Cardiovascular Disorders

Physiologic considerations in pregnancy

Cardiovascular physiology

Ventricular function in pregnancy

• ?HR & blood volume
  • ?Transmitral gradient and left atrial pressure (at rest and during exercise)
  • Systolic ejection murmur
  • Peripheral edema
• Respiratory adaptation
  • Progesterone induces ?minute ventilation through an increase in tidal volume, but the respiratory rate is unchanged.
  • The enlarging uterus ? diaphragm to be elevated ? ?FRC

Diagnosis of heart disease

Diagnostic studies

Classification of Functional Heart Disease

Preconceptional Counseling

Peripartum management considerations

Labor and Delivery

Analgesia and Anesthesia

Intrapartum Heart Failure

Puerperium

NYHA I, II	Morbidity ?? ?? ????. Sepsis, bacterial endocarditis ??!
NYHA III, IV	???? ?? ?? ?? bed rest ??? pregnancy interruption ??.  Epidural ??, vaginal delivery > C-sec
Mitral insufficiency	?? ??? ? ??? ??. ??? ??? x
Mechanical valve	?? ? warfarin – ?? ? full heparin – ?? ?? heparin ?? ??? dual 6? – ? ? warfarin
Peripartum DCMP	CXR: Impressive cardiomegaly / EF < 45%
Infective endocarditis	Ampicillin 2g, or cefazolin or ceftriaxone 1g IV

Surgically corrected heart disease

Valve Replacement before Pregnancy

Anticoagulation

Cardiac Surgery During Pregnancy

Pregnancy axer Heart Transplantation

Valvular heart disease

Mitral Stenosis

Physiologic changes often precipitate symptoms of fatigue, exercise intolerance, or dyspnea in previously asymptomatic patients with rheumatic mitral stenosis.

The loss of an effective “atrial kick” and decrease in diastolic filling times seen with AF and RVR further increases left atrial pressure, with dramatic worsening of pulmonary congestion/edema.

Mitral Insufficiency

Mitral Valve Prolapse

Aortic Stenosis

Aortic Insuwiciency

Pulmonic Stenosis

Congenital heart disease

ASD / VSD / AVSD

Persistent (Patent) Ductus Arteriosus

Cyanotic Heart Disease

Pregnancy axer Surgical Repair

Eisenmenger Syndrome

Pulmonary hypertension

Cardiomyopathies

HCMP

DCMP

Peripartum Cardiomyopathy

• Clinical features
  • Onset of HF during last months of pregnancy or within 5 months following delivery
  • LV systolic dysfunction with LVEF <45%
  • Associated with mitral regurgitation
  • Absence of other causes of HF
  • Absence of heart disease prior to final month of pregnancy
  • Dyspnea, peripheral edema, pulmonary edema with hyperventilation and respiratory alkalosis.

Other Cardiomyopathy Types

Heart failure

Diagnosis

Management

Infective endocarditis

Diagnosis and Management

Pregnancy

Endocarditis Prophylaxis

Arrhythmias

Bradyarrhythmias

Supraventricular Tachycardias

Ventricular Tachycardia

Prolonged QT-Interval

Diseases of the aorta

Aortic Dissection

Marfan Syndrome

Aortic Coarctation

Ischemic heart disease

Myocardial Infarction During Pregnancy

Pregnancy with Prior Ischemic Heart Disease

Chronic Hypertension

?? ???/????, MI, HF?? ??? Cix
Preeclampsia risk ?, placental abruption, FGR, preterm, perinatal death? ?
Anti HTN drug
Diurteics (?? thiazide), ACEI? ??!!
Methyldopa? ?? ??. Or hydralazine

Pulmonary Disorders

Asthma

PG, ergonovine

Pneumonia

CAP (community-acquired pneumonia)

• Etiology: S.pneumonia – m/c.
• Low threshold for admission – The presence of comorbidities (e.g., asthma, immunologic disorders, renal disease) warrants inpatient management.

Management

• In general: https://hsnow.net/infectious-diseases/h131-pneumonia/
• The approach to antibiotic therapy during pregnancy is the same as that for the general adult population,
  • excluding potentially teratogenic medications, e.g.,: clarithromycin, fluoroquinolone, tetracycline
• Attenuated Influenza vaccine

Tb

HER – 3? 9?? ??. Mycin??, amikacin? CIx ????(TST+) – isoniazid 1? ?? Disseminated Tb? ?? ?? ??? ???? ??. ??? Tb? ? ???? ??? INH 1?. ????.

DVT

LMWH

Thromboembolic Disorders

Postpartum ovarian vein thrombosis
� Risk factors – Virchow�s triad
? Venous stasis (ovarian venous dilation)
? Hypercoagulability (hormone-mediated increase in clotting factors)
? Endothelial damage (interapartum vascular injury or uterine infection)
� Clinical presentation
? 1 week after delivery
? Fever & localized abdominal pain