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PENYAKIT MATERNAL DALAM

KEHAMILAN
(Medical and Surgical Complications)
Daliman, Dr, Sp.OG(K)FM
RS Margono Soekarjo/ FK Unsoed,
Purwokerto

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PENYAKIT MATERNAL DALAM
KEHAMILAN
POKOK
BAHASAN :
1. PENYAKIT
KARDIO
VASKULER

2. PENYAKIT
DIABETES
MELLITUS

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Cardiovascular Disorders
 PHYSIOLOGICAL CONSIDERATIONS IN PREGNANCY
 DIAGNOSIS OF HEART DISEASE
 PERIPARTUM MANAGEMENT CONSIDERATIONS
 SURGICALLY CORRECTED HEART DISEASE
 VALVULAR HEART DISEASE
 CONGENITAL HEART DISEASE
 PULMONARY HYPERTENSION
CARDIOMYOPATHIES
 HEART FAILURE
 INFECTIVE ENDOCARDITIS
 ARRHYTHMIAS
 DISEASES OF THE AORTA
 ISCHEMIC HEART DISEASE
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Cardiovascular Disorders
1.Physiological 2. Diagnosis of Heart
consideration in Disease,
pregnancy,
 Diagnostic studies ( ECG,
Chest Radiography,
 Cardiovascular Echocardiography),
physiology,  Classification of
Functional Heart Disease,
 Ventricular function in  Preconception
pregnancy counceling,
 Congenital Heart Disease
in offspring

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Cardiovascular Disorders
3. Peripartum 4. Surgically corected
mangement heart disease,
consideration,
 Valve Replacement before
Labor and delivery pregnancy (anticoagulation,
(analgesia and recommendation for
anesthesia, intrapartum anticoagulation,
heart failure), contraception),
 Cardiac surgery during
Puerperium, pregnancy (mitral
Sterilization and valvotomy during
contraception. pregnancy),
 Pregnancy after heart
transpalntation.
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Cardiovascular Disorders
5. VALVULAR 6.CONGENITAL
HEART DISEASE, HEART DISEASE,
 MITRAL STENOSIS  SEPTAL DEFECTS (ASD,
(Pregnancy outcome, VSD, ATRIOVENTRICULAR
management), SEPTAL DEFECTS),
 MITRAL  PERSISTENT (PATENT)
DUCTUS ARTERIOSUS/ PDA,
INSUFFICIENCY  CYANOTICC HEART DISEASE
(Mitral Valve Prolapse/ (Pregnancy after Surgical
MPV), Repair, Fallot tetralogy,
transposition of the great
 AORTIC STENOSIS Vessels, Single Functional
(Pregnancy, management), Ventricle, EISENMENGER
 AORTIC INSUFFICIENSI, syndrome)
 PULMONIC STENOSIS
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Cardiovascular Disorders
7. PULMONARY
HYPERTENSION,

DIAGNOSIS,
PRONOSIS,
PULMONARY
HYPERTENSION
AND PREGNANCY
(Management, Labor
and Delivery)
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Cardiovascular Disorders
8. Cardiomyoppathies,
 Hypertrophyc cardiomyopathy,
 Dilated cardiomyopathy (PERIPARTUM
CARDIOMYOPATHY, prognosis),
 Other primary Causes of Cardiomyopathy
(Arrhythmogenic Right Ventricular Dysplasia, Restrictive
Cardiomyopathy)

9. HEART FAILURE,
Dianosis,
Management,
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Cardiovascular Disorders
10. INFECTIVE 11. ARRHYTHMIAS,
ENDOCARDITIS,
Bradyarrhythmias,
Diagnosis, supraventricularTac
Management, hycardias,
Endocarditis in Ventricular
pregnancy Tachycardia,
(Endocarditis Prolonges QT-
prophylaxis) Interval.

