Gynecology April 1st

8/14/2019 Gynecology April 1st

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Pregnancy with internalmedical diseases

Department of

gynaecology and

obstetrics


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Cardiovascular changes in normalpregnancy

The major cardiocirulatorychanges that occur during normalpregnancy include an increase in

cardiac output and blood volumeand a decrease in peripheralresistance


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1.During normal pregnancy 6-8.5L of fluidand 500-900mmol of sodium are retainedbecause of the action of

progesterone renin aldosterone andprolactin A dilutional anemia occurs as adresult of the greater increase in plasmavolume relative to red cell mass

2. .renal blood flow increases by 30% and uterine blood flow reaches 500mL/min at

term 3. .hormonal changes include a rise in levels of

estrogen and progesterone renin


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4. Additional hemodynamic changes occurduring the various stage of labor and deliverydepend on the patients positon,the degree of

sedation, 5cardiac output increase by about 20% witheach uterine contraction as 300-500mL ofblood is expelled form the contractiong uterus.

6 systolic blood pressure also rises with eachcontractin,increasing the load on the leftventricle by 10%,while the heart ratefalls.pain,fear ,and anxiety contribute furtherto an increase in cardiac output.these chagesare less marke if the patient is in the lateral

decubitus position during labor or receivinge idural anesthesia.


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hemodyanmic and respiratory changes ofnormal pregnancy

Physiologic direction and time of time ofpeak

variable percent of change onset effect

weeks 1cardiac output increased 30-50 +-10 20-

30

2heart rate increased10-25 10-14 40 3blood volume increased25-50 6-10 32-36 4plasma volume increased 40-50 6-10 32 5red cellmass increased20-40 6-10 40

6blood pressure increased first trimester 20


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Physiologic direction and time of time of peak variable percent of change onset ffect weeks 7 pulmonary and increased40-30 6-10 20-24 peripheralvascular resistance 8 oxygen Consumption increased15-30 12-16 40 9 tidal volume increased40 6-10 40


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7the cardiac output as plasma volumeincrese by 20-60%because of a shift of

blood from the uterus as placenta intothe vascular space as well as resorptionof interstitial fluid .

8. .the hemodynamic changes of

pregnancy begin to regress shortly afterdelivery,and pre-pregnancy levels areusually reached within 2weekspostpartum ,but may take longer.


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9. The hemodynamic changes ofnormal pregnancy can result in

symptoms and signs that mimicthose of heart disease,oftenmaking it difficult to differentiate

the two


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Symptoms and signs of normal

pregnacy mimicking heart disease Clinical manifestations and mechanisms 1Palpitations /cardiac awareness -

increased heart rate;increased strokevolum,increased ectopy 2. Nasal stuffiness - vasodilatation, increased cutaneous blood flow

3. Dyspnea

shortness ofbreath orthopnea , --increasedprogesterone causing hyperventilationlow alveolar co2 tension

upward displacement of diaphragm


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4.Decreased exercise Tolerance easyfatigability - weight gain,lack ofexercise,increased cardiac output atrest limiting maximum cardiac outputincrease with exercise

5.Dizziness;lightheadedness; Syncope

---decreased venous return due tocompression of inferior vena cava byenlarged uterus and Increased venouscapacitance


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6epigastric or subxiphoid pain bloating heartburm displacement

of diaphragm,stomach,and liver bylarge uterus;decreasedgastrointestinal motility

Heat intolerance sweating andflushing ,--increased cutaneousblood flow and increased metabolic

rate


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signs 1. sinus tachycardia;ectopic beats (ventricular

,atrial )-- increased cardiac output; increasedo2demand;decreased

threshold for ectopic beats and arrhythmias 2. bounding pulses and capillary pulsations ----

increased cardiac output, decreased totalperipheral resistance;widened pulse pressure;

increased cutaneous blood flow 3. prominent jugular venous Pulsations--

increased cardiac output,decreased venoustone; right ventricular volume overload


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4. plethoric facies increased cutaneousblood flow

5. lateral displacement of cardiac apexmechanical,high diaphragm, right andleft ventricular volume overload

6. widely split s1and s2--increasedcardiac output,increased heart soundsvenous return,delayed right ventricularemptying


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7. third heart sound--increased cardiacoutput,,rapid filling of ventricles

