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% / RheumatismalMS (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 dyspneahypertension 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 outputincreased preload of normal pregnancyincrease 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 fibrillationstenosis and are treated aggressively. Atrial predisposes to mural thrombus formation and embolization that can cause strokedespite 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 diseasepredominantly mitral stenosis—Sawhneyof 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 developreduced

• 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 βblocker 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 tachycardiarelated heart failure.

• Epidural analgesia for labor is idealfluid 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 • Environmental factors are also important. One example is a study from Tibet in which the prevalence increased among women living at higher altitudes (> and was presumably due to lower oxygen

Congenital Heart Disease in Offspring

Many congenital heart lesions appear to be inherited as polygenicof this, some women with congenital heart

give birth to similarly affected infants.

important. One example is a study important. One example is a study the prevalence of fetal heart disease was

at higher altitudes (> 3600 meters) to lower oxygen concentrations

• Congenitally corrected transposition of the great arteries (CCTGA) is a rare heart defect. Only 0.5 to 1 percent of all people with heart defects have CCTGA.

Congenitally corrected transposition of the great arteries (CCTGA) is a percent of all people with heart

• In CCTGA both ventricles (pumping chambers) of the heart are reversed. Fortunately, the arteries are reversed too, so the heart actually "corrects" the abnormal development, thus the name "congenitally corrected transposition of the great arteries."

In CCTGA both ventricles (pumping chambers) of the heart are reversed. Fortunately, the arteries are reversed too, so the heart actually "corrects" the abnormal development, thus the name "congenitally corrected transposition of the great arteries."

• In CCTGA, the heart twists abnormally during fetal development, and the ventricles are reversed: The stronger left ventricle pumps blood to the lungs and the weaker right ventricle has the harder chore of pumping blood to the entire body. The right ventricle is not built to last as long as the left ventricle.last as long as the left ventricle.

In CCTGA, the heart twists abnormally during fetal development, and the ventricles are reversed: The stronger left ventricle pumps blood to the lungs and the weaker right ventricle has the harder chore of pumping blood to the entire body. The right ventricle is not built to

Signs and symptoms of CCTGA

• People with CCTGA experience a wide variety of symptoms, depending on other problems with the heart. There are sick newborns, with low oxygen level, who need care immediately after birth, and there are healthy people who can live a normal life for many years, without any treatment.many years, without any treatment.

• Symptoms may include fainting from the block in the electrical conduction, or fatigue, as the heart is unable to pump enough blood to the body.

Signs and symptoms of CCTGA

People with CCTGA experience a wide variety of symptoms, depending on other problems with the heart. There are sick newborns, with low oxygen level, who need care immediately after birth, and there are healthy people who can live a normal life for many years, without any treatment.many years, without any treatment.

Symptoms may include fainting from the block in the electrical the heart is unable to pump enough blood

Treatment for CCTGA

• Treatment for CCTGA varies according to the type and severity of symptoms and associated defects. In some patients, especially those that have no additional heart defects, there may not be a need to do anything.

• For patients that do need surgery, the type of operation will vary according to the associated defects. There are several operations used in this condition

Treatment for CCTGA

Treatment for CCTGA varies according to the type and severity of symptoms and associated defects. In some patients, especially those that have no additional heart defects, there may not be a need to do

For patients that do need surgery, the type of operation will vary according to the associated defects. There are several operations

Outlook

• Because of enormous strides in medicine and technology, today many children born with congenitally corrected transposition of the great arteries go on to lead healthy, productive lives as adults. Outcomes are also better for those born without additional heart defects.

Because of enormous strides in medicine and technology, today many children born with congenitally corrected transposition of the great arteries go on to lead healthy, productive lives as adults. Outcomes are also better for those born without additional heart defects.

Can women with CCTGA have children?

• Most women with CCTGA can have children successfully. The exceptions are if your heart function is too weak, if you have serious lung problems, and/or if you have low oxygen levels in your body.

Can women with CCTGA have children?

Most women with CCTGA can have children successfully. The exceptions are if your heart function is too weak, if you have serious lung problems, and/or if you have low oxygen levels in your body.

Pregnancy and long-term cardiovascular outcomes in women with

Int J Gynaecol Obstet.Kowalik

• in Poland between April 1991 and April 2012

• RESULTS:

Of the 20 pregnancies among 13 women identifiedthe 19 deliveries, 14 (74%) were vaginal and required premature delivery for documented deterioration of right ventricular required premature delivery for documented deterioration of right ventricular function. There were no pregnancy-related maternal deaths. In heart disease was diagnosed in the offspring

• CONCLUSION:

Successful pregnancy can be achieved by most women with common cardiovascular complications are supraventricular arrhythmias but pregnancy does not seem to impair right ventricular function in the long term

term cardiovascular outcomes in women with CCTGA

Obstet. 2014 MayKowalik E

2012 were retrospectively reviewed.

identified, 19 (95%) were successful. Of %) were vaginal and 5 (26%) were cesarean. One patient

required premature delivery for documented deterioration of right ventricular required premature delivery for documented deterioration of right ventricular related maternal deaths. In 1 case, congenital

heart disease was diagnosed in the offspring.

Successful pregnancy can be achieved by most women with ccTGA. The most common cardiovascular complications are supraventricular arrhythmias but pregnancy does not seem to impair right ventricular function in the long term.