20 left axis deviation. Common findings include transient ST segment and T wave changes, the presence of a Q wave and inverted T waves in lead III, an attenuated Q wave in lead AVF, and inverted T waves in leads V1, V2, and, occasionally,V3. ECG changes can be related to a gradual change in the position of the heart and may mimic left ventricular (LV) hypertrophy and other structural heart diseases.

Performing sub maximal exercisetests to reach 80% of predicted maximal heart rate in asymptomatic pregnant patients with suspected CVD. There is no evidence that it increases the risk of spontaneous abortion.

Semirecumbent cycle ergometry appears to be the most comfortable modality

TAKE HOME MESSAGE 5

CAD IS NOT AN ABSOLUTE CONTRAINDICATION FOR PREGNANCY .EXERCISE TEST AND STRESS ECHOCARDIOGRAPHY CAN BE DONE SAFELY.IN CASE OF ACUTE CORONARY EVENT ANGIOPLASTY IS THE PREFFERRED METHOD OF REVASCULARISATION.

In general, caesarean delivery is reserved for obstetric indications.

TAKE HOME MESSAGE 6

Holter monitoring should be performed in patients with known :previous paroxysmal or persistent documented arrhythmia [VT, atrial fibrillation (AF), or atrial flutter or those reporting symptoms of palpitations.

TAKE HOME MESSAGE 6

MOST PALPITATIONS ARE BENIGNE BUT HOLTER MONITORING MAY DETECT SERIOUS ARRYTHMIA ESPECIALY WITH THE PRESENCE OF A MURMUR ,DYSPNEA,OR RISK FACTORS.