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Valvular Heart Disease in Pregnancy

Jan 28 | 1:30 PM

Significant hemodynamic changes occur during pregnancy, which can lead to decompensation in the setting of severe valvular disease. Cardiac output increases by 30-50% due to increased stroke volume and, to a lesser extent, increased heart rate later in pregnancy. Pregnancy is accompanied by physiologic anemia due to greater expansion in plasma volume than in red blood cell mass. Together, these changes lead to increased flow, and thus increased gradients, across pre-existing valvular lesions. Let's understand these dynamics of valvular heart diseases in pregnancy with Dr. Munjal Pandya.

[Music] good evening everyone uh i am dr rucha uh i welcome you all on behalf of team netflix and we are back with one interesting uh discussion uh on velvet heart disease in pregnancy uh we have dr munjal pandya with us uh welcome sir and it's honor to have you and have such great discussions again uh so sir is uh assistant professors at amc uh mit medical college he is honorary secretary of department gynecology society uh m so uh over to you sir uh i won't take much time thank you thank you so much uh good evening all the respected uh delegates and my flix team for giving me this opportunity and uh i would try to highlight the saline features with regards to well welfare heart disease and you know we'll have a discussion in the end hopefully thank you so can we have the presentation please so uh as an obstetrician it is actually a challenge to deal with any kind of medical disorder mainly respiratory and cardiac uh most of the times follow practical purposes as well as for medical legal aspects we would refer such patients to the physician or the specialist super specialist whenever needed but from our side when it comes to counseling that particular patient that patient belongs to us most of the times so the patient would require the explanation as well as we would uh require uh the looking up of uh why and where and how to proceed are the questions we need to have in your mind as well so to begin with uh i would uh say that voluminous heart disease is uh actually the quarter of cardiac diseases in pregnancy an important cause of maternal mortality when it comes to medical disorders uh developing countries have a huge number of childhood rheumatic diseases which are not um you know unearthed till the stress or physical stress uh comes into the picture and then the problem starts where uh the treatment would be there but still at the most of the times they you know stay undiagnosed leading to consequences uh future consequences when it comes to rheumatic heart disease more than 15 million people suffer from rhd globally causing more than four lacks of deaths annually which is a huge number and many of them stay undiagnosed when it comes to diseases and there are stenotic and regurgitant lesions uh with regards to walls the stenotic ones are not much very much well tolerated from the by the patient and the regurgitants uh stay you know in the range of well tolerated valvular heart disease where the symptoms you know precipitate late or many times do not precipitate at all with regards to physiological changes we know that the cardiac output and blood volume rises to approximately 50 percent of the pre-pregnancy state at around 32 weeks of gestation after which it plateaus as we can see from the figure the labor and delivery time is something where the cardiac output again rises now this particular rise is of because of two basic reasons one there will be pumping of blood from the uterine sinuses into the vascular compartment due to each uterine contraction at the same time there will be rise in catecholamine levels due to labor pains now this catecholamine increase would lead to more of fossil constriction and more burden as well on the heart later on after delivery the postpartum phase is very much important with regards to two major factors one sepsis and the other anemia both of them will aggravate the condition will add up to the load on the heart maternal heart even after delivery so we need to keep in mind a lot of points while dealing with this kind of patients coming on to stinotic lesions the mitral stenosis are poorly tolerated in pregnancy leading cardiac cause of maternal mortality uh the finding might be incidental but it will be helpful with regards to prevention of future consequences clinical features would have exertional listening postural symptoms mid diastolic rumbling murmur at the apex but may be difficult to diagnose in patients with pulmonary edema and rapid tachycardia we need to keep in mind that any kind of systolic murmur may be physiological maybe pathological but any kind of diastolic murmur is always always and always pathological so we need to filter out with regards to those murmurs radiological signs there will be enlarged left atrium and the ecg would show bifid p wave uh in addition to all the physiological normal ecg changes with regards to third trimester there will be increase in systemic vascular resistance this particular resistance will lead to more load on the heart in form of more pressure on left sided heart that is left atrium and left ventricle in labor and immediate postpartum phase there will be hyper dynamic circulation again