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in Pregnancy
• A thorough knowledge
– is essential
• In order to understand
– the additional impact of cardiac disease
Physiological Changes
Blood pressure ↓ 10 mm Hg ↑ ↓
• ECG:
• Arrhythmias, left ventricular hypertrophy,
ST segment and T wave abnormalities
CD main threat to pregnant
women
• Heart failure
• Subacute infective endocarditis
• Hypoxia and cyanosis
• Venous thrombosis and pulmonary
embolism.
The impact of CD in
pregnant women
• Gestation period:
• increased blood volume, heart burden
• Delivery period:
• uterine contractions
• blood pressure↑
• the blood flow increases
• pulmonary artery pressure increased
• sudden interruption of placental circulation
• abdominal pressure plummeted
The impact of CD in
pregnant women
• Puerperium:
– uterine contractions
– retented Interstitial fluid returned to circulation
• The greatest change period in systemic
blood circulation and heart burden
– 32 to 34 weeks
– Intrapartum
– 3 days postpartum
• easily induced heart failure
The impact of CD in
pregnant women
• A validated cardiac risk score
• Predict a maternal chance of having
adverse cardiac complications
Table 2 Risk factor and maternal cardiac event rates
Maternal
cardiac 5% 27% 75%
event rates
Table3 Predictors of Maternal Risk for Cardiac Complications
NYHA III/IV 1
or cyanosis
• Before pregnancy:
– detailed examination to determine
whether she is suitable to pregnant
• access to counselling
– specialized
– multidisciplinary
– preconception
• In order to empower them to make
choices about pregnancy
Not suitable for pregnancy !
• Cardiac function grade Ⅲ ~ Ⅳ
• Those who previously had heart failure
• A pulmonary hypertension, severe
stenosis the main A, Ⅲ atrioventricular
block, atrial fibrillation, atrial
flutter,diastolic gallop;
• Cyanotic heart disease
• Active rheumatic or bacterial endocarditis
The main aims of
management
• To optimize the mother's condition
during the pregnancy
– considering ß-blockers
– Thromboprophylaxis
– pulmonary arterial vasodilators
• To monitor for deterioration
• Minimize any additional load on the
cardiovascular system
Pregnant women with CD
• Should be assessed clinically as soon as possible
• A multidisciplinary team and appropriate
investigations undertaken
• The core members of the team should include:
• Suitably experienced obstetricians
• Cardiologists
• Anaesthetists
• Midwives
• Neonatologists
• Intensivists
Management of
gestation period
• Regular prenatal care
• Early prevention of heart failure
– adequate rest
– appropriate weight limit
– treatment the motivation of heart failure
: infection, anemia,PIH
• The treatment of heart failure
– as same as those who are not pregnant
Mode of Delivery
• Vaginal delivery:
– cardiac function Ⅰ ~ Ⅱ grade
– not a fetal macrosomia
– cervical conditions are good
• Cesarean section:
– Marfan syndrome : expansion of the aortic
root> 45 mm
– use warfarin during delivery
– sudden hemodynamic deterioration
– severe pulmonary hypertension and severe
aortic stenosis
Management in intrapratum
• First stage of labor
• Semi-recumbent position, oxygen
masks, attention Bp, R, P, heart rate,
– cedilanid : 0.4mg +5% GS20ml iv slow
(when necessary)
– antibiotics : during labor to 1 week after
postpartum
Vaginal delivery
• Low-dose regional analgesia:usually
recommended
• providing effective pain relief
• reduce the further increases in
– cardiac output
– myocardial oxygen demand
• Be careful not to inhibit the neonatal
breathing
Management in intrapratum
• Second stage of labor:
– episiotomy, facilitate instrumental delivery to
shorten the stage
• Third stage of labor:
– Ergot disabled to prevent venous pressure
increased
– injection of morphine or pethidine immediately
postpartum
– abdominal pressure sandbags
– control the liquid velocity
Management in puerperium
• Monitoring heart rate, blood oxygen,
blood pressure during delivery 24
hours
• She could not breast-feeding
– more than grade Ⅲ cardiac function
• Prophylactic antibiotics
• High-level maternal surveillance
Thanks four your
listening