Pregnancy with internal

medical diseases

Department of
gynaecology and
obstetrics
 Cardiovascular changes in normal
pregnancy
 The major cardiocirulatory
changes that occur during normal
pregnancy include an increase in
cardiac output and blood volume
and a decrease in peripheral
resistance 。
 1.During normal pregnancy ， 6-8.5L of fluid
and 500-900mmol of sodium are retained
because of the action of
progesterone ， renin ， aldosterone ， and
prolactin 。 A dilutional anemia occurs as a
dresult of the greater increase in plasma
volume 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
 4. Additional hemodynamic changes occur
during the various stage of labor and delivery
depend on the patient’s positon,the degree of
sedation,
 5cardiac output increase by about 20% with
each uterine contraction as 300-500mL of
blood is expelled form the contractiong uterus
.
 6 systolic blood pressure also rises with each
contractin,increasing the load on the left
ventricle by 10%,while the heart rate
falls.pain,fear ,and anxiety contribute further
to an increase in cardiac output.these chages
are less marke if the patient is in the lateral
decubitus position during labor or receiving
epidural anesthesia.
 hemodyanmic and respiratory changes of
normal pregnancy
 Physiologic direction and time of time of
peak
 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
 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
 7the cardiac output as plasma volume
increse by 20-60%because of a shift of
blood from the uterus as placenta into
the vascular space as well as resorption
of interstitial fluid .
 8. .the hemodynamic changes of
pregnancy begin to regress shortly after
delivery,and pre-pregnancy levels are
usually reached within 2weeks
postpartum ,but may take longer.
 9. The hemodynamic changes of
normal pregnancy can result in
symptoms and signs that mimic
those of heart disease,often
making it difficult to differentiate
the two
 Symptoms and signs of normal
pregnacy mimicking heart disease
 Clinical manifestations and mechanisms
 1Palpitations /cardiac awareness -
 increased heart rate;increased stroke
volum,increased ectopy
 2. Nasal stuffiness - vasodilatation,
 increased cutaneous blood flow
 3. Dyspnea ， shortness of
breath ， orthopnea , --increased
progesterone causing hyperventilation
low alveolar co2 tension
upward displacement of diaphragm
 4.Decreased exercise Tolerance ， easy
fatigability - weight gain,lack of
exercise,increased cardiac output at
rest ， limiting maximum cardiac output
increase with exercise
 5.Dizziness;lightheadedness; Syncope
 ---decreased venous return due to
compression of inferior vena cava by
enlarged uterus and Increased venous
capacitance
 6epigastric or subxiphoid pain ，
bloating heartburm – displacement
of diaphragm,stomach,and liver by
large uterus;decreased
gastrointestinal motility
 Heat intolerance ， sweating and
flushing ,--increased cutaneous
blood flow and increased metabolic
rate
signs
 1. sinus tachycardia;ectopic beats (ventricular
,atrial )-- increased cardiac output; increased
o2demand;decreased
threshold for ectopic beats and arrhythmias
 2. bounding pulses and capillary pulsations ----

increased cardiac output, decreased total

peripheral resistance;widened pulse pressure;
increased cutaneous blood flow
 3. prominent jugular venous Pulsations--

increased cardiac output,decreased venous

tone; right ventricular volume overload
 4. plethoric facies increased cutaneous
blood flow
 5. lateral displacement of cardiac apex
mechanical,high diaphragm, right and
left ventricular volume overload
 6. widely split s1and s2--increased
cardiac output,increased heart sounds
venous return,delayed right ventricular
emptying
 7. third heart sound--increased cardiac
output,,rapid filling of ventricles
 8. systolic murmur (left sternal edge or
precordial) increased cardiac
output,turbulent flow through
pulmonary valve, increased venous
return,increased mammary flow
 9. continuous murmurs--venous
hum,mammary soufflé,increased
venous distensibility
 10. varicose veins--obstruction of
inferior vena cava by
uterus,increased venous
distensibility
clinical manifestations mechanisms

