Managing Heart Failure in Pregnancy or Post Partum

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Text of Managing Heart Failure in Pregnancy or Post Partum

  • ManagingHeartFailureinPregnancyorPostPartum

    KarenSliwaTheHa9erIns;tuteforCardiovascularResearchinAfrica(HICRA)

    UniversityofCapeTownUCTPrivateAcademicHospital

    www.ha%er.uct.ac.za

  • Case2

    25yearoldwomenSuddenonsetofshortnessofbreath4weeksprepartumMedicalHx:Nil(noHT,noFHx,notsmoking)Examina;on:

    Obese(104kg) HR120bpm BP180/110 JVPraised Lungs:pulmonaryoedema

  • Case2

    Differential diagnosis 1.Pulmonary Embolus 2.Pre-excisiting Hypertension

  • Case2

    CXR and ECG:

  • Case2

    echocardiography:

  • Case2

    Blood tests: HIV negative, D-dimers negative, normal Thyroid function test

    Diagnosis: Hypertensive Heart Failure

  • Diure;csHydralazineBetablocker

    Diure;csHydralazineBetablocker

    Accordingtostandardheartfailureguidelines

    Notpregnant

    Earlypregnancy

    Latepregnancy

    Postpartum

    Diure;csAceinhibitorBetablocker

    Effectonfetus

  • Acuteheartfailure

    ManagingacuteheartfailureduetoPPCM/HTinpregnancyisnodifferentthanthatappliedtoacuteHFarisingfromanyothercause

    Oxygeninordertoachieveanarterialoxygensatura@onof95%,using,wherenecessary,noninvasiveven@la@onwithaposi@veendexpiratorypressure(PEEP)of57.5cmH2O.

    Intravenousdiure@cs,whenthereisconges@onandvolumeoverloadwithanini@albolusoffurosemide2040mgi.v.,isrecommended.

    Intravenousnitrateisrecommended(e.g.nitroglycerinestar@ngat1020g/minupto200g/min)inpa@entswithasystolicbloodpressure>110mmHgandmaybeusedwithcau@oninpa@entswithSBPbetween90110mmHg.

    Inotropicagentsshouldbeconsideredinpa@entswithalowoutputstate,indicatedbysignsofhypoperfusion

  • PPCMmanagementofchronicheartfailure

    A"erdeliveryPPCM/HTheartfailureshouldbetreatedinaccordancewiththecurrentguidelines

    Duringpregnancythefollowingrestric@onstotheseguidelinesapply:

    Drug Indica;onACEinhibitorsandAngiotensinIIreceptorblocker(ARBs)

    Contraindicatedbecauseofseriousrenalandotherfoetaltoxicity(IC).AT1receptorblockersprobablycausesimilartoxicity.

    HydralazineandlongacBngnitrates

    Itisbelievedthatthiscombina@oncanbeusedsafely,insteadofACEinhibitors/ARBs,inpa@entswithPPCM.

    Betablockers Notshowntohaveteratogeniceffects.

    Beta1selec@vedrugspreferredbecausebeta2receptorblockadecanhaveanan@tocoly@cac@on.

    DiureBcs Shouldbeusedsparinglyascancausedecreasedplacentalbloodflow

    Furosemideandhydrochlorothiazide

    Mostfrequentlyused

    Aldosteroneantagonists Spironolactonethoughttohavean@androgeniceffectsinfirsttrimester.

    Eplerenoneeffectsonthehumanfoetusuncertain,avoidduringpregnancy.

  • Breastfeeding

    Basedonthepostulatednega@veeffectsofprolac@nsubfragments(HilfikerKleinerCell2007),breas^eedingisnotadvisedinpa@entswithsuspectedPPCM,evenifthisprac@ceisnotfullyevidencebased.

    SeveralACEinhibitors(captopril,enalaprilandquinapril)havebeenadequatelytestedinbreas^eedingwomen.

  • Timingandmodeofdelivery

    Ateamcomprisingacardiologist,obstetrician,anaesthesiologist,neonatologistandintensivecarephysician)shoulddiscusstheplannedmodeandconductofdeliveryineachcase.

    Theprimaryconsidera@onshouldbematernalcardiovascularbenefit.

    Ingeneral,spontaneousvaginalbirthispreferableinwomenwhosecardiaccondi@oniswellcontrolled,withanapparentlyhealthyfoetus.

    PlannedCaesareansec@onispreferredforwomenwhoarecri@callyillandinneedofinotropictherapyormechanicalsupport.

  • Ques;ons?