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Cardiovascular Disorders
12. DISEASE OF THE AORTA,
 Aortic Dissection,
MARFAN syndrome (effect of pregnancy on
Marfan syndrome, PERINATAL outcome,
Aortic Coarctation (effect of pregnancy
on Coarctation,

13. ISCHEMIC HEART DISEASE (IHD),


 Pregnancy with prior IHD,
 Myocardial Infarction during Pregnancy.
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KEMATIAN MATERNAL
DAN PENYAKIT

KARDIOVASKULER
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KEMATIAN MATERNAL DAN
PENYAKIT KARDIOVASKULER DALAM KEHAMILAN

PENYAKIT JANTUNG sebagai komplikasi


lebih dari 1 % dari seluruh kehamilan, tetapi
menjadi penyebab utama kematian ibu tidak
langsung sekitar 20 % dari seluruh
kematian IBU (Simpson, 2012).

Dari analisis, kematian maternal oleh karena


hipertensi dan perdarahan angkanya
turun secara progresif, sedangkan
keterlibatan penyakit kardiovaskuler
persentase meningkat tajam (Berg, 2010).
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PENYAKIT KARDIOVASKULER
DALAM KEHAMILAN
Kenaikan prevalensi  Lebih dari setengah
penyakit kardiovaskuler orang dewasa 20 th
dalam kehamilan atau lebih memiliki
minimal 1 faktor
sebagai komplikasi
risiko penyakit
kehamilan disebabkan kardiovaskuler (Fryar,
oleh peningkatan 2012).
angka  Prevalensi faktor risiko
penyebabnya, diantara wanita usia
reproduksi sangat
termasuk obesitas, dramatik, terkait faktor
hipertensi, and diantaranya
keterlambatan hamil.
diabetes.
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PERTIMBANGAN FISIOLOGI PADA
KEHAMILAN
FISIOLOGI
KARDIOVASKULER

FUNGSI
VENTRIKEL
pada
KEHAMILAN

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5 PRINSIP PERUBAHAN
FISIOLOGIS PADA KEHAMILAN:
1. PENURUNAN Systemic Vascular
Resistance (SVR).
2. PENINGKATAN volume intravaskuler.
3. PENINGKATAN volume intravaskelur
POSTPARTUM, dari
AUTOTRANSFUSI.
4. HIPERKOAGULOPATI.
5. TANDA PENINGKATAN CARDIAC
OUTPUT SELAMA PERSALINAN.
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PERUBAHAN HEMODINAMIK PADA HAMIL ATERM DAN
12 MINGGU POSTPARTUM (Clark and coll., 1989)
PARAMETER PERUBAHAN (%) KETERANGAN
Cardia output + 43
Heart rate + 17
Left ventricular stroke + 17
work index
Vascular resistance:
 systemic - 21
 pulmonary -34
Mean arterial pressure +4
Colloid osmotic pressure - 14

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Kondisi fisiologis pada kehamilan.
 Peningkatan perubahan hemodinamik sebesar
lebih dari 50% puncaknya pada trimester kedua
(midpregnancy) selama 8 minggu dapat
memberikan efek pada wanita berlatar belakang
penyakit jantung.
 Pada awal kehamilan peningkatan stroke volume
sebagai akibat hasil penurunan resistensi
perifer, sedangkan pada akhir kehamilan
peningkatan stroke volume dan penurunan nadi
akibat dari penambahan pengisian atrium oleh
karena hipervolemia kehamilan.
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 Penjelasan adaptasi maternal terhadap kondisi
overload volume natural pada ibu hamil
melibatkan kontrol ekspresi/ fungsi gen dari
sinyal molekul memediasi hipertrofi reversibel
(Eghbali and co-workers, 2006). Kondisi ini
diaktivasi oleh estrogen atau G-protein-couple
receptor agonist seperti endothelin-1 atau
angiotensin II.

 Wanita dengan latar belakang penyakit


jantung kemungkinan tidak dapat
beradaptasi dengan perubahan di atas dan
disfungsi ventrikel menyebabkan gagal
jantung kardiogenik.
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 Sebagian kecil wanita disfungsi kardiak berat muncul
sebelum midpregnancy, sebagian yang lain gagal
jantung muncul setelah kehamilan 28 minggu, setelah
kehamilan memicu hipervolemia dan cardaic output
meningkat encapai maksimum.

 Kebanyakan kegagalan jantung berkembang


peripartum, ketika kondisi obstetrik pada
umumnya lebih membebani fungsi jantung.