8. systolic murmur (left sternal edge orprecordial) increased cardiacoutput,turbulent flow throughpulmonary valve, increased venous

return,increased mammary flow 9. continuous murmurs--venous

hum,mammary souffl,increased

venous distensibility


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10. varicose veins--obstruction ofinferior vena cava by

uterus,increased venousdistensibility


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4. ectopic beats supraventriculartachycardias decreased threshould

for ectopic beats and arrhythmias


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electrocardiogram leftward or rightward axis

nonspecific st-twave changes--

mechanical displacement ofshift,diaphragn, right ventricularvolume overload ,altered

sympathetic tone and alteredrepolarization sequence


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echocardiogram/lopplerultrasound

1.increased left and right ventricularend diastolic dimensions-increased

blood volume increased cardiac output 2. increased velocity of circumferential

increased ejectionfraction,hyperdynamic function

myocardial fiber shortening increased contractility,increased cardiac

output ,increased sympathetic tone


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symptoms and signs suggesting

significant cardiovascular disease 1. sever or progressive dyspnea and

orthopnea,especiallu at rest 2.paroxysmal nocturnal dyspnea,signs of pulmonary edema,cough,forthy pink sputum 3.effort syncope or chest pain 4.chronic cough ,hemoptysis 5.clubbing ,cyanosis,or persistent edema of extremities 6.increased jugular venous pressure,abnomal venous

pulsations

7 accentuated or barely audible first heart sound 8.fixed of paradoxic splitting of s2 ,single s2


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10 ejectionclick or late systolic click,opening snap

11.friction rub 12.systolic murmur of grace III Or II jor

gradeIV intensity or palpable thrill 13. any diastolic murmur cardiomegaly

with diffuse sustained right or left

ventricular heave 14electrocardiographic evidence of

significant arrhythmias


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etiology

cardiovasvular disease is the mostimportant nonobstetric cause ofdisability and death in pregnanct

women. it is not surprising that the added

hemodynamic burdren ofpregnancy,labor,and delivery can

aggravate symptoms and precipitatecomplications in a woman withpreexisting cardiacdisease.however,even a previouslyhealthy women may develop

cardiovascular problems specificallyrelated to re nanc


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classification .heart disease can be classified as

congenital or acquired operated or unoperated .Acquired diseases can be

infectious,autoimmune,

degenerative, malignant, oridiopathic.


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evaluation of the patient withheart disease

include a careful medical history

,complete physical examinaton noninvasive laboration test in order toestablish a diagnosis and to determinethe severity of the disease in order tofacilitate planning the patients

management the degree of functional disability is

graded according to the following newyork heart association classidication


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class I:no symptoms limitingordinary physical activity

classII slight limiting with mild tomoderate activity but no symptomsat rest

classIII marked limitation with lessthan ordinary activity ;dyspnea or

pain in minimal activity . classIX symptoms at rest or with

minimal activity and symptoms offrank congestive heart failure.


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Medical history physical examination laboratory test


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A electrocardiogram

B echocardiogram

C Doppler echocardiography

D exercise tolerance test


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A electrocardiogram

The electrocardiogram (ECG) is

useful for determiningabnormalities of rhythm and thepresence of conduction defects,

evidence of chamber enlargement,and signs of myocardial orpericardial diaease ,ischemian,or

infarction.


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B echocardiogram

The transthoracic (TTE) echocardiogram(both M and 2-dimensional secto scan) is arapid , safe and reliable tool for differntiation

the physiologic murmurs resulting from theincreased cardiac output of a normalpregnancy from the murmurs of congenitalor acquired heart disease.theechocardiogram can provide informationabout abnormalities of anatomy andfunction of the chambers,valves, andpericardium


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the echocardiogram can provideinformation about the patients

volume status and differentiatecardiac from noncardiac caused ofpulmonary edema that areimportant for diagnosis and

treatment


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C Doppler echocardiography

determination of bood flow andvelocity ,quantitation of pressure

gradients and the degree ofregurgitaiton,as well as formeasuring intracardiac shunts and

estimation of pulmonary pressure


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D exercise tolerance test

Exercise studies such as thetreadmill test are normally not

used during pregnancy, However,the may be useful in a

woman contemplatin pregnancy or

in early pregnancy


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E miscellaneous

1.a throat cuture to diagnose the presence ofbeta-hemolytic streptococcal infection

2.and a Creative protein and antistreptolysin

titer if antecedent streptococcal infection issuspected . 3.serial blood cultures are indicated if

infective endocarditis is suspected . 4.chest x-ray ,cardiac catheterization ,and

radioomuclide scans are generallu avordedduring pregnancy, since since the radiationcan be harmful to the fetus ,especially erly ingestation. however ,these tests can beperformed with careful shielding og theabdomen and pelvis ,if the mothers

condition requires it.


