IN THE NAME OF ¢â‚¬¢ Fatigue, palpitations, cough, and hemoptysis are also common. ¢â‚¬¢ With more severe

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  • IN THE NAME OF GODIN THE NAME OF GODIN THE NAME OF GODIN THE NAME OF GOD

  • Cardiac disease in pregnancypregnancy

    Cardiac disease in gnancygnancy

  • MITRAL STENOSIS

    • 33 y/o G3L2(2c/s)

    • GA 34 + 5

    • CC: LP & dyspnea

    • PMHx: MS sinse 4 yrs ago due to Rheumatism• PMHx: MS sinse 4 yrs ago due to Rheumatism

    • PSHx: 2c/s

    • DHx: metoral 50 mg q6h/ ASA/ Enoxaparin monthly/Diltiazem 30 mg bid

    ago due to Rheumatismago due to Rheumatism

    h/ ASA/ Enoxaparin 40 daily/ Penicillin

  • • PR: 110 RR: 28 T: 37 BP:110

    • FHR: 145

    • V/E : 1f

    • Heart : diastolic murmur 2/6• Heart : diastolic murmur 2/6

    • Lung: crackle

    • Abd: FH : 34w/ contraction + /

    110/75

  • • Last sono: s/c/ post/ nl/ 33w (OK)

    • Echo at 1th trimester: EF:60% / Rheumatismal MS (1.4cm2)/ mild to mod MR/ PTMC score: TR/ mild PI/ Top nl PH( sPAP=35) at rest /TR/ mild PI/ Top nl PH( sPAP=35) at rest /

    • REC: therapeutic abortion versus PTMC in pregnancy and TEE just before PTMC

    • ECG: sinus tachycardia

    Rheumatismal MV with mod to severe )/ mild to mod MR/ PTMC score:6-7/ No PS / No AS/ mild

    ) at rest /) at rest /

    REC: therapeutic abortion versus PTMC in pregnancy and TEE just

  • Diagnosis

    • Pulmonary edema

  • PLAN

    • Cardiologist consult: Lasix 20 mg stat & q

    • C/S and TL

    • CCU

    • Finally Discharged with Metoral / Ferosemide• Finally Discharged with Metoral / Ferosemide

    mg stat & q6h

    Ferosemide/ ASA/ Enoxaparine dailyFerosemide/ ASA/ Enoxaparine daily

  • MS

    • Rheumatic endocarditis causes most mitral stenosis lesions.

    • The normal mitral valve surface area is

    stenosis narrows this to < 2.5 cm2, symptoms usually

    • The most prominent complaint is dyspnea• The most prominent complaint is dyspnea hypertension and edema.

    • Fatigue, palpitations, cough, and hemoptysis are also common.

    • With more severe stenosis, the left atrium dilates, left is chronically elevated, and significant passive hypertension develops.

    causes most mitral stenosis lesions.

    The normal mitral valve surface area is 4.0 cm2, and when

    , symptoms usually develop.

    dyspnea due to pulmonary venous dyspnea due to pulmonary venous

    Fatigue, palpitations, cough, and hemoptysis are also common.

    With more severe stenosis, the left atrium dilates, left atrial pressure is chronically elevated, and significant passive pulmonary

  • • These women have a relatively fixed cardiac output increased preload of normal pregnancy increase cardiac output, may cause edema.

    • A fourth of women with mitral stenosis have first time during pregnancy.

    fixed cardiac output, and thus the pregnancy, as well as other factors that

    , may cause ventricular failure and pulmonary

    of women with mitral stenosis have cardiac failure for the

  • • With significant stenosis, tachycardia filling time and increases the mitral gradient. well as pulmonary venous and capillary pulmonary edema. Thus, sinus tachycardia is prophylactically with β-blocking agents. pulmonary edema. Thus, sinus tachycardia is prophylactically with β-blocking agents.

    • Atrial tachyarrhythmias, including fibrillation stenosis and are treated aggressively. Atrial predisposes to mural thrombus formation and embolization that can cause stroke despite a sinus rhythm.

    tachycardia shortens ventricular diastolic filling time and increases the mitral gradient. This raises left atrial as well as pulmonary venous and capillary pressures and may result in

    tachycardia is often treated agents.

    tachycardia is often treated agents.

    fibrillation, are common in mitral stenosis and are treated aggressively. Atrial fibrillation also

    formation and cerebrovascular stroke. Atrial thrombosis can develop

  • Pregnancy Outcomes

    • In general, complications are directly associated with the valvular stenosis.

