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CVD IN PREGNANCY (PREGNANCY-SPECIFIC
CHANGES (Orthostatic hemodynamic…
CVD IN PREGNANCY
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MYOCARDIAL INFARCTION
Risk factors
- tobacco smoking, arterial hypertension, obesity
- older age, hyperlipidemia, diabetes mellitus
- Mode of labor is determined by clinical manifestation:
cesarean section (coronary instability)
shorter 2nd phase of labor, spinal anesthesia
- Oxytocin and Metergin are not recommended
due to potential risk of coronary artery constriction
etiology
- atherosclerosis, primary or secondary vasospasm
(medications, preeclampsia)
- thrombangiitis obliterans, congenital defects (abnormal ramifications of coronary arteries)
- hypertrophic cardiomyopathy, spontaneous coronary artery dissection
ROUTINE TREATMENT
- ROUTINE: (beta-adrenolytics, aspirin, calcium channel blockers, nitrates, thrombolytic therapy)
- Lack of improvement: INVASIVE TREATMENT: coronarography, PTCA, by-pass
Risk: arrhythmia, arterial embolism, toxicity of a contrast agent, vascular injury
LABOR
- In patients requiring cardiac surgery, cesarean section should be considered after the 28th week, i.e. prior to
the surgical treatment
- Coronary instability in early pregnancy constitutes indication to termination
- Whenever possible, labor should be avoided up to 14 days after the fresh myocardial infarction
- Decision on the mode of pregnancy termination after myocardial infarction should be based on usual obstetrical indications and clinical status of a mother
ACQUIRED HEART DEFECTS
mitral stenosis
Risk assessment
- I NYHA - heart not enlarged, without the signs of congestion, regular sinus rhythm – safe pregnancy and labor
- II NYHA - risk of sudden deterioration
increase pulmonary resistance, increase cardiac output,
increase venous return
- II/III NYHA – consider commissurotomy or valvuloplasty
- IV NYHA – pregnancy contraindicated
- Optimally, the defect should be corrected before pregnancy
- Indications to commissurotomy or valvuloplasty in pregnancy:
Absolute: pulmonary edema,persistent pulmonary congestion, hemoptysis.
Scheduled procedure: optimally between 20 and 24 weeks
Emergency procedure – at any time of pregnancy
LABOR
- Maintain heart rate at 70-90/min
Control of pain – spinal
anesthesia, narcotics
Avoid terbutaline
Beta-adrenolytics in tachycardia
Reduce activity
- Maintain preload:
Avoid heavy blood loss
Avoid overhydration
- diuretics
-
- Normal area of the mitral valve orifice – 4.0-5.0 cm2
- Mitral valve orifice area <1.5 cm2
significant limitation of left ventricular filling at diastole
preventing appropriate increase in cardiac output
decrease in left ventricular preload - tachycardia,
increase in left atrial preload - arrhythmia - atrial fibrillation – pulmonary edema (usually at 28-32 weeks)
aortic stenosis
- Rarely as an isolated cardiac defect
- Results from developmental malformation of the valves
(especially tricuspid valve) or has rheumatic origin
- (+) circulating blood volume - (+) left ventricular pressure - (+) valve gradient - (+) left ventricular load
- Women >30 years of age and pre-pregnancy NYHA class II
may present with anginal pain, syncope, acute left ventricular heart failure and sudden death due to arrhythmia
- Young women – pregnancy well tolerated by limited exercise
(valve gradient <50 mmHg)
LABOR
SEVERE
- Area <1 cm2, Gradient >75 mmHg, EF <55%
- Surgical
correction
MODERATE
- Area <1-1.5 cm2, Gradient 50-75mmHg
- Limited physical activity, Monitoring of symptoms
MILD
- Area >1.5 cm2, Gradient <50 mmHg
- Limited physical activity, Monitoring of symptoms
aortic insufficiency
- Maternal risk is determined by severity of the defect
- Women with asymptomatic insufficiency - pregnancy well tolerated
- (-) peripheral resistance, shortened diastolic time, (-) mitral regurgitation (relative)
- Severe aortic insufficiency: markedly enlarged heart,
electrocardiographic signs of left ventricular overload: pregnancy – rapid circulatory failure
mitral valve prolapse
- Most common heart defect in young women (30% of population)
- Usually asymptomatic (palpitations - beta-adrenolytics)
- Incidence of pre- and postpartum complications
- similar as in general population
- Pregnancy and labor well tolerated
HEART DEFECT
LABOR
- prophylactic antibiotic therapy:
artificial valve, history of a rheumatic disorder,
acquired or congenital cardiac defect
history of infectious endocarditis
hypertrophic cardiomyopathy
mitral valve prolapse and regurgitation after cardiac surgeries
anticoagulation therapy
- 1st trimester - heparin (2-2.5-fold increase in APTT)
- 2nd trimester - coumarin derivatives (INR 2.0 – 3.0)
- 3rd trimester - heparin (2-2.5-fold increase in APTT)
- Intrapartum - withdrawal of heparin
- Postpartum- reimplementation of heparin at 6-12 h
coumarin 3-6 days after labor
management
- Reduction of physical exercise level
- 1st trimester – pharmacotherapy only if absolutely
necessary (developmental defects – impaired organogenesis)
- 2nd trimester – rest in a lateral recumbent position
- Hospitalization - beginning at peak hemodynamic load
- Avoidance of standing position
- Dietary restriction of salt and fluids
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-
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STAGES OF HEART FAILURE
according to the New York Heart Association (NYHA)
Class I – No limitation of physical activity. Ordinary physical activity does not cause cardiovascular symptoms.
Class II – Slight limitation of physical activity. Ordinary physical activity does not cause cardiovascular symptoms (dyspnea, anginal pain, fatigue, palpitation).
Class III – Less than ordinary physical effort causes cardiovascular symptoms, resulting in limitation of activity.
Patients do not experience the symptoms at rest.
Class IV – The symptoms manifest at any physical activity and are present even at rest.
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- Congenital defects (atrial septal defect, ventricular septal defect, patent ductus arteriosus, pulmonary stenosis, aortic coarctation, tetralogy of Fallot, Eisenmenger’s syndrome, primary pulmonary hypertension)
- Acquired defects (mitral stenosis, mitral and aortic insufficiency, aortic stenosis, mitral valve prolapse)
- Myocarditis, Arterial hypertension, Cardiomyopathies, Coronary artery disease, Arrhythmia, Status after heart transplant