 Pada 542 wanita dengan penyakit jantung, dilaporkan


oleh Etheridge dan Pepperell (1977), 8 dari 10
kematian ibu terjadi peripartum.
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INDIKATOR KLINIS PENYAKIT JANTUNG
PADA KEHAMILAN.
TANDA-TANDA:
 SESAK NAFAS PROGRESIF ATAU SESAK NAFAS SAAT BERBARING.
 BATUK PADA MALAM HARI.
 HEMOPTISIS.
 PINGSAN.
 NYERI DADA.

TEMUAN KLINIK.
 SIANOSIS, CLUBBING OF FINGER.
 DISTENSI V JUGULARIS MENETAP.
 SISTOLIK MUMUR DERAJAT 3/6 ATAU LEBIH.
 DIASTOLIK MUMUR.
 KARDIOMEGALI.
 ARITMIA MENENTAP.
 SPLIT SUARA JANTUNG KEDUA MENETAP.
 KRITERIA HIPERTENSI PULMONAL.
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PREDIKTOR KOMPLIKASI KARDIAL,
DIANTARANYA:
1. KEGAGALAN JANTUNG SEBELUMNYA,
TRANSIENT ISCHEMIC ATTACK, ARITMIA ATAU
STROKE.
2. BERBASIS NYHA KLAS III ATAU IV, ATAU SIANOSIS.
3. Left-sided obstruction didefinisikan sebagai area
katup mitral kurang dari 2 cm2, area katup aorta
kurang dari 1,5 cm2, atau puncak aliran ventrikel
kiri tract gradient diatas 30 mmHg dengan
echocardiography.

4. Fraksi ejeksi kurang dari 40%.


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DIAGNOSIS OF HEART DISEASE
Diagnostic Studies

Electrocardiography
Chest Radiography
Echocardiography

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 Menurut the Centers for Disease Control and
Prevention, penyakit jantung menjadi penyebab
utama kematian wanita umur 25-44 tahun (Kung and
coll., 2008).

 Kelainan jantung dengan berbagai variasi berat dan


komplikasi diperkirakan 1% dari seluruh kehamilan,
bermakna berkontribusi terhadap angka kesakitan
dan kematian maternal.
 Cardiomyopathy dikaitan dengan kematian maternal
di USA sebesar 8% (Chang and coll., 2003).
 Angka Kematian Maternal sebagai akibat komplikasi
penyakit jantung di Brazil sebesar 2,7% (Avila and ass.,
2003), sementara di USA tahun 1991 pada pasien selama
dirawat di RS untuk melahirkan sebesar 7,6% (Callaghan
and ass., 2008).
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Professional Guide to Diseases (Eighth Edition),
2005
Cardiovascular disease in pregnancy: Causes and
incidence
(Professional Guide to Diseases (Eighth Edition))

Approximately 1% to 2% of pregnant females have


cardiac disease, but the incidence is rising because medical
treatment today allows more females with rheumatic
heart disease (present in more than 80% of
patients who develop cardiovascular complications) and
congenital defects (present in 10% to 15% of patients)
to reach childbearing age. Coronary artery disease
accounts for about 2% of cardiovascular complications.
Read more at http://www.wrongdiagnosis.com/h/heart_disease/causes.htm?ktrack=kcplink

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Handbook of Diseases, 2003
Cardiovascular disease in pregnancy:
Causes (Handbook of Diseases)

Rheumatic heart disease is present in


more than 80% of patients who develop
cardiovascular complications. In the rest,
these complications stem from congenital
defects (10% to 15%) and coronary artery
disease (2%).
Read more at http://www.wrongdiagnosis.com/h/heart_disease/causes.htm?ktrack=kcplink