    • Recall that investigators from the large Canadian women with a mitral-valve area < 2 women with a mitral-valve area < 2 another study, Hameed (2001) described mitral stenosis— 43 percent developed heart failure developed arrhythmias. Fetal-growth in those women with a mitral valve area

    Pregnancy Outcomes

    are directly associated with the degree of

    large Canadian study found that 2 cm2 were at greatest risk. In 2 cm2 were at greatest risk. In

    ) described 46 pregnant women with percent developed heart failure and 20 percent

    growth restriction was more common a mitral valve area < 1.0 cm2.

  • Pregnancy Outcomes

    • Prognosis is also related to maternal functional capacity

    • Among 486 pregnancies complicated by rheumatic heart disease predominantly mitral stenosis—Sawhney of 10 maternal deaths were in women in of 10 maternal deaths were in women in

    Pregnancy Outcomes

    maternal functional capacity.

    complicated by rheumatic heart disease— Sawhney (2003) reported that eight

    were in women in NYHA classes III or IV.were in women in NYHA classes III or IV.

  • Management

    • Limited physical activity is generally

    • If symptoms of pulmonary congestion develop reduced

    • Dietary sodium is restricted• Dietary sodium is restricted

    • Diuretics are given

    • A β-blocker drug is usually given to slow the ventricular response to activity

    is generally recommended.

    congestion develop, activity is further

    to slow the ventricular response to

  • • If new-onset atrial fibrillation develops, 10 mg, is given, or electrocardioversion

    • For chronic fibrillation, digoxin, a β blocker is given to slow ventricular blocker is given to slow ventricular

    • Therapeutic anticoagulation with heparin fibrillation. Some recommend heparin severe stenosis even if there is a sinus rhythm

    develops, intravenous verapamil, 5 to electrocardioversion is performed.

    β-blocker, or a calcium-channel is given to slow ventricular responseis given to slow ventricular response

    Therapeutic anticoagulation with heparin is indicated with persistent recommend heparin anticoagulation for those with

    sinus rhythm

  • • Labor and delivery are particularly symptomatic mitral stenosis. Uterine contractions output by increasing circulating blood

    • Pain, exertion, and anxiety cause tachycardia• Pain, exertion, and anxiety cause tachycardia related heart failure.

    • Epidural analgesia for labor is ideal fluid overload. Abrupt increases in capillary wedge pressure and cause

    • Wedge pressures increase most immediately postpartum.

    and delivery are particularly stressful for women with Uterine contractions increase cardiac

    by increasing circulating blood volume.

    tachycardia with possible rate-tachycardia with possible rate-

    is ideal, but with strict attention to avoid . Abrupt increases in preload may increase pulmonary

    cause pulmonary edema.

    pressures increase most immediately postpartum.

  • • Most consider vaginal delivery to be preferable in stenosis. Elective induction is reasonable.

    to be preferable in women with mitral reasonable.

  • Congenitally Corrected Transposition of Great Arteries

    (CCTGA)

    Congenitally Corrected Transposition of Great Arteries

    (CCTGA)

  • • 30 y/o G1

    • PMHx: CCTGA

    • PSHx: Neg

    • DHx: Digoxin / metohexale / ASA /• DHx: Digoxin / metohexale / ASA /

    • Echo: CCTGA / EF: 30-35%/ mod TR/ PAP

    • Fetal echo: Nl

    %/ mod TR/ PAP 30 (repeat every 3 month)

  • • WHO class: 4

    • REC: therapeutic abortion

    • The Pt refused

  • • WHO 4— Very high risk of maternal mortality pregnancy contraindicated and termination discussed

    1) Pulmonary arterial hypertension

    2) Severe systemic ventricular dysfunction (NYHA III2) Severe systemic ventricular dysfunction (NYHA III

    3) Previous peripartum cardiomyopathy with any residual impairment of left ventricular function

    4) Severe left heart obstruction

    5) Marfan syndrome with aorta dilated >

    maternal mortality or severe morbidity; termination discussed :

    Pulmonary arterial hypertension

    Severe systemic ventricular dysfunction (NYHA III-IV or LVEF < 30%)Severe systemic ventricular dysfunction (NYHA III-IV or LVEF < 30%)

    cardiomyopathy with any residual impairment

    syndrome with aorta dilated > 40 mm

  • • Betamethasone at 28 w

    • Elective C/S at 37w

    • CCU

    • Discharged with methohexal / digoxin / • Discharged with methohexal / digoxin /

    • REC: barrier

    / digoxin / enalapril/ digoxin / enalapril

  • Congenital Heart Disease in Offspring

    • Many congenital heart lesions appear to be inherited as characteristics. Because of this, some women with congenital lesions give birth to similarly affected

    • Environmental factors are also important. One example is a study • Env