 1. capillary telangiectases--increased
estrogen level and I ncreased venous
distensibility
 2. pulmonary rales --atelectasis due to
hypoventilation of lung bases because
of displacement of diaphragm
 3. edema(legs,occasionally hands and
face) mechanical obstruction of inferior
vena by uterus,increased venous
pressure in legs
 ectopic beats supraventricular
tachycardias --decreased
threshould for ectopic beats and
arrhythmias
 4. ectopic beats supraventricular
tachycardias decreased threshould
for ectopic beats and arrhythmias
electrocardiogram
 leftward or rightward axis
nonspecific st-twave changes--
mechanical displacement of
shift,diaphragn, right ventricular
volume overload ,altered
sympathetic tone and altered
repolarization sequence
echocardiogram/loppler
ultrasound
 1.increased left and right ventricular
end diastolic dimensions-increased
blood volume increased cardiac output
 2. increased velocity of circumferential
increased ejection
fraction,hyperdynamic function–
myocardial fiber shortening
 increased contractility,increased cardiac
output ,increased sympathetic tone
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
 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
etiology
 cardiovasvular disease is the most
important nonobstetric cause of
disability and death in pregnanct
women.
 it is not surprising that the added
hemodynamic burdren of
pregnancy,labor,and delivery can
aggravate symptoms and precipitate
complications in a woman with
preexisting cardiac
disease.however,even a previously
healthy women may develop
cardiovascular problems specifically
classification
 .heart disease can be classified as
congenital or acquired
 operated or unoperated
 .Acquired diseases can be
infectious,autoimmune,
degenerative, malignant, or
idiopathic.
evaluation of the patient with
heart disease
 include
 a careful medical history
 ,complete physical examinaton
 noninvasive laboration test in order to
establish a diagnosis and to determine
the severity of the disease in order to
facilitate planning the patient’s
management
 the degree of functional disability is
graded according to the following new
york heart association classidication
 class I:no symptoms limiting
ordinary physical activity
 classII slight limiting with mild to
moderate activity but no symptoms
at rest
 classIII marked limitation with less
than ordinary activity ;dyspnea or
pain in minimal activity .
 classIX symptoms at rest or with
minimal activity and symptoms of
frank congestive heart failure.
 Medical history
 physical examination
 laboratory test
 A electrocardiogram
 B echocardiogram
 C Doppler echocardiography
 D exercise tolerance test
 A electrocardiogram
 The electrocardiogram (ECG) is
useful for determining
abnormalities of rhythm and the
presence of conduction defects,
evidence of chamber enlargement,
and signs of myocardial or
pericardial diaease ,ischemian,or
infarction.
 B echocardiogram
 The transthoracic (TTE) echocardiogram
(both M and 2-dimensional secto scan) is a
rapid , safe and reliable tool for differntiation
the physiologic murmurs resulting from the
increased cardiac output of a normal
pregnancy from the murmurs of congenital
or acquired heart disease.the
echocardiogram can provide information
about abnormalities of anatomy and
function of the chambers,valves, and
pericardium
 the echocardiogram can provide
information about the patient’s
volume status and differentiate
cardiac from noncardiac caused of
pulmonary edema that are
important for diagnosis and
treatment
C Doppler echocardiography
 determination of bood flow and
velocity ,quantitation of pressure
gradients and the degree of
regurgitaiton,as well as for
measuring intracardiac shunts and
estimation of pulmonary pressure
D exercise tolerance test
 Exercise studies such as the
treadmill test are normally not
used during pregnancy,
 However,the may be useful in a
woman contemplatin pregnancy or
in early pregnancy
E miscellaneous
 1.a throat cuture to diagnose the presence of
beta-hemolytic streptococcal infection
 2.and a Creative protein and antistreptolysin
titer if antecedent streptococcal infection is
suspected .
 3.serial blood cultures are indicated if
infective endocarditis is suspected .
 4.chest x-ray ,cardiac catheterization ,and
radioomuclide scans are generallu avorded
during pregnancy, since since the radiation
can be harmful to the fetus ,especially erly in
gestation. however ,these tests can be
performed with careful shielding og the
abdomen and pelvis ,if the mother’s
condition requires it.
Rheumatic heart disease
 Active rheumatic carditis ,although
rare during pregnancy,can be a
serious and potentially fatal