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 The diseased heart is sometimes unable to meet the
normal demands of pregnancy: 25% increase in
cardiac output, 40% to 50% increase in plasma
volume, increased oxygen requirements,
retention of salt and water, weight gain, and
alterations in hemodynamics during delivery. This
physiologic stress often leads to the heart’s failure
to maintain adequate circulation (decompensation).
 The degree of decompensation depends on the
patient’s age, the duration of cardiac disease, and
the heart’s functional capacity at the pregnancy’s
outset.
Read more at ttp://www.wrongdiagnosis.com/h/heart_disease/causes.htm?ktrack=kcplink
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BEBERAPA PENYAKIT JANTUNG PADA KEHAMILAN.
1. PENAYKIT KATUP JANTUNG (stenosis mitral, insufisiensi
mitral, stenosis aorta, insufisiensi aorta, stenosis pulmonal).
2. PENYAKIT JANTUNG BAWAAN, SEPERTI defek septum
(ASD, VSD, ATRIOVENTRICULAR SEPTAL DEFECT), PERSISTEN
DUCTUS ARTERIOSUS, PENYAKIT JANTUNG SIANOSIS
(tetralogi Fallot, Ebstein anomaly), EISENMENGER SYNDROME.
3. HIPERTENSI PULMONAL (Idiopatik, left-side atrial or
ventricel disease, left-side valvular disease, chronic obstructive
pulmonary disease, interstitial lung disease, dsb).
4. Kondisi kardiovaskuler lain (Mitral valve prolaps,
peripartum cardiomyopathy, hypertrophic
cardiomyopathy, inefective endocarditis, aritmia).
5. PENYAKIT PADA AORTA (aortic dissection, Marfan syndrome,
coaortasio aortae).
6. ISCHEMIC HEART DISEASE (IHD).
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Cardiovascular Disease in Pregnancy
Jill B. Whelan, Loryn S. FeinbergDate: 17 January 2017
Abstract
• Establishing the level of maternal and fetal risk is central to the
management of heart disease in pregnancy. A preconception
evaluation of severity of cardiac disease, functional class, left
ventricular function, pulmonary pressures, and need for
anticoagulation during pregnancy should guide risk assessment.
Assessment of the risk of pregnancy in heart disease should
include an interdisciplinary approach with providers and patients
and a detailed discussion of short- and long-term morbidity and
mortality to both the mother and fetus. High-risk predictors of
maternal morbidity and mortality include maternal left
ventricular ejection fraction less than 40 %, New York Heart
Association (NYHA) class II–IV symptoms (Table 1), or left-sided
obstructive valve lesions or outflow obstruction.
Keywords Pregnancy – Heart disease -Congenital -Anticoagulation -Arrhythmia -Myocardial
infarction - Heart failure
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Cardiovascular Disease in Pregnancy
Jill B. Whelan, Loryn S. FeinbergDate: 17 January 2017

• These factors are also known to be predictive of neonatal


complications, including premature birth, intrauterine growth
restriction, respiratory distress syndrome, and death. In general,
treatment of any high-risk cardiac lesions should be performed when
appropriate and feasible prior to conception. Most patients with relatively
low-risk conditions are successfully managed throughout pregnancy, labor,
and delivery with conservative treatment designed to optimize
intravascular volume status, heart rate, and systemic preload and
afterload. In certain conditions, where risk cannot be modified, such
as cyanotic congenital heart disease, congestive heart failure with an
ejection fraction <30 %, or severe pulmonary hypertension, pregnancy
should be strongly discouraged as patients with these conditions do not
typically tolerate the hemodynamic changes of pregnancy.
Keywords
Pregnancy – Heart disease -Congenital -Anticoagulation -Arrhythmia -Myocardial infarction - Heart failure

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PERSALINAN DAN KELAHIRAN

SC (Simpson, 2102),
 Pada umumnya dilakukan pada:
persalinan dapat
1. Dilated aortic root >
dilakukan aman,
4 cm, atau
pervaginam aneurysma aortae,
dengan induksi 2. Acute severe CHF,
persalinan,
3. Recent myocardial
sedangkan SC infarction,
terbatas atas
4. Severe symptomatic
indikasi OBSTETRI. aortic stenosis.
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PENANGANAN PENYAKIT JANTUNG PADA
KEHAMILAN.

