1.Presented by :- Dr MangilalModerator:- Dr AvnishBhardwaj

2. Introduction CARDIAC disease in pregnancy remains an important etiology of maternal ,fetal morbidity and mortality. Mitral stenosis is the most commonly acquired valve lesion encountered in pregnant women and is almost invariably caused by RHD. Pregnancy and the peripartum period worsen symptoms of cardiac disease. 3. Presenting Complaints A 37 year old woman presented at 28 weeksgestational age with inability to lie and becamedyspneic even when speaking (class IV). Had complete placenta previa, possible placentaaccreta. 4. Past History Patient complained of dyspnea with moderate exertionbefore pregnancy( class II ) Past medical history No history of TB, DM, HTN, Asthma,convulsion,chest pain Drug history no history of any drug allergy. Family history- not significant 5. Obs. history Gravida 2, Para 1 Previous h/o Cesarean section delivery 16 yr earlier 6. Clinical examination Physical examination revealed an arterial blood pressure of102/60 mmHg, Regular heart rate of 108 beats/min, Respiratory rate of 22 breaths/min. There were diastolic(grade 2) and holosystolic( grade 3)apical murmurs. The patients lungs were clear to auscultation bilaterally, and she had mild pedal edema. Her symptoms improved with heart rate control using 25 mg metoprolol orally twice daily. 7. Investigation Electrocardiogram showedsinus tachycardia and leftatrial enlargement. Transthoracicechocardiogram revealedmoderate to severe mitralstenosis, moderate to severemitral regurgitation, andmoderate pulmonaryhypertension with estimatedpulmonary artery systolicpressure of 54 mmHg. Therewas moderate tricuspidregurgitation. Left and right ventricularsystolic function werenormal.PROVISIONAL DIAGNOSIS-PREGNANCY WITH MS 8. Management Cesarean section was planned at 36 weeks gestational age in a cardiac operating room with cardiopulmonary bypass capabilities on standby. 9. Prophylaxis against acid aspiration, 30 ml sodiumbicitrate was administered orally in the holding area. Patient was positioned in the left uterine displacement Initial systemic arterial blood pressure was 125/65(mean 76)mmHg. Her heart rate was 105 beats/min. Remifentanil (0.2 gm/kg/min) was started toattenuate the sympathetic response to laryngoscopyand intubation. 10. Induction Etomidate, and Succinylcholine was used for relaxant administered ina rapid sequence fashion.Maintenance Remifentanil infusion(0.05 0.1ug /kg/min),Low level of Isoflurane(less than 0.5 minimum alveolarconcentration),Vecuronium for muscle relaxant.Higher doses of inhalational agents were avoided to prevent uterineatony.Depth of anesthesia was monitored using bispectral index valuesfrom 4060 were maintained during the intraoperative period.The patient was ventilated using 100% oxygen to maintainnormocarbia. 11. Intra op monitoring by TEE ,Colour doppler Three-dimensional ultrasound reconstruction of themitral valve showed significant commissuralfusion(mitral valve area 1.4cm2). Cesarean section was performed withoutcomplications. After delivery, 40 U oxytocin was administeredintravenously in 2 hr. 12. Initially monitored in the operating roomafter extubation to ensure normocarbia and stablepulmonary artery pressures. Then transferred to the cardiac care unit for postoperativemonitoring. The patient was discharged from the cardiac careunit on postoperative day 1 and from the hospital onpostoperative day 5. She underwent mitral valve repair and tricuspid valve annuloplasty 4 months later. 