adding up to the load on the heart when there is significant mitral stenosis that particular stenosis will lead to more of left atrial dilatation now this particular left atrial dilatation along with hyperdynamic circulation will lead to increased chances of thromboembolic events and that is why we are concerned about those kind of mitral stenosis and their categorization there will be higher rates of preterm delivery and intrauterine growth restriction of fetus the principles of medical management will be to reduce the heart rate so that the heart rate is reduced the left atrium will have more time to get filled up and the oxygenation of the tissues will be maintained with faster heart rate it will be difficult for left atrium and ventricle to get filled up with proper amount of blood that is required for the body so in microstenosis there are two things one reduction in afterload which will actually uh which will actually lead to reflex tachycardia which will again decrease the time of left ventricular and atrial feeling and that is why we want to avoid reduction in afterload at the same time there will be reduction in preload due to mitral stenosis which will again reduce the after load so that will be a vicious cycle we need to keep in mind that particular balance of maintaining preload as well as after load with regards to severe mitral stenosis it is tempted ball area less than one centimeter square we can go for percutaneous balloon volvuloplasty majorly in the second trimester at least before 20 weeks of gestation with regards to moderate mitosis we have all the options open the fitness for mitral valve tommy would require ecocardiographic because we need to know the mobility thickness and degree of calcification of the leaflets the classification of commissures or significant mitral regurgitation are generally unsuitable for such procedures and if percutaneous valvuloplasty is not available closed commissioner tummy remains an alternative and open heart surgery again is something where all the other options are exhausted and there is uh you know a threat to the life of the mother then open heart surgery is the last option we have with regards to mitral stenosis aortic stenosis it is quite rare in pre-pregnancy we need to have two analysis one is echocardiography with regards to severity of aortic stenosis which is diagnosed beforehand and the diameter of that aortic valve and the other one is exercise tasting we need to have the exercise tolerance as well as the appearance or the range after which the symptoms appear with regards to asymptomatic pre-pregnant females the features which would predict favorable outcome during pregnancy are absence of symptoms they arise asymptomatic normal ecg normal exertional bp rise aortic valve area more than or equal to one centimeter square and normal left ventricular function the medical therapy is diuretics and cautious beta blockage at low initial dose because the higher the beta the dosage the more chances of pre-synchro sync up and hypotension vasodilators are strictly to be awarded we need to keep this in mind we cannot just uh you know try to reduce blood pressure in case of uh in such cases of aortic stenosis because it will again lead to hypotension and then sudden uh consequences of those sudden hypotension when there is failure of medical therapy we need to terminate pregnancy keeping maternal health in mind and percutaneous volvoloplasty is to be preferred in a view of cardiologists opinion and valve replacement is needed in terminal cases where there is calcification so in calcified walls we will not uh proceed with perpetrators volvoloplasty and cesarean section again is an option with regards to termination of pregnancy when the maternal health is at a compromise pulmonic stenosis mild and moderate ones are well tolerated by severe one would lead to preeclampsia more chances of preterm delivery and more chances of thromboembolic complications the severe ones even if asymptomatic should be considered for any kind of management that is suitable for the patient like balloon volvuloplasty surgical volvo tommy or particulateness valve replacement before pregnancy so that is uh you know a big or a major part with regards to preconceptional counselling all the systemic assessment especially the assessment of cardiac disorders or the valvular heart disease recreating lesions uh there will be reduction in systemic vascular resistance in normal physiological changes of pregnancy which may lead to worsening of regurgitation and onset of signs and symptoms consistent with fluid overload or pulmonary edema which we commonly called as a right heart failure hypertension may also precipitate similar symptoms at an early stage of plasma volume expansion the expansion happens from 6 weeks of gestation onwards up to 32 weeks of gestation and then it plateaus such regurgitant lesions usually respond well to diuretic therapy because the volume overload will be reduced a little severely symptomatic women with impaired left ventricular systolic dysfunction or pulmonic hypertension are at increased risk of maternal and fetal complications so we need to keep uh these two uh categories in mind while dealing with recurrent lesions now prosthetic walls that are majorly two one is bioprosthetic valves and the other one is mechanical