Overview of Cardiac issues of Pregnancy

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Contents

Background

  • CV disease complicates 1- 4% of all pregnancies
  • Together with DVT/PE has surpassed hemorrhage, infection, and hypertensive disorders as leading cause of maternal mortality (20-30%)
  • Increasing #s of women with congenital heart disease reaching childbearing age


Historical Background

  • Experience of CHF in Pregnancy - Michel Peter 1874
  • “On the Bearing of Chronic Disease of the Heart Upon Pregnancy and Parturition” - Angus MacDonald 1877
  • “Heart Disease and Pregnancy” - James Mackenzie 1878
  • “Heart Disease and Pregnancy” - William Breed and Paul Dudley White 1923
  • “Atlas of Congenital Heart Disease” - Maude Abbott 1936


Hemodynamic Changes of Pregnancy

  • Blood Volume
  1. Plasma volume expands by 40-50%
    1. Steroid hormone and prostaglandin secretion
    2. Sodium retention of 500-1000 meq
    3. Average 8.5 liter increase in total body water
  2. Red blood cell volume increases by 30%
  • Cardiac output increases by 30-50%
  1. Increased endogenous catecholamines
    1. HR rises by 10-20 beats/min
    2. Stroke volume increases
  2. Compression by uterus can counteract
  • Systemic vascular resistance falls
  1. Placenta serves as large AV shunt
  2. Endothelial prostacyclin and circulating progesterone
  • Small changes in systemic BP
  1. Slight fall in systolic BP
  • Larger decrease in diastolic BP
  1. Vascular changes
  2. Estrogen may lessen collagen deposition
  3. Circulating elastase may break up elastic lamellae
  • Respiratory changes
  1. Compensated respiratory alkalosis
  2. Increased maternal 2,3 DPG

Labor, Delivery and Post-partum Period

  • 300-500 cc “transfusion” with each contraction
  • HR and BP increase with pain and anxiety
  • Maternal blood loss
  1. 300-400 cc with vaginal delivery
  2. 500-800 cc with C-section
  • Relief of compression by gravid uterus

Possible Symptoms in the Normal Pregnant Patient

  • Fatigue
  • Dyspnea on exertion
  • Orthopnea
  • Lower extremity edema
  • Presyncope
  • Palpitations

CV Exam of the Normal Pregnant Patient

  • Mild resting tachycardia
  • Bounding pulses with slightly widened pulse pressure
  • Prominent jugular venous pulsations
  • Third heart sound
  • Bibasilar crackles (atelectasis from compression by gravid uterus)
  • Systolic flow murmur over pulmonic area
  • Prominent, laterally displaced PMI
  • Lower extremity edema
  • Cervical venous hum
  • Mammary soufflé (late term/ lactation)

Echo exam of the normal pregnant patient

  • Mild ventricular enlargement
  • Diastolic dimension most evident
  • EF preserved
  • PR and TR (low pressure) is common
  • Small pericardial effusion
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