complication.the diagnosis is based on
the 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 。
mitral valve disease
 mitral stenosis is the most common
lesion in young women with rheumatic
heart disease
 1..most patients with mild to moderate
stenosis who are in sinus rhythm
tolerate pregnancy well ,although the
risk for superimposed infective
endocarditis is ever present even in
hemodynamically mild disease.
 .2.those with moderate to severe
disease are more likely to develop
complication such as pulmonary
venous congestion or frank pulmonary
edema,right ventricular hypertension
 3. .however,sudden and unexpected
deterioration can occasionalluy occur
during pregnancy in patients with any
degree of mitral stenosis
 4.new onset of atrial fibrillation in a
previously asymptomatic woman can
precipitate acute pulmonary
edema,which occasionally requires
emergency commissurotomy.
 5.The normal hemodynamic changes of
pregnancy put patients with mitral
stenosis is at special risk to raising left
atria pressure.and the onset of atria
fibrillation .
 the pregnant cardiac patient is
also at the risk for the
development of thromboembolic
complications because of
the.hypercoagulable state of the
blood during pregnancy as well as
venous stasis in the leg
 A clinical findings
 1.pulmonaty venous congestion
;dyspnea on exertion,and later at
rest;right ventricular failure;atrial
arrhythmias,and
occasionally,hemoptysis.fatigue and
decrease in exercise tolerance are
more often manifestations of mitral
insufficiency
 .the characteristic findings on
physical examination include a
right ventricular lift ,a loud first
heart shound(s-1),accentuated
pulmonic component of the second
heart sound (P-2),an opening snap
(os),and alow frequency diastolic
rumble at the apex with presystolic
accentuation
 The electrocardiogram is often normal
but may indicate left atrial enlargement
,right axis deviation ,or even right
ventricularly useful for defining the
anatomy of the valve and intravalvular
structure,quantitaiton the degree of
stenosis and associated regurgitation
,and identifying the presence of
abnormalities in other valves and
pulmonary artery pressure.
treatment
 1.The goals of treatment for the
patient with mitral stenosis should
be to prevent or treat tachycardia
and atrial fibrillation, to avoid fluid
overload ,and to avoid
unnecessary increases in oxygen
demand such as occur with anxiety
or physical activity.
 2. digitalis, quinidine,occasionall, sodium restriction and
diuretics may be necessary for treating congestive
failure and atrial arrhythmias
 3anemia, intercurrent infection,and thyrotoxicosis
should be corrected.
 3.1. cardiac surgery or balloon
valvuloplasty,although rarely necessary as an adjunct
to careful medical management of patients with chronic
rheumatic heart diseae,occasionally becomes
necessary as a life-saving maneuver in patients
with sever mitral stenosis
 .3.2in an occasional patient ,mitral valve
replacement may be nesessary as an emergency
procedure during pregnancy
 .4patients who have had a valve replaced with
a prosthetic valve require anticoagulatin
 .5the teratogenic and fetotoxic effects of
warfarin and the risks of bleeding for the
mother and fetus during labor and delivery
must be balanced against the risks of
thromboembolic episodes
 6patient with rheumatic valvular disease should
be delivered vaginally at term unless cesarean
section is indicated for obsteric reasons.
 7appropriate analgesia should be given during
labor ,and epidural
 8.1careful hemodynamic monitoring
during labor and delivery is inducated in
patient with compromised circulation.
 8.2postpartum oxytocics should be
given cautiously and blood loss carefuly
monitored
 .8.3redistribution of fluid from the
interstitial to the intravascular space
immediately postpartum can precipitate
pulmonary edema in compromised
 infective endocarditis
 Endocarditis is an acute or subacute
inflammatory process resulting from
blood-borne infection (streptococcus )
 ,abnomal heart valves and the
endocardium in the proximity of
congenital anatomic defects are
preferential sites for involvement by
blood-borne infection.
 .infected maternal from vegetations can
embolize from right-sided lesion such as
the tricuspid valve to the lungs,and
from left-sided lesion to the systemic
circulation
 patients with endocardites often give a
history of recent extensive dental work
,intravascular or urologic
procedures,cardiac,surgery,or
intravenous illicit drug abuse
 Clinical findigs
 The diagnosis is based on symptoms such
as persisitent fever sweats,weakness,and
embolic phenomena ,both to the lungs and
to the periphery in an individual with risk
