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Cardiac Disease in

Pregnancy

Cardiac Disease in Pregnancy

Cardiovascular Changes in Pregnancy

Ante
partum

Blood volume increases by 50%


Systemic vascular resistance decreases by
20%
Blood pressure
Systolic BP decreases by 5-10mmHg
Diastolic BP decreases by 10-15mmHg
After 24weeks BP increases to
nonpregnant level by term
CVP remains unchange ( 10cm H20)
Heart rate increases by 10-15bpm

Cardiac Disease in Pregnancy

Cardiovascular Changes in Pregnancy

Ante
partum

Cardiac output increases by 30-50%


Increases as early as 5-10weeks
Peaks at 20-24weeks
Left ventricular ejection Fraction increases
Blood is hypercoagulable

Cardiac Disease in Pregnancy

Cardiovascular Changes in Pregnancy

Ante
partum

EKG changes
Left axis deviation by 15
Low voltage QRS
T wave inversion in lead III
Q waves in lead III dan aVF
Premature atrial dan ventricular beats
Chest x-ray changes
Horizontal position of heart
Small pleural effusions early postpartum

Cardiac Disease in Pregnancy

Cardiovascular Changes in Pregnancy

Intra
partum

Cardiac output increases by 20-30% in


active labor
Each contraction squeezes 300-500mL of
blood out of uterus into circulation
Blood pressure increases by 10-20mmHg
during a contraction
Supine position may decrease cardiac
output by 30%
Oxygen consumption is 100% higher than
measured prior to labor

Cardiac Disease in Pregnancy

Cardiovascular Changes in Pregnancy

Post
partum

Cardiac output increases by 10-20% in


immediate postpartum period
Increase in stroke volume
Reflex bradycardia
These changes persist for 1-2 weeks after
delivery

Cardiac Disease in Pregnancy

Cardiovascular Disease in Pregnancy


Etiology

Congenital heart disease


Cyanotic
Acyanotic
Acquired heart disease
Rheumatic heart disease
Coronary heart disease
Pregnancy-Associated Cardiomyopathy
Peripartum Cardiomopathy

Cardiac Disease in Pregnancy

Cardiovascular Signs and Symptoms of


Pregnancy

Normal

Abnormal

- Fatigue

- Syncope

- Dyspnea

- Paroxysmal nocturnal dyspnea

- Occasional palpitations

- Tachycardia >120 beats/min

- Systolic murmur (12/6)

- Sustained arrhythmia

- Pulsation of neck veins

- Shortness of breath at rest

- Dependent edema (lower extr)

- Distention of neck veins

- Loud, wide split S1

- Summation gallop
- Systolic murmur (46/6)
- Diastolic murmur
- Chest pain
- Hemoptysis

Cardiac Disease in Pregnancy

- Cyanosis
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Clinical Classification NYHA


1. Class I
Uncompromised (no limitation of physical activity):
These women do not have symptoms of cardiac
insufficiency or experience anginal pain.

2. Class II
Slight limitation of physical activity: These women
are comfortable at rest, but if ordinary physical
activity is undertaken, discomfort results in the form
of excessive fatigue, palpitation, dyspnea, or anginal
pain
Cardiac Disease in Pregnancy

Clinical Classification NYHA


3. Class III
Marked limitation of physical activity: These women
are comfortable at rest, but less than ordinary
activity causes excessive fatigue, palpitation,
dyspnea, or anginal pain.

4. Class IV
Severely compromised (inability to perform any
physical activity without discomfort): Symptoms of
cardiac insufficiency or angina may develop even at
rest, and if any physical activity is undertaken,
discomfort is increased.
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Risks for Maternal Mortality Caused by


Various Types of Heart Disease

Group Cardiac Disorder


I

Atrial septal defect


Ventricular septal defect
Patent ductus arteriosus
Pulmonic or tricuspid disease
Fallot tetralogy, corrected
Bioprosthetic valve
Mitral stenosis, NYHA class I and II

Cardiac Disease in Pregnancy

Mortality
< 1%

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Risks for Maternal Mortality Caused by


Various Types of Heart Disease

Group Cardiac Disorder


II

Aortic coarctation without valvular

Mortality
5-15%

involvement
Fallot tetralogy, uncorrected
Marfan syndrome, normal aorta
Mechanic Prosthetic valve
Mitral stenosis, NYHA class III and
IV
Aortic stenosis
Previous myocardial infarction
Cardiac Disease in Pregnancy

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Risks for Maternal Mortality Caused by


Various Types of Heart Disease
Group Cardiac Disorder
III

Pulmonary hypertension
Aortic coarctation with valvular
involvement
Marfan syndrome with aortic
involvement
Peripartum Cardiomopathy

Cardiac Disease in Pregnancy

Mortality
25-50%

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Diagnostic criteria for PPCM


all must Cardiac failure developing in the last month
of pregnancy or within 5 months of delivery
be
present No identifiable cause of the cardiac failure
No recognizable heart disease before the
last month of pregnancy
An ejection fraction of less than 45%, or
the combination of an M-mode fractional
shortening of less than 30% and an enddiastolic dimension greater than 2.7 cm/m2
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Management
Prakonsepsi

Konseling untuk tidak hamil bila


ada riwayat kardiomiopati
peripartum

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management
Antepartum

Terminasi kehamilan bila


didapatkan echocardiography
yang abnormal
Terapi medis bila ada gejala
antikoagulan

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management
Intrapartum

Periksa adanya gagal jantung

Hindari kelebihan cairan


Invasive monitoring

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management
Postpartum

Hindari kelebihan cairan

Diskusikan metoda kontrasepsi

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Management
Selama
kehamilan
perhatikan

Bed rest
Restriksi cairan
Diet rendah garam
Pemberian obat golongan diuretik
Dapat ditambahkan obat golongan
vasodilator dan digitalis
Pemberian antikoagulan profilaksis
selama kehamilan dilnjutkan dengan
dosis penuh selama 7-10hari
postpartum
Percepat kala II

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Kontrasepsi
Jenis

Barier/kondom
Pil oral kontrasepsi
Kontrasepsi bebas estrogen
IUD
Tubektomi/vasektomi

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The End

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