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New Treatments for Medical Problems in Pregnancy

Heart disease. It occurs in approximately one percent of all pregnancies, obviously in varying degrees, from something as minor as some arrhythmias or palpitations, to anything as severe as critical aortic stenosis, which hopefully you don't have to deal with too much. It is important to remember that fetal heart disease also occurs in approximately 7 in 1000 live births.

Things to remember when you are considering heart disease in pregnancy, some of the changes that happen, include a total body sodium increase, which also helps lead to a total body water increase. You also have a simultaneous blood volume increase and red blood cell mass increase. You know that in the second trimester, this also gives you a physiological anemia. Remember that the cardiac output normally increases by thirty to fifty percent in pregnancy, by as early as the end of the first trimester.

What do you need to think about regarding what is normal and what you need to refer to a cardiologist for? Typically, your PMI is shifted. It is normal for the first heart sound to be increased. The second heart sound can be especially late in pregnancy.

A systolic flow murmur is a systolic ejection murmur at the sternal border; this is common. You can hear it if you listen closely enough in up to ninety-six percent of pregnant woman. This does not need a cardiology referral unless, for some reason, the woman is symptomatic; she has JVD, you think it is louder than your average flow murmur.

Just a brief review, if you want to look at congenital heart disease, you can think of it in terms of shunt - is it a left to right shunt or a right to left shunt? Left to right shunt is what happens at the beginning and right to left is what happens when it gets really bad. Types of lesions includes ASD, VSD or patent ductus - these are left to right shunts. Potential complications associated with these are arrhythmias, congestive heart failure and end-stage pulmonary hypertension. Pressure overload and hypertrophied ventricles and probably the most common is the bicuspid aortic valve stenosis, although this is most common in an older population.

Some more about valvular congenital disease. As mentioned, it is the most common form. Typically, it is acquired. Most common is rheumatic heart disease, which affects the heart valves. Mitral, aortic, pulmonic and tricuspid disease are all included in this. The mitral and aortic, unfortunately, are what will cause the most problems in pregnancy. Pulmonic and tricuspid are less likely to cause a problem. Mitral and aortic stenosis are the lesions with the fixed cardiac output. These are probably some of the most common valvular lesions that you will be faced with. A lot of it depends on whether there is critical stenosis or not.

Insufficiency is actually relatively well tolerated in pregnancy. In part, this is due to the decreased vascular resistance. Mitral valve prolapse is something that you will also come across; it occurs in twelve to seventeen percent of reproductive age women. Symptoms that women will typically complain of are palpitations, dyspnea on exertion, atypical chest pain, syncope and panic attacks. Ironically, we think that this must get worse in pregnancy, because we have so many women who have complained of this.

Post partum cardiomyopathy is something I hope you never see. It is hard to diagnose; it is almost a diagnosis of exclusion. You have to rule out viral myocarditis, hypertensive cardiomyopathy, lupus and everything else. First and foremost, rule out any previous disease, other known etiologies, and it should occur within six months of delivery. The incidence is variable, depending on which series you look at. There have seen reports of some of the African tribes who go out and labor in the salt plains in Africa and it is higher in that population.

Treatment considerations overall, when you have a woman with cardiac disease, remember that most cardiovascular changes are completed by the first trimester and prior to labor, you can consider both medical and surgical intervention. You can do open heart surgery on a woman, if she needs it. If she has valve replacement or if she blows out an old valve, you don't really have a choice. There are lots of case reports about open heart surgery.

One the hard things when you are dealing with a cardiologist and are working in conjunction with a cardiologist, the assumption by people who don't have a lot of experience with pregnant women and cardiac disease is that a C. section is by far better for the patient, because for some reason it is less stressful. However, that is not true and there is even some evidence to show that it is more dangerous to do C. sections on these women with heart disease. I know it is difficult sometimes to convince cardiologists of this, but it is not necessarily in the patient's best interests.

We talked about chronotropic regulation. There is also inotropic regulation. People in heart failure or people with cardiomyopathy may need digoxin, pressors, Dopamine, whatever. Volume control is also very important; you need to consider the preload versus the afterload.