walls the prosthetic walls are at minimal risk during pregnancy the anticoagulation is not required until and unless they are associated with arrhythmias they degenerate over time mitral faster than aortic and if the female is of less than 40 years of age redo surgery will be required in such cases while the mechanical ones would have significant maternal and fetal complications majorly there are two risks like thrombosis and sepsis and anticoagulation is must throughout lifetime when the prosthetic this mechanical valves are in uh situ so uh this is a table we all are aware of it the anticoagulation part they call that warfarin would lead to fetal embryopathy but there is a study and there is a recommendation as well that if warfarin is in those of less than or equal to 500 milligram per day it will not lead to any kind of embryopathy but still to be on safer side we are shifted to lmwh or unfractionated hyperin lower molecular weight heparin has to be started only after monitoring with anti-tank a level which need to be from point eight to one point two so this is one thing we need to keep in mind the other option is unfractionated which can be given intravenously now from 12 weeks onwards we can again restart warfarin up to 35 to 36 weeks again shifting on to lmwh or unfractionated hippering and or aspirin whenever required uh up to uh departure partualization and then we can again start work for any postpartum phase so this is the basic concept we have with regards to anticoagulation during pregnancy and postpartum so this is a chart uh it is available uh there are there were few classifications with regards to cardiac disease in pregnancy one was zahara classification the other one was carpric one classification next one was carpet two classification but this is modified who classification with regards to cardiac diseases in pregnancy we need to keep in mind because it will highlight the cases and categorize the cases according to the category the category two would require vigilant classification i mean monitoring category three will require once a month uh follow-up cardiac follow-up with regards to uh up to uh second trimester and third trimester every week and the fourth category are not advised to get pregnant but even if they wish to continue the pregnancy that the more vigilant cardiac follow-up and world cup will be required till the pregnancy can be continued till the balance is not tipped off against the favor of maternal health the pre-pregnancy assessment is much more important as we saw in previous slides of aortic stenosis and pulmonic stenosis and uh the multidisciplinary team approach has to be there because at the end we would as uh require anesthetist help as well because the component of pain will add up to the cardiac load as we see uh with regards to catecholamine release and that is why we would require energy even if the patient is going for vaginal delivery monitoring uh routine antenatal monitoring in form of fetal baseline scan 13-week ante that is nickel translucency scan 20 weeks of fetal anomaly scan with focus on rolling out cardiac disease and fetus why because the females who are having congenital heart disease will require this particular scan as the fetus will be of uh you know at more risk than the females without cardiac disease to get congenital heart disease so we need to rule out cardiac disease as well at around you know anomaly scan along with the growth scans that may follow after 20 weeks of gestation cardiac monitoring antibiotic prophylaxis thromboprophylaxis will be individualized taking patient and the relative in the confidence and in getting involved i mean involving them into decision making process the mode of delivery it is always vaginal delivery with short-term second stage and good analgesia scissor and delivery will lead to increased chances of hemorrhage postpartum sepsis and thromboembolic disease they have to be reserved for obstetric indication only along with operative vaginal delivery so operative virginia delivery and cesarean section are to be done for obstetric purposes only in cardiac business patients or valvular vertices patients this is a table you will be able to find it in acog and all other criteria and guidelines where the diseases are mentioned and in all you know diseases if you can zoom in the vagina delivery is the preferred route along with epidural energy we need to keep in mind one thing that left or heart disease or stenotic lesions where there is reduction in after load are the patients where epidural anesthesia or analgesia is the only thing which will work spinal anesthesia needs to be avoided because spinal anesthesia would lead to hypotension and left or stenotic lesions which will having which will be having left i mean reduced after load will be aggravated uh with spinal anesthesia so those are the patients where if required analgesia and anesthesia has to be of epidural uh mode if labor starts or emergency delivery is to be carried out while still on warfarin scissoring section has to be performed under general anesthesia which with fresh frozen plasma the other option in case of volume overload is cryo precipitate crop residue period will require one tenth of volume of ffe with equal impact so we need to keep in mind this particular thing insertion of pelvic and subrectus drains may be preferred in case of scissor and section again the approach needs to be individualized uh again there are people who would uh keep uh abdominal or pelvic drain uh even in cases of fiber optical placenta which is again a good practice if the patient is going into dic or early phase of dic so such things need to be kept in mind uh while dealing with uh this uh is relatively contraindicated with because of obvious reasons it will actually uh you know more uh lead to more of hypertensive changes and not good for cardiac patients oxytocin has adverse effects and low dose oxidation efficient can be used because uh the larger dose would lead to more of water retention again aggravating the condition or the load on heart with regards to complicated volume heart disease the mechanical wall thrombosis is a very rare phenomenon still encountered if the walls are like uh you know older clinical features would be a new onset dyspnea reduced exercise tolerance dizziness or new onset palpitations or thrombolic or thromboembolic event careful clinical examination followed by echocardiography evolution is must european society has suggested that in asymptomatic cases anticoagulation may remove thrombus in 85 percent of cases thermoelectrics and fiber analytics do not cross the placenta they are not harmful and in critically ill patients where surgery is not immediately available uh this are the options where patients will be benefited as per the studies endocarditis so whenever there is a prosthetic walls this patients when they get fever we need to keep in mind endocarditis endocarditis on mechanical prosthetic valves is an indication for wall replacement prevention is by minimizing pv or pulverizing examination restricting instrumentation during labor and delivery as we discussed previously attention has to be given to antisepsis during labor and complete removal of placenta and prophylactic antibiotics whenever the need arises so antibiotic prophylaxis is not must with regards to each and every prosthetic wall patients anticoagulation is must for mechanical walls so antibiotic prophylaxis needs to be given when there is prosthetic wall during labor anyway we are going giving this particular profile access during labor when the patient is in labor or even during cesarean section prior history of endocarditis cyanotic heart defects and volvulopathy so these are the indications where we need antibiotic prophylaxis so uh one more study was there where they said if you are giving antibiotics um during a labor or caesarean section nothing additional needs to be done but these are the patients where antibiotics are must so we need to keep in mind contraception so it has to be tailored we previously called in um as a cafeteria approach so it has to be tailored to individual and their needs couples needs taking into account her medical history educational and social circumstances efficacy against safety should be weighed to mention few uh if we uh talk about npa that is deport metroxy progesterone acetate injections which are to be given three monthly there will be tendency to fluid retention one more thing is obviously dmp is something if you give for long term there are more chances of bond loss loss as well so we need to keep in mind and we need to explain it to the patient barrier and lng iocd are safest and most effective especially in cases of cardiomyopathy reduced systolic ventricular function cyanotic heart disease and advanced pulmonary hypertension so these are the specific cases where barrier and lng iocd were found to be safest and most effective talking about other contraceptive methods oral contraceptive pills will increase chances of thromboembolic events arterial as as well as venus progesterone or nipples were found to be safest but as we know they have to be taken at particular time of the day in continuous manner and missing one or two pills will reduce uh efficacy drastically uh with regards to scissor and table ligation i would uh you know make it a point that when you do abdominal tubulication or postpartum tubular gation uh they have uh you know failure rate of three in thousand but with regards to caesarean uh tubal ligation or tubal ligation during social insection the failure rate is one in 200 which is much more than uh normal abdominal tubal ligation so these are the things we need to discuss with the patient with the couple and their safety and how effective they are and the longevity of those contraceptive methods and the choice will be of the patients so with regards to take home message i would say that preconception and ongoing risk assessment and a tailored multidisciplinary management approach are essential with regards to this voluminous heart assist patients mitral stenosis is the most common acquired valvular heart lesion in pregnancy contributing to majority of maternal deaths from cardiac diseases eternal vigilance and timely management are necessary for optimum maternal and parental outcome mechanical valves varfarin offers the lowest risk of maternal thromboembolic complications whereas low molecular weight heparin offers the lowest fetal risk we need to keep this this thing in mind while starting with anticoagulation and vaginal delivery is the preferred mode anyway uh in any of the you know if the indication arises of termination of pregnancy so this was valvular heart disease in pregnancy in brief now i think uh we would invite the questions thank you it was really great so everyone here uh be uh please uh feel free to put all your questions in the comment section or you can raise hand and come on stage uh we will accept your request and take you on stage so i just wanted to know one thing that you mentioned at the end of the slide so uh you say that warfarin is associated with low maternal risk and low molecular weight uh heparin is associated with low fetal so while choosing how do we go about it in the second or third trimester so basically uh as we talked that warfarin is the preferred choice from 12 to 36 weeks of gestation because uh with regards to lmwh we need to keep on monitoring anti-10 level now which is not visible most of the times plus uh honestly lmwh is something which is anyway going to be started from 36 weeks onwards so there is a defined uh period where we need warfarin where we need lmwh with regards to lmwh if we uh talk about it um there are two things one is therapeutic dose and the other is prophylactic one when we are dealing with therapeutic dose we would have a minimum gap of at least 12 hours before proceeding with termination of pregnancy for safer you know coagulation profile with regards to prophylactic element privilege it will be like six hours minimum six hours but in case of offering uh as we know that you know it is a longer time and protein sulfate and all of the things will be needed so obviously after 36 weeks lmwh is preferred because of its own reasons and warfarin is something where we do not require monitoring and that is a phase where we can be you know without worry and anticoagulation will be taken care of by the optimal dose of warfarin so and again as i mentioned uh even before 12 weeks the guidelines would suggest that warfarin is safe if the daily dose is less than five milligram right yeah understood so uh doctors has posted is uh toasted in sieve during pregnancy so yeah that is the thing uh we have uh the option we are left with because methyl ergometrine is something we are not uh going uh to give and oxytocin will not have that uh effect so carboprostates again in absence of contraindication like bronchioli bronchiologist respiratory problem is the choice with regards to uterotonics so there is one more question uh dr sudhantu has asked fluid management in heart disease in latent and active level so yeah basically food management is again an individualized approach so uh it depends again on observation there are times when buzzing a delivery the patient's uh sure of vaginal delivery uh like second third fourth gravida uh the nil by mouth is not a protocol which where which is uh being followed by many of the obstetricians uh they are uh you know kept on fluid as well so again you need to weigh with regards to the vitals like blood pressure if you if she's going into hypertension she would require more of the flu if she is having normal tensive status the flu is like uh if you are having nilburgh mouth status then you can uh have a slow drift but at the same time uh we need to keep uh watch on respiratory system she must not go into pulmonary edema phase and uh i think uh so it is an individualized approach there are times when you would like to utilize oxytocin 2.5 units or 5 units for labor augmentation or induction in that case again fluid retention is to be kept in mind because these patients are on the brink of that imbalance of fluid imbalance so it is an individualized approach for prop uh with proper management and monitoring that is like auscultation right so dr ashok is asking what about a mitral valve prolapse so mitral prolapse is something uh which is uh uh many times undiagnosed and uh which would not cause much problem but yeah uh with regards to recognition lesions as we discussed uh we need to uh you know keep in mind uh the right heart failure at the same time a volume uh expansion is something which would uh or might aggravate but again mvp is something which is not uh much uh you know uh threatening uh due to pregnancy or its outcome as per my knowledge but anyway if i encounter such patients i would definitely have a cardio opinion before you know proceeding anything with regards to counseling and management uh as i discussed for two reasons because of their experience they are having ample amount of experience as compared to us and second thing medical purpose so cardio opinion is something which so dr shweta and dr abu bakr has asked how often do we need a monitoring of pti and iron pregnancy so uh that is something we require in ufh that is unfractionated apparent when we give uh intravenously and again uh it is in first and uh last trimester after 36 weeks uh again as we know that there are two things like therapeutic and prophylactic so accordingly we can have iron up to 2.5 and more than that anything more than that is something that is not uh you know good for patient as well as the fetus because that would be like thermotic events which would actually occlude the placenta you minute uteroplacental you know sinuses or the vascular system at the same time causing huge threat to maternal system so uh ptinr needs not to be repeated if control but when you change the dose when you shift the medication when you shift from wafer into ufh then yes definitely it will be required and it will be required when you are opting for termination of pregnancy especially so in form of cesarean section so it will be required fresh ptiner will be required for sure in those times so according to you which is the best antihypertensive in pregnancy just last one question i saw uh not much yeah right anti-hypertensive is something uh lebron is the first choice anyway uh alpha method previously was uh considered as second line but again uh it has been discontinued for some time so laboratory is amazing it takes time for uh you know it's half life to get set in but uh an amazing medication with least uh chances and you know proportion of introverted growth restriction in pregnancy and uh the safest even uh in hypertensive emergencies and urgencies intravenous laboratorial has been found to be quite superior as compared to others and just to mention that sublingual uh uh you know uh the step in uh philippine is something which is discontinued has been discontinued must not be used and there are times when people you know have the drop of that sublingual medication and it will lead to more of a certain hypotension putting maternal health at risk feeders um you just forget about features so please discontinue if at all somebody is using that but ivy level and maintenance those in form of oral laboratory are enough if you need you can add in the philippine 10 or 20 milligram later on but again in that case uh you need to weigh the risk you know balance if because of this many antibiotics the fetus is surely going to going into iugr as well as you know will have a compromise of health that's right uh i hope this answers your question dr jagdish and if you have uh want to understand more about hypertension in pregnancy we had done one interesting session uh you will find it in cases in obj club uh please do watch it just let me check that what is the maximum dose of laboratory in pregnancy so as i said iv and oral both we do post iv then followed by oral how frequent is valvola her disease in pregnancy incidence rate uh dr sophia is asking so could you please just yeah uh from literature honestly uh the global literature suggests that it is like uh less than one to two percent but yeah uh in india we are not uh much sure of those statistics because we are dealing with rheumatic heart disease congenital ones majorly and they are not much frequently reported so around one to two percent more than that right uh so dr vishnu is asking what is which is the choice of antibiotic for profile access in when there is a prosthetic wall so when there is prosthetic wall we would require it uh in case of uh you know query endocarditis or when the patient goes in labor uh and uh keto we won't be using it but yeah uh simple amoxicillin is good enough but there are times now people have shifted to intravenous effort to examine you know higher medications but yeah simple amoxicillin is good enough and we have been using that since long and there has been no problem right uh so dr harleen is asking uh which medication is to be given if you want to know whether patient is having true labor or false labor contractions how do we differentiate so basically yeah true and false is something that is uh you know that comes down to degree of an obstetrician so uh medications um is all together different thing we need we need to be you know able to uh differentiate true and false uh uh i would like to tell one thing that uh with regards to true and false labor you have different various criteria like labor pains uh you know each contraction consisting more than at least more than 30 to 40 seconds two contraction in ten minutes these are the criteria but nowadays acog has accepted uh in the year i think 2016 that uh six is new four now this is wonderful six centimeter is the deletion after which the active phase starts previously it was thought to be four centimeter so now up to even up to six centimeter the patient can still be in latent phase and that is that is why we need to have modified uh photographs so six is new four because of uh working females because of the females who are actually uh robust enough um the six centimeter is uh something where we still will be counting as a latin phase so this was uh one thing okay so uh we have taken all the questions actually so i have covered everything stuff with this we can end the session today and hope to see you again soon with some interesting stuff thank you so much thank you so much for all the kind words and uh thank you for uh you know uh giving me this particular opportunity because uh you know it's an honor uh to be a part of such a uh noble platform where uh you know you you all work hard and it's just like 20 or 30 minutes for an audience but for you people it's like you know hours together you know days before that particular event so hats off to you all thank you so much thank you thank you so much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 558 others

SPEAKERS

dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gynaecological Society | Assistant Professor, AMCMET Medical College, Ahmedabad

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gy...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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