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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 Peripheral Vascular Resistance Increased Decreased

Blood Pressure

Mid pregnancy decrease

Pulmonary Blood Pressure Heart Size Cardiac output Stroke volume

Unchanged Increased Increased Increased

Systolic murmurs
Diastolic murmurs

Common
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. Pulmonary H.T. cause unknown ASD: Eisenmengers ASD closed residual pulmonary HT Bicuspid aortic valve; endocarditis Coartation repair; endocarditis Previous ASD; arrythmia 3 1 2 1 1 1 1

Deaths from Acquired Cardiac Disease


Puerperal 7 Cardiomyopathy Cardiomyopathy and 5 myocarditis Aneurysm thoracic aorta 5 Myocardial Infarction Endocarditis normal valve Heart Failure cause unknown 5 1
2

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