Synopsis: Cardiovascular Diseases

in Pregnancy

ER TEAM January 2015

Epidemiology

⬜ Complicates > 1% of all pregnancies

⬜ 7.6% severe obstetrical morbidities

⬜ Leading cause of indirect maternal deaths (20%).

⬜ RSCM → 44%

⬜ Most frequent event: hypertensive disorders (6-8%).

Physiological Considerations in Pregnancy

⬜ Cardiac output increases 40%

⬜ Maximal by midpregnancy
⬜ First increase in stroke volume, then decrease in SVR, then
increased end-diastolic ventricular volume.
⬜ Later in pregnancy → increased heart rate

⬜ Women with underlying cardiac disease may not always

accommodate these changes → ventricular dysfunction
→ cardiogenic heart failure.
⬜ Mostly develops peripartum, some after 28 weeks, rarely
before midpregnancy
Physiological Considerations in Pregnancy
Physiological Considerations in Pregnancy

⬜ Physiological changes in pregnancy can affect

absorption, excretion, and bioavailability of all drugs.

⬜ Higher dosage of drugs are required to achieve

therapeutic levels
⬜ Due to increased intravascular blood volume, raised renal
perfusion, higher hepatic metabolism
⬜ Drug dose adjustment
Effect of Pregnancy on Maternal
Heart Disease

⬜ Changes in pregnancy that exceeds maternal capacity

→ heart failure, pulmonary edema

⬜ Danger periods of cardiac decompensation:

⬜ 12-16 wga → hemodynamic changes begin
⬜ 28-32 wgs → maximum changes
⬜ Labor & delivery → fluctuations in CO due to uterine
contractions (increase) and maternal pushing (decrease).
⬜ After delivery of placenta → backflow
⬜ 4-5 days after delivery
Effect Maternal Heart Disease on
Pregnancy

⬜ Pregnancy outcome is compromised by presence of

cardiac disease.

⬜ Fetal death → due to maternal deterioration.

⬜ Fetal morbidity → preterm, IUGR, congenital heart

disease

⬜ Mostly due to chronic tissue hypoxia

 Diagnosis of Heart Disease

⬜ Physiological
adaptations of normal
pregnancy may
induce symptoms &
alter findings that may
confound diagnosis of
heart disease.
Diagnose and Treat Heart Disease in
Pregnancy
Radiation exposure in cardiovascular
diagnostic procedures
NYHA Classification
Predictors of Cardiac Events
Labor Management
⬜ Vaginal delivery is a better option than CS
⬜ Risk of bleeding, infection, clotting complications are less
⬜ CS is associated with DVT, TE
⬜ Not associated with acute shift in blood volume

⬜ BUT Take into consideration:

⬜ Duration of labor
⬜ Difficulty of vaginal delivery
⬜ It may be preferable to perform a quick CS than a long and
difficult vaginal delivery.
Labor Management
Post-partum care
⬜ Uterotonics
⬜ Slow IV oxytocin infusion (< 2 U/min) → avoid systemic
hypotension.
⬜ Prostaglandin F analogues
⬜ Methylergonovine → contraindicated due to risk (> 10%) of
vasoconstriction and hypertension.

⬜ Early ambulation, elastic bandage → reduce risk of TE

⬜ Hemodynamic monitoring → at least 24 hrs (risk of heart

failure)