factors for endocarditis.
 .physical findings include petechial
hemorrhages,clubbing of the fingers and
toes,splenomegaly,osler’nodes
 the diagnosis is confirmed by the finding of
a positive blood culture or demonstration
of vegetations on the valves by
echocardiography.
 prevention
 Patients at risk for developing
infective endocarditis include those
with underlying congenital or acquired
valvular heart disease and intravenous
durg abusers
 Myocarditis
 Acute inflammation of the
myocardium may be due to rheumatic
fever , such as infecion with group B
.coxsackie viruses or protozoal disease
.
 the myocarditis may be acute or
subacute,may be associated with
symptoms of systemic illness,and may
occur at any time.during pregnancy,
 .the clinical manifestations are those of
chest pain fever pulmonary
rales,tachycardia,edema,and systolic
murmurs and gallops on physical
examination;as well as
cardiomegaly,reduced ventricular
function,conduction defects ,and arrythmias
on electrocardiogaraphy and
echocardiography.
 4.specific serologic and bacteriologic tests
may reveal the identity of the initiation
 the clinical course is variable,
 .the disease may run an
acute,subacute ,or chronic cours ;be
self –limited with complete recovery ;or
lead to progressive myocardial fibrosis
and eventually to cardiomyopathy
Peripartum
cardiomyopathy
 Peripartum cardiomyopathy is
used to describe this form of
cardiac failure when the onset
occurs in the last months of
pregnany or within 6 months
postpartum ,and no specific
etiology or prior heart disease is
identified
 .The clinical manifestations are those of
right and left ventricular failure with
pulmonary congestion,hepatomegaly
.low cardiac output,chest
pain.hemoptysis and cough ,fatigue
,dyspnea ,decreased exercise
tolerance,edema,systolic murmurs,third
heart sound ,elevated jugular venous
pressure,pulmonary rales,and
cardiomegaly.
 arrhyhmias and pulmonary as well as
systemic emboli are common
 the electrocardiographic changes are
nonspecific
 include arrhythmias ,low QRS
voltage,left ventricular hypertrophy,
 on echocardiography,there is evidence
of enlargement of all
chambers,generalized decrease in wall
motion,reduced ejection fraction ,and
often mural thrombi
Treatment and prognosis
 .The prognosis depends on the
degree to which the cardiomegaly
is reversible with standard
treatment for congestive heart
failure,
 use of anticoagulants are indicated
for patients with intractable heart
failure and repeated embolic
episodes.
 In addition to controlling precipitating
or aggravating factors,the principles of
management of angina pectoris and of
myocardial infarction in pregnant
women do not differ from those in
nonpregnant patients
 smoking should be forbidden and
other risk factiors meticulously
controlled.
 control of hypertension treatment of
hypotension,.standard therapy to
reduce oxygen demands and to
improve myocardial perfusion include
bed rest
 women who have had a myocardial
infarction before or during pregnancy
should be delivery vaginally,if possible
with epidura anesthesia and outlet
forceps to shorten the second stage of
labor.careful intrapartum
hemodynamic monitoring may be
indicated,
 Congenital heart
disease
 .the common congenital cardiac
anomalies can be broadly grouped under
various categories such as cyanotic or
acyanotic ,simple or complex,mild or
severe,and compatible with a normal
pregnancy or a contraindication for
pregnancy.
 obstructive lesions of the right or left
ventricular outflow tract that result in
pressure overload of the ventricle,such as
pulmonary stenosis,or coarcation of the
aorta
 left to right shunts resultingin ventricular
volume overload and increased pulmonary
blood flow,such as atrial septal
defect,atrioventricular canal,ventricualr
septal defect,endocardial cushion
defect,patent ductus arteriosus,and truncus
arteriosus.
 Cyanotic or hypoxic congenital heart
disese in which unoxygenated
venous blood enters the systemic
circulation,such as tetralogy of
fallot,Eisenmenger’s
complex,tricuspid atresia,pulmonary
atresia,single ventricle ,transposition
of the great arteries,and ebsterin’s
anomaly,complex lesion may
combine several of these features.
 .Operative procedures for correctionor
palliation are now available for almost
all of these defectis and are performed
even in small infants .
 2.however,problems persist in most
patients becaues of residual
inoperable lesions and the need
for anticoagulation
 Patients with acyanotic congenital heart disease
tolerat pregnanyc well ,whether the heart disease has
been surgically corrected or not ,and have a low
incidence of spontaeous abortions and premature
labor.

