Kehamilan & penyakit

jantung
Pendahuluan

• Fisiologi

Hamil Perubahan dalam KVS

- Hidremia  puncak 32 – 34 mg
- Anemia dilusional (vol plasma ↑ 30 % + sdm ↑
18 % + Hb ↑ 19 %)
- Postpartum  imbibisi ekstravaskuler ke
intravaskuler ≈ vol plasma ↑ (± 2 minggu)
- Frekuensi nadi ↑, prekordium bergeser ke kiri,
bising sistolik di apeks + katup pulmonal
Pendahuluan

• Fisiologi

Hamil Penyakit Jantung

- Hamil 32 – 36 mg
- Partus Kala II
- Postpartum
 Key Cardiovascular Changes During Pregnancy
Blood Flow to Other Organs Increased
Peripheral Vascular Resistance Decreased

Blood Pressure Mid pregnancy decrease

Pulmonary Blood Pressure Unchanged

Heart Size Increased
Cardiac output Increased
Stroke volume Increased
Systolic murmurs Common
Diastolic murmurs Potentially pathological

EKG changes LAD, low voltage

 Cardiac Changes in Pregnancy

• Cardiac output : ↑ 50 %
• Fase aktif : ↑ 40%
• Segera post partum : 10-20%
• Cardiac exam is different during pregnancy
• Many patients will have an S3 after midpregnancy
• Diastolic murmurs are usually considered serious
• Systolic murmurs (“flow murmurs”) common
• Displacment of heart is to right and upwards
• EKG shows left axis deviation and low voltage QRS complexes
Cardiac Changes in Pregnancy
Hemodynamic Changes in Pregnancy
Penyakit jantung dalam kehamilan

•Frekuensi : 12 % ( >> demam

rheuma  dahulu) + kelainan
kongenital (± 50 %) + Hipertensi
heart disease (peripartum)

•Mortalitas : 8 -15 %
Penyakit jantung dalam kehamilan
 Deaths due to Congenital Cardiac Disease

Primary Pulmonary H.T. 3

Pulmonary H.T. cause 1
unknown
ASD: Eisenmenger’s 2
ASD closed residual 1
pulmonary HT
Bicuspid aortic valve; 1
endocarditis
Coartation repair; 1
endocarditis
Previous ASD; arrythmia 1
 Deaths from Acquired Cardiac
Disease

Puerperal 7
Cardiomyopathy
Cardiomyopathy and 5
myocarditis
Aneurysm thoracic aorta 5
Myocardial Infarction 5
Endocarditis normal 1
valve
Heart Failure cause 2
unknown
Penyakit jantung dalam kehamilan
•Penyakit jantung  Hipoksia + sianosis
- Hasil konsepsi † (abortus)
- Hasil konsepsi hidup
Prematur
IUGR
Gawat janin
 Penyakit jantung dalam kehamilan

•Diagnosa (sulit)
- Anamnesis : riwayat sakit jantung
- Pemeriksaan fisik :
Bising diastolik, presistolik, pansistolik
Pembesaran jantung
Bising jantung nyaring (thrill)
Aritmia berat
 Diagnosa
•Symptoms
- Progressive dyspnea or orthopnea
- Nocturnal cough
- Hemoptysis
- Syncope
- Chest pain
 Diagnosa
•Clinical findings
- Cyanosis
- Clubbing of fingers
- Persistent neck vein distention
- Systolic murmur grade 3/6 or greater
- Diastolic murmur
- Cardiomegaly
- Persistent arrhytmia
- Persistent split second sound
- Criteria for pulmonary hypertension
Risiko

•Ringan :
• ASD / VSD
• PDA
• Tetralogi fallot yang terkoreksi

•Sedang :
• MS, AS
• Riwayat infark miokard
• Tetralogi fallot yang tidak terkoreksi
Risiko
•Berat :
•Pulmonary hipertension
•Marfan syndrom dengan aorta
yang terganggu
Prognosis
•Kapasitas fungsi jantung
•Komplikasi  peningkatan
beban jantung
•Kualitas pelayanan kesehatan
 Klasifikasi
•Kelas I
No limitation of physical activity
•Kelas II
Slight limitation of physical activity
•Kelas III
Marked limitation of physical activity
•Kelas IV
Inability to performed any physical activity
without discomfort
Penatalaksanaan
•Kelas I & II
-Preventif & pengenalan dini tanda CHF
-Cegah bakterial endokarditis 
Preventif terhadap infeksi, Smoking,
obat suntik dkk
-Batasi obat
-Labor & delivery
Penatalaksanaan

•Kelas I & II
-Labor & delivery :
Partus pervaginam (kecuali indikasi obstetri
Kurangi rasa nyeri/painless labor
Observasi ketat tanda vital (kontraksi)
Intrapartum heart failure (udem paru –
hipoksia –hipotensi) tatalaksana sesuai
penyebab
 Penatalaksanaan
•Kelas I & II
-Puerperium:
HPP, infeksi, anemia &
tromboemboli  komplikasi
yang serius
Sterilisasi  stabilisasi KU
Penatalaksanaan
•Kelas III & IV
-Continued or terminated ?
-Vaginal delivery is preferred with
epidural analgesia
-Surgical procedure could be done in
facility with experience with complicated
cardiac disease