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Rheumatic heart disease

Active rheumatic carditis ,althoughrare during pregnancy,can be a

serious and potentially fatalcomplication.the diagnosis is based onthe jones criterial

1. evidence of a preceding group A

streptococcal infection 2. the minor criteria Included fever,

arthralgias ,elevated sedimentation

rate,and first degree heart block


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mitral valve disease

mitral stenosis is the most commonlesion in young women with rheumatic

heart disease 1..most patients with mild to moderate

stenosis who are in sinus rhythmtolerate pregnancy well ,although the

risk for superimposed infectiveendocarditis is ever present even inhemodynamically mild disease.


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4.new onset of atrial fibrillation in apreviously asymptomatic woman can

precipitate acute pulmonaryedema,which occasionally requiresemergency commissurotomy.

5.The normal hemodynamic changes of

pregnancy put patients with mitralstenosis is at special risk to raising leftatria pressure.and the onset of atriafibrillation .


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the pregnant cardiac patient isalso at the risk for the

development of thromboemboliccomplications because ofthe.hypercoagulable state of the

blood during pregnancy as well asvenous stasis in the leg


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A clinical findings 1.pulmonaty venous congestion

;dyspnea on exertion,and later atrest;right ventricular failure;atrialarrhythmias,andoccasionally,hemoptysis.fatigue and

decrease in exercise tolerance aremore often manifestations of mitralinsufficiency


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.the characteristic findings onphysical examination include a

right ventricular lift ,a loud firstheart shound(s-1),accentuatedpulmonic component of the second

heart sound (P-2),an opening snap(os),and alow frequency diastolicrumble at the apex with presystolicaccentuation


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The electrocardiogram is often normalbut may indicate left atrial enlargement

,right axis deviation ,or even rightventricularly useful for defining theanatomy of the valve and intravalvularstructure,quantitaiton the degree of

stenosis and associated regurgitation,and identifying the presence ofabnormalities in other valves andpulmonary artery pressure.


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treatment

1.The goals of treatment for thepatient with mitral stenosis should

be to prevent or treat tachycardiaand atrial fibrillation, to avoid fluidoverload ,and to avoid

unnecessary increases in oxygendemand such as occur with anxietyor physical activity.


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2. digitalis, quinidine,occasionall, sodium restriction anddiuretics may be necessary for treating congestivefailure and atrial arrhythmias

3anemia, intercurrent infection,and thyrotoxicosis

should be corrected. 3.1. cardiac surgery or balloonvalvuloplasty,although rarely necessary as an adjunctto careful medical management of patients with chronicrheumatic heart diseae,occasionally becomesnecessary as a life-saving maneuver in patientswith sever mitral stenosis

.3.2in an occasional patient ,mitral valvereplacement may be nesessary as an emergencyprocedure during pregnancy


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.4patients who have had a valve replaced witha prosthetic valve require anticoagulatin

.5the teratogenic and fetotoxic effects of

warfarin and the risks of bleeding for themother and fetus during labor and deliverymust be balanced against the risks ofthromboembolic episodes

6patient with rheumatic valvular disease shouldbe delivered vaginally at term unless cesareansection is indicated for obsteric reasons.

7appropriate analgesia should be given duringlabor ,and epidural


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8.1careful hemodynamic monitoringduring labor and delivery is inducated in

patient with compromised circulation. 8.2postpartum oxytocics should be

given cautiously and blood loss carefulymonitored

.8.3redistribution of fluid from theinterstitial to the intravascular spaceimmediately postpartum can precipitate

pulmonary edema in compromised


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infective endocarditis

Endocarditis is an acute or subacuteinflammatory process resulting from

blood-borne infection (streptococcus ) ,abnomal heart valves and the

endocardium in the proximity of

congenital anatomic defects arepreferential sites for involvement byblood-borne infection.