 however,patients with class II-IV severity at the onset

of pregnancy have a high incidence of spontaneous
abortions and stillbirths ,and interruption of pregnancy
or postponement until a corrective or palliative
procedure can be performed for cardiac indications
may be required.in patients with congestive heart
failure or large intracardiac shunts,pregnancy is not
well tolerated
 1. atrial septal defect
 Ostium secundum atrial septal
defect ,one of the most common
forms of congenital heart
disease,is well tolerated by most
wonen

 .the electrocardiogram is more likely to
show left axis deviation,although the
incomplete right bundle branch block
may be present as well
 the echocardiogaram and color flow
doppler studies are useful to define the
location of the atrial septal defect and
the degree of involvement of the mitral
and tricuspid valves.
 2.ventricualar septal defect
 Isolated centicualr septal defect
 tend to close spontaneously before
the woman reaches adulthood.women
with small to moderatesized
ventricular septal defects tolerate
pregnancy well,a
 the electrocardiogram may be normal
or show left ventricular
hypertrophy,while the
echocardiogram and doppler studies
identify the magnitude of the shunt
and size of the ductus,as well as the
degree of ventricular hypetrophy.
 3.pulmonic valve stenosis is well tolerated if
the gradient across the pulmonary valve is
less than 80mmHg,since the valve continues
to enlarge in relation to body mass.
 women with a high transvalvular gradient
and right ventricular hypertrophy,,the risk of
right ventricualr failure and atrial
arrhythmias is increased,and assisted
delivery is recommeded
 4.coarctation of the aorta
 Coarctation of the aorta result in hypertesion
of the arms with lower pressures in the
legs.pregnant patients are at incresased
heart failure.
 .endocardiits prophlyaxis is required for
delivery ,even in operated cases ,and blood
pressure control must be carefully
maintained.
 5.cyanotic congeital heart diseas
 In women with cyanotic congeitalheart
disease,both maternal and fetal
morbidituy and mortalit rates are
high.the incidence od spontaneous
abortions,stiilbirths ,prematurity ,and
low birhweight is high
pulmonary hypertesion
 The commen cause of pulmonary
hypertension are as follows
 increased resistance to pulmonary blood flow
at any of several sites in the pulmonary
vascular bed.this may be due to multiple
pulmonary emboli,primary pulmonary vascular
disease,takayasu’s arteritis,or infestation with
schistosomes or filariae
 increased pulmonary blood flow as in left-to –
right intrtaor extracardiac shunts with the
development of secondary pulmonary vasular
diaease
 increased resistance to pulmonary venous
drainage,as in increased left ventricular end –
diastolic pressure,left ventricular failure,or
mitral stenosis
 pulmonary parenchymal disorders such as
sarcoid 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 irreversible
structual changeds and obilerative pulmonary
vascular disease in response to the increased
pulmonary flow.
 the cardiac defect does not relieve the
pulmonary hypertension and because
there is a high rate of operative and
postoperative mortality due to right
ventricular failure. early in pregnancy
because of the added hemodynamic
load
 patients with pulmonary
hypertension should be counseled
against becoming pregnant or
should be advised to have an early
induced aborion
 When pregnancy occur and is
continued,patients should avoid all
unnecessary exertion,especially in
the third trimester
 patiens should be delivered vaginally
under epidural anesthesia,with close
and continued hemodynamic monitoring
In an intensive care unit .close
observation must continous for at least
3-5days postpartum,although
compoications and even death can
occur as late as 3-2weeks after delivery
,as the normal postpartum
hemodymamic changes occur.
 General management of
heart disease in pregnancy
 1.established a diagnosis of heart
disease ， and assess the severity and
functional status with appropriate
noninvasive diagnostic studies ， preferably
those that do not involved ionizing
radiation 。
 2.establish a method of regular follow-up ，
close surveillance ， and consultation with
a cardiologist and other supporting
personnel 。
 3.reduce unnecessary cardiac work by
ensuring regular rest and by avoidance of
excess exertion ,heat and humidity.
 4.Make certain that the patient receives an
adequate diet ,avoids excessive weight
gain,and complies with a regimen of
moderate sodium restriction when
indicated.
 5.Treat intercurrent infections
,anemia ,fevers,thyrotoxicosis,and other
disorders
 6.Treat paroxysmal arrhythmias with
appropriate drugs or DC
cardioversion;prevent recuring arrhythmias
with approved antiarrhythmic drugs
 7.In parients with chronic atrial
fibrillation,large left atrium,prosthetic
valves,or recurring thromboembolism who
require anticoagulant therapy,switch from
oral anticoagualnts containing coumarin
type drugs to subcutaneous heparin.
 8.Treat chronic venous insufficiency with
wellfitting elasticized support hose.
 9.Theat congestive heart failure with bed
rest ,digitalis ,and diuretics,and treat
precipitating factors if recognized.
 10Provide prophylaxi against infective
endocarditis at the time of delivery
 11In women with compromised caridac
function,provde carefeul hemodynamic
monitoring of both the mother and the fetus
during labor and delivery and in the postpartum
period.in patients with pulmonary
hypertension,heart failure ,or major arrhythmias
,continue postpartum monitoring for 4-5days to
avoid late complications
 12To decrease the work of bearing down and
associated pain and
 anxiety ,provide epidural anesthesia for
delivery and use outlet forceps to shorten the
third stage of labor
 13Operative valvotomy or valve replacement
is rarely necessary during pregnancy and may
be forestalled with the less invasive technique
of balloon valvotomy ,but should be
considered at any time during pregnancy
(inconsultation with a cardiologist and cardiac
surgeon )if raipid deterioration occurs ,if a
prosthetic valve fails ,or if an emergency
compocaiton develops.
 Fetal echocardiography after
20weeks of gestation is a useful
technique for detecting fetal
cardiac abnormalities,especially in
women with congenital heart
diaease or prior offsping with
anomalies .the finding of an
abnormality can be helpful in
planning perinatal manegment of
the fetus