13. Heart disease with pregnancy Epidemiology - incidence of cardiac disease inpregnant 0.2% to 3% of pregnancies are complicated by maternal heartdisease in developed countries Heart diseases are still the second most common non obstetricalcause of maternal mortalityRheumatic heart disease accounts for majority of cases (~ 75%) inIndia while congenital heart disease are most common in developedcountries-- Mitral stenosis is the most commonly acquired valve lesionin pregnant women and is almost caused by RHD. 14. .RHD Highly prevalent in developing countries. India, the prevalence of RHD is 6:1,000 ( school- aged children) Carditis occurs in 3080% of patients with acute rheumatic fever, and at least 60% of untreated patients develop chronic RHD. 15. Physiological changes - Consideration In PregnancyThe most important changes in cardiac function occurs inthe first 8 weeks of pregnancy with maximum changes at 28weeks Vascular resistance Blood pressure Heart rate Stroke volume CO Blood volume 30% - 50% 16. The fall in the peripheral resistance is about 20-30% at 21-24 weeks & returns to normal at term. This fall is due to1. The trophoblastic erosion of endometrial vessels, the placental bed serves as a large arteriovenous shunt causing lowered systemic vascular resistance2. There is physiological vasodilatation which is believed to be secondary to endothelial prostacyclin and circulating progesterone.3 .Anemia decreases blood viscosity with resultant decreasein systemic vascular resistance. 17. Physiological changes during pregnancy 18. Physiological changes during labour 19. Risk of haemodynamic stress At the time of labor and delivery, pain and anxietyincrease catecholamine release with resultantincreases in heart rate, arterial blood pressure, andcardiac output. Auto-transfusion of up to 500 ml with eachcontraction , increases preload and, hence cardiacoutput. After delivery, there is an additional increase in venousreturn as a result of auto-transfusion from thecontracting uterus as well as from the loss of foetalcompression of the inferior vena cava. 20. Features in Pregnancy which canmimic cardiac disease1. Dyspnoea - due to hyperventilation, elevateddiaphragm.2. Pedal Edema3. Cardiac impulse- Diffused and shifted laterally due toelevated diaphragm.4. Jugular veins may be distended and JVP raised.5. Systolic ejection murmurs along the left sternalborder occur in 96% of pregnant women and arebelieved to be caused by increased flow across theaortic and pulmonary valves. 21. Criteria to diagnose cardiac diseaseduring pregnancy: 1.Presence of diastolic murmurs. 2.Systolic murmurs of severe intensity (grade III) 3.Unequivocal enlargement of heart (X-ray) 4.Presence of severe arrythmias, atrial fibrillation or flutter . 22. Risk of cardiovascular complications duringpregnancyRisk ofcardiovascularcomplications during pregnancyHigh riskLow risk Intermediate risk ofofof complicationscomplications ( 1%) complications (5-15%) or death (25%) 23. Low risk of complications ( 1%): Corrected tetralogy of fallot Atrial septal defect Ventricular septal defect Patent ductus arteriosus Mild pulmonic or tricuspid valve disease Mitral stenosis (NYHA class I, II) Mild regurgitant valve lesion Bioprosthetic valve Compensated heart failure (NYHA class I, II) 24. Intermediate risk of complications (5-15%): Mechanical valve prosthesis Aortic stenosis (mild to moderate) Mitral stenosis with atrial fibrillation Mitral stenosis (NYHA class III, IV) Uncorrected cyanotic congenital heart disease (tetralogy of fallot) Uncorrected coarctation of the aorta Previous myocardial infarction 25. High risk of complications or death (25%): Pulmonary hypertension (severe) Eisenminger syndrome Marfan disease with aortic root involvement Peripartum cardiomyopathy Severe aortic stenosis NYHA class IV heart failure 26. The indications for Termination ofpregnancy1. Eisenmengers syndrome.2. Marfans syndrome with aortic involvement3. Pulmonary hypertension.4. Coarctation of aorta with valvular involvement.Termination should be done before 12weeks of pregnancy. 27. The New York Heart Association (NYHA) Grading of functional capacity of the heart:No functional limitation of activitySymptoms with extraCLASS I ordinary physical work.Mild limitation of physical activity. Symptoms with ordinaryCLASS IIphysical workMarked limitation of physical Symptoms with less thanCLASS III activityordinary physical workCLASS IVSevere limitation of physical Symptoms at restactivity 28. Prognosis depends on the functional status NYHA classes I and II lesionsusually do well during pregnancy and have afavorable prognosis (mortality rate of