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.infected maternal from vegetations canembolize from right-sided lesion such as

the tricuspid valve to the lungs,andfrom left-sided lesion to the systemiccirculation

patients with endocardites often give a

history of recent extensive dental work,intravascular or urologicprocedures,cardiac,surgery,orintravenous illicit drug abuse


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Clinical findigs

The diagnosis is based on symptoms suchas persisitent fever sweats,weakness,andembolic phenomena ,both to the lungs and

to the periphery in an individual with riskfactors for endocarditis. .physical findings include petechial

hemorrhages,clubbing of the fingers andtoes,splenomegaly,oslernodes

the diagnosis is confirmed by the finding ofa positive blood culture or demonstrationof vegetations on the valves byechocardiography.


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prevention

Patients at risk for developinginfective endocarditis include those

with underlying congenital or acquiredvalvular heart disease and intravenousdurg abusers


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the clinical course is variable, .the disease may run an

acute,subacute ,or chronic cours ;beself limited with complete recovery ;orlead to progressive myocardial fibrosis

and eventually to cardiomyopathy

P i


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Peripartumcardiomyopathy

Peripartum cardiomyopathy isused to describe this form of

cardiac failure when the onsetoccurs in the last months ofpregnany or within 6 months

postpartum ,and no specificetiology or prior heart disease isidentified


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.The clinical manifestations are those ofright and left ventricular failure withpulmonary congestion,hepatomegaly

.low cardiac output,chestpain.hemoptysis and cough ,fatigue,dyspnea ,decreased exercisetolerance,edema,systolic murmurs,third

heart sound ,elevated jugular venouspressure,pulmonary rales,andcardiomegaly.

arrhyhmias and pulmonary as well as

systemic emboli are common


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the electrocardiographic changes arenonspecific

include arrhythmias ,low QRSvoltage,left ventricular hypertrophy,

on echocardiography,there is evidenceof enlargement of all

chambers,generalized decrease in wallmotion,reduced ejection fraction ,andoften mural thrombi


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Treatment and prognosis

.The prognosis depends on thedegree to which the cardiomegaly

is reversible with standardtreatment for congestive heartfailure,

use of anticoagulants are indicatedfor patients with intractable heartfailure and repeated embolic

episodes.


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In addition to controlling precipitatingor aggravating factors,the principles of

management of angina pectoris and ofmyocardial infarction in pregnantwomen do not differ from those in

nonpregnant patients


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women who have had a myocardialinfarction before or during pregnancy

should be delivery vaginally,if possiblewith epidura anesthesia and outletforceps to shorten the second stage of

labor.careful intrapartumhemodynamic monitoring may beindicated,


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Cyanotic or hypoxic congenital heartdisese in which unoxygenated

venous blood enters the systemiccirculation,such as tetralogy offallot,Eisenmengerscomplex,tricuspid atresia,pulmonary

atresia,single ventricle ,transpositionof the great arteries,and ebsterinsanomaly,complex lesion maycombine several of these features.


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.Operative procedures for correctionorpalliation are now available for almost

all of these defectis and are performedeven in small infants .

2.however,problems persist in most

patients becaues of residualinoperable lesionsand the needfor anticoagulation


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Patients with acyanotic congenital heart diseasetolerat pregnanyc well ,whether the heart disease hasbeen surgically corrected or not ,and have a lowincidence of spontaeous abortions and premature

labor.

however,patients with class II-IV severity at the onsetof pregnancy have a high incidence of spontaneousabortions and stillbirths ,and interruption of pregnancy

or postponement until a corrective or palliativeprocedure can be performed for cardiac indicationsmay be required.in patients with congestive heartfailure or large intracardiac shunts,pregnancy is notwell tolerated


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1. atrial septal defect Ostium secundum atrial septal

defect ,one of the most commonforms of congenital heartdisease,is well tolerated by most

wonen


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.the electrocardiogram is more likely toshow left axis deviation,although the

incomplete right bundle branch blockmay be present as well the echocardiogaram and color flow

doppler studies are useful to define the

location of the atrial septal defect andthe degree of involvement of the mitraland tricuspid valves.


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2.ventricualar septal defect Isolated centicualr septal defect tend to close spontaneously before

the woman reaches adulthood.womenwith small to moderatesized

ventricular septal defects toleratepregnancy well,a


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3.pulmonic valve stenosis is well tolerated ifthe gradient across the pulmonary valve isless than 80mmHg,since the valve continuesto enlarge in relation to body mass.

women with a high transvalvular gradientand right ventricular hypertrophy,,the risk of

right ventricualr failure and atrialarrhythmias is increased,and assisteddelivery is recommeded


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4.coarctation of the aorta Coarctation of the aorta result in hypertesion

of the arms with lower pressures in thelegs.pregnant patients are at incresasedheart failure.

.endocardiits prophlyaxis is required for

delivery ,even in operated cases ,and bloodpressure control must be carefullymaintained.


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5.cyanotic congeital heart diseas In women with cyanotic congeitalheart

disease,both maternal and fetalmorbidituy and mortalit rates arehigh.the incidence od spontaneous

abortions,stiilbirths ,prematurity ,andlow birhweight is high


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pulmonary hypertesion

The commen cause of pulmonaryhypertension are as follows

increased resistance to pulmonary blood flow

at any of several sites in the pulmonaryvascular bed.this may be due to multiplepulmonary emboli,primary pulmonary vasculardisease,takayasus arteritis,or infestation withschistosomes or filariae

increased pulmonary blood flow as in left-to right intrtaor extracardiac shunts with thedevelopment of secondary pulmonary vasulardiaease


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increased resistance to pulmonary venousdrainage,as in increased left ventricular end diastolic pressure,left ventricular failure,ormitral stenosis

pulmonary parenchymal disorders such assarcoid or chronic fobrosis

hypoventilation sydromes chromic hypoxia,as in high altitude dwellwes

or heavy cigarette smokers patient with large intracardiac left-to right

shunts eventually develop irreversiblestructual changeds and obilerative pulmonaryvascular disease in response to the increasedpulmonary flow.


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the cardiac defect does not relieve thepulmonary hypertension and because

there is a high rate of operative andpostoperative mortality due to rightventricular failure. early in pregnancy

because of the added hemodynamicload


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patients with pulmonaryhypertension should be counseled

against becoming pregnant orshould be advised to have an earlyinduced aborion

When pregnancy occur and iscontinued,patients should avoid allunnecessary exertion,especially inthe third trimester


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patiens should be delivered vaginallyunder epidural anesthesia,with closeand continued hemodynamic monitoringIn an intensive care unit .closeobservation must continous for at least3-5days postpartum,although

compoications and even death canoccur as late as 3-2weeks after delivery,as the normal postpartumhemodymamic changes occur.

G l t f


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General management ofheart disease in pregnancy

1.established a diagnosis of heartdisease and assess the severity andfunctional status with appropriate

noninvasive diagnostic studies

preferablythose that do not involved ionizingradiation

2.establish a method of regular follow-upclose surveillance and consultation witha cardiologist and other supportingpersonnel

3.reduce unnecessary cardiac work byensuring regular rest and by avoidance ofexcess exertion ,heat and humidity.


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4.Make certain that the patient receives anadequate diet ,avoids excessive weightgain,and complies with a regimen of

moderate sodium restriction whenindicated.

5.Treat intercurrent infections,anemia ,fevers,thyrotoxicosis,and other

disorders 6.Treat paroxysmal arrhythmias with

appropriate drugs or DCcardioversion;prevent recuring arrhythmias

with approved antiarrhythmic drugs


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7.In parients with chronic atrialfibrillation,large left atrium,prostheticvalves,or recurring thromboembolism who

require anticoagulant therapy,switch fromoral anticoagualnts containing coumarintype drugs to subcutaneous heparin.

8.Treat chronic venous insufficiency withwellfitting elasticized support hose.

9.Theat congestive heart failure with bedrest ,digitalis ,and diuretics,and treatprecipitating factors if recognized.


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Fetal echocardiography after20weeks of gestation is a useful

technique for detecting fetalcardiac abnormalities,especially inwomen with congenital heartdiaease or prior offsping with

anomalies .the finding of anabnormality can be helpful inplanning perinatal manegment ofth f t

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Gynecology April 1st