1. NYHA I-II, BIASANYA TANPA MORBIDITAS,


PERSALINAN PERVAGINAM, SC JIKA ADA INDIKASI
OBSTETRI.
2. NYHA III-IV, 3%, KASUS BERAT, JARANG TERJADI (DI
NEGARA MAJU), DITAWARKAN TERMINASI, JIKA
DILANJUTKAN BERI PENJELASAN RISIKO, PERAWATAN
KETAT DI RS, DAPAT LAHIR PERVAGINAM DENGAN
EPIDURAL ANESTESI, SC JIKA ADA INDIKASI OBSTETRI.
3. KOREKSI PEMBEDAHAN PADA KELAINAN JANTUNG
BAWAAN ATAU DIDAPAT, DILAKUKAN SEBELUM HAMIL
(MORTALITAS MATERNAL 3-4%, LEBIH BANYAK KEMATIAN
JANIN), PERLU PEMILIHAN ANTIKOAGULAN YANG TEPAT.
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Classification of Functional Heart
Disease
The clinical classification
of the New York
Heart Association
(NYHA) was first published
• Class II. Slight
in 1928, and it was revised
limitation of physical
for the eighth time in 1979. activity: These women
are comfortable at rest,
• Class I. but if ordinary physical
Uncompromised—no activity is undertaken,
limitation of physical
activity: These women discomfort in the form
do not have symptoms of excessive fatigue,
of cardiac insufficiency palpitation, dyspnea, or
or experience anginal anginal pain results.
pain.
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Classification of Functional Heart
Disease
The clinical classification
of the New York Heart
Association (NYHA) was • Class IV. Severely
first published in 1928, compromised—inability
and it was revised for to perform any physical
the eighth time in 1979.
activity without
Class III. Marked discomfort: Symptoms
limitation of physical of cardiac insufficiency
activity: These women
are comfortable at rest, or angina may develop
but less than ordinary even at rest. If any
activity causes physical activity is
excessive fatigue,
palpitation, dyspnea, or undertaken, discomfort
anginal pain. is increased.
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PENYAKIT JANTUNG SIANOTIK
Ultimate right-to-left shunt
Initial left-to-right shunt

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World Health Organization (WHO) Risk Classification of
Cardiovascular Disease and Pregnancy

WHO 1—Risk no higher than general population


Uncomplicated, small, or mild:
o Pulmonary stenosis, Ventricular septal defect, Patent ductus arteriosus,
Mitral valve prolapse with no more than trivial mitral regurgitation,
Successfully repaired simple lesions: Ostium secundum atrial septal
defect, Ventricular septal defect, Patent ductus arteriosus, Total
anomalous pulmonary venous drainage, Isolated ventricular extrasystoles
and atrial ectopic beats

WHO 2—Small increase in risk of maternal mortality


and morbidity If otherwise uncomplicated:
o Unoperated atrial septal defect, Repaired Fallot tetralogy, Most
arrhythmias

WHO 2 or 3—depends on individual case Mild left


ventricular impairment
o Hypertrophic cardiomyopathy, Native or tissue valvular heart disease not
considered WHO 4, Marfan syndrome without aortic dilation, Heart transplantation

Risk Category - Associated Conditions


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World Health Organization (WHO) Risk Classification of
Cardiovascular Disease and Pregnancy

WHO 3—Significantly increased risk of maternal mortality or expert


cardiac and obstetrical care required
o Mechanical valve, Systemic right ventricle—congenitally corrected
transposition, simple, transposition post-Mustard or -Senning repair, Post-
Fontan operation, Cyanotic heart disease, Other complex congenital heart
disease

WHO 4—Very high risk of maternal mortality or severe morbidity;


pregnancy contraindicated and termination discussed
o Pulmonary arterial hypertension, Severe systemic ventricular dysfunction
(NYHA III-IV or LVEF < 30%), Previous peripartum cardiomyopathy with
any residual impairment of left ventricular function, Severe left heart
obstruction, Marfan syndrome with aorta dilated > 40 mm
Modified from Thorne, 2006.

Risk Category - Associated Conditions


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RISIKO MATERNAL YANG DIKAITKAN
DENGAN KEHAMILAN.
(Berghella, 2012)

Grup I: risiko kematian minimal (<1%),


diantaranya ASD, VSD, Pulmonic atau Tricuspid
valvular disease, Tetralogy of Fallot yang terkoreksi,
Bioprostetic heart valve, Mitral steonosi (NYHA klas
I dan II), Marfan syndrome (normal aorta),
Insufisiensi Aorta atau Mitral, Hypertrophic
Cardiomyopathy.

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RISIKO MATERNAL YANG
DIKAITKAN DENGAN KEHAMILAN.
(Berghella, 2012)

Grup II: RISIKO KEMATIAN MODERAT (5-15%),


diantaranya MITRAL STENOSIS (NYHA III-IV),
artificial mechanical hearth valve (jika antikoagulan
heparin), stenosis aorta, coartatio aortae
(uncomplicated), uncorected Tetralogy Fllaot,
Myocardial infarktion.
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RISIKO MATERNAL YANG DIKAITKAN
DENGAN KEHAMILAN.
(Berghella, 2012)

Grup III: RISIKO KEMATIAN BERAT (>25%),


diantaranya Pulmonary hypertension
(PHTN), coartatio aorta (complicated), Marfan
syndrome (dengan aortic root >4 cm), severe
DILATATED CARDIOMYOPATHY.
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Professional Guide to Diseases (Eighth Edition), 2005

Cardiomegaly/Congestive Heart Failure:


Differential Overview
(Field Guide to Bedside Diagnosis)
Congestive heart failure, Hypertensive left
ventricular hypertrophy, Anterior myocardial ischemia,
Athlete’s heart, Mitral regurgitation, Aortic stenosis, High
output, Hypertrophic obstructive cardiomyopathy,
Pulmonary hypertension, Cor pulmonale, Dilated
cardiomyopathy, Endocarditis, Pericardial effusion,
Left ventricular aneurysm, Mitral stenosis, Amyloidosis
Read more at http://www.wrongdiagnosis.com/h/heart_disease/causes.htm?ktrack=kcplink

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Source: Field Guide to Bedside Diagnosis, 2007

Heart failure: Causes (Handbook of Diseases)


Heart failure may result from a primary abnormality of the heart muscle (such as an
infarction), inadequate myocardial perfusion due to coronary artery disease, or
cardiomyopathy. Other causes include:

 mechanical disturbances in ventricular filling during diastole when there’s too little blood for the
ventricle to pump, as in mitral stenosis secondary to rheumatic heart
disease or constrictive pericarditis and atrial fibrillation
 systolic hemodynamic disturbances such as excessive cardiac workload due to volume
overloading or pressure overload that limit the heart’s pumping ability.

These disturbances can result from mitral or aortic insufficiency, which causes volume
overloading, and aortic stenosis or systemic hypertension, which results in increased resistance to
ventricular emptying.

Reduced cardiac output triggers three compensatory mechanisms: ventricular dilation,


hypertrophy, and increased sympathetic activity. These mechanisms improve cardiac output at the
expense of increased ventricular work.
Read more at http://www.wrongdiagnosis.com/h/heart_disease/causes.htm?ktrack=kcplink

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STANDARD CARDIAR CARE FOR
LABOR AND DELIVERY
1. Accurate diagnosis,
2. Mode of delivery based on obstetrics indication,
3. Medical management initiated early in labor (proonged labor avoided,
induction with a favorable cervix),
4. Maintanance of hemodynamic stability (invasive hemodynamic
monitoring when require, initial-compensated hemodynamic reference
point, specific emphasis based on particular cardiac condition),
5. Avoidence of pain and hemodynamic responses (epidural analgesia
with narcotic/low0dose local technique),
6. Consideration for prophylactic antibiotics when at risk for endocarditis,
7. Avoidance of maternal pushing (caudal block for dense perineal
anesthesia, low forceps or vacuum delivery),
8. Avoiddance of maternal blood loss (proactive management of the third
stage, early but appropriate fluit replacement),
9. Early volume management postpartum (often careful but aggressive
diuresis)

(Gabbe., et.al, 2017. OBSTETRICS, Normal and Problem Pregnancies)


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CARDIOMYOPATHY
 Dilated CARDIOMYOPATHY is characterized by
development of pulmonary edema in the context of
LV dysfunction and dilatasion (on
echocardiographic examination),
 Peripartum cardiomyopathy is a rare syndrome of
heart failure that presents in late pregnancy or
postpartum,
 The diagnosis is made after excluding other causes
of pulmonary edema and heart failure.
The mortality rate for peripartum
cardiomyopathy (PPCM) is reported 25 % to 50 %.
Death is usually due to progressive CHF,
arrhythmia, or thromboembolism.
(Gabbe., et.al, 2017. OBSTETRICS, Normal and Problem Pregnancies)
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Diagnosis criteria for PPCM
1. Heart failure within
the last month of Ejection fraction
pregnancy or within 5 of < 45% or
months postpartum, fractional
2. Absence of prior heart shortening of <
disease, 30%,
3. No determineable
cause, LV end-diastolic
4. Echocardiographyc dimension of >2.7
indication of LV cm/m2
dysfunction  (Gabbe., et.al, 2017. OBSTETRICS, Normal
and Problem Pregnancies)
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KEY POINT
o HEMODYNAMIC changes in pregnancy may adversely affect
maternal cardiac performance,
o Intercurrent events such as INFECTION during PREGNANCY are
ususally the cause of DECOMPENSATION,
o Women with heart disease in pregnancy frequently have unique
psychosocial needs,
o Labor, delivery and postpartum are periods of
hemodynamicinstability,
o The postpartum period can be caracterized as a “perfect storm”
of volume loading, tachycardia, and increase afterload; each of
these may contribute to the destabilization of a pregnant woman
with heart disease.
o Invasive hemodynamic monitoring should be used to address
specific clinicval questions,
(Gabbe., et.al, 2017. OBSTETRICS, Normal and Problem Pregnancies)
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KEY POINT
o Many maternal heart conditions can be
medically managed during pregnancy,
o Management anticoagulation in women with
mechanicalvalves requires an experienced
team and careful considerationof the balance
between maternal and fetal risk followed by
apropriate counseling. Very aggressive
therapeutic monitoring is required.
o Mother with cyanotic heart disease are at
particular risk for adverse fetal and neonatal
outcomes
(Gabbe., et.al, 2017. OBSTETRICS, Normal and Problem Pregnancies)
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KEY POINT
o Eisenmenger syndrome, Marfan syndrome
with the dilated AORTA , and PULMONARY
HYPERTENSION with right heart dysfunction
are associated with a VERY HIGH RISK for
MATERNAL MORTALITY,
o Many woman with CONGENITAL HEART
DISEASE can SUCCESSFULLY complete a
pregnancy,
o PRECONCEPTION COUNCELING is based on
achieving a balance between MEDICAL
INFORMATION and the PATIENT’S VALUE
system
(Gabbe., et.al, 2017. OBSTETRICS, Normal and Problem Pregnancies
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DIABETES MELLITUS
IN PREGNANCY

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Diabetes Mellitus
 TYPES OF DIABETES
 PREGESTATIONAL • According to the National
DIABETES Center for Health Statistics
 DIAGNOSIS (2013), the number of adults
 FETAL EFFECTS diagnosed with diabetes in
 MATERNAL EFFECTS the United States has
 MANAGEMENT OF tripled from 6.9 million in
DIABETES IN PREGNANCY 1991 to 20.9 million in 2011.
 GESTATIONAL DIABETES
 SCREENING AND • Astoundingly, the Centers
DIAGNOSIS for Disease Control and
 MATERNAL AND FETAL Prevention (2010) have
EFFECTS estimated that the number
of Americans with diabetes
 MANAGEMENT will range from 1 in 3 to 1
in 5 by 2050.
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TYPES OF DIABETES
o Absolute insulin
deficiency The terms
characterizes type 1 insulin-
diabetes. dependent
diabetes mellitus
o In contrast, defective
insulin secretion, (IDDM) and
insulin resistance, or noninsulin-
increased glucose dependent
production diabetes mellitus
characterizes type 2 (NIDDM) are
diabetes now obsolete.
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Etiological Classification of
Diabetes Mellitus
o Type 1: β-Cell o Other types
 Genetic mutations of β-cell function—
destruction, usually MODY 1–6, others
absolute insulin  Genetic defects in insulin action
 Genetic syndromes—Down, Klinefelter,
deficiency Immune- Turner
mediated Idiopathic  Diseases of the exocrine pancreas—
pancreatitis, cystic fibrosis
o Type 2: Ranges from  Endocrinopathies—Cushing syndrome,
pheochromocytoma, others
predominantly insulin  Drug or chemical induced—
resistance to glucocorticosteroids, thiazides, β-
adrenergic agonists, others
predominantly an  Infections—congenital rubella,
insulin secretory cytomegalovirus, coxsackievirus
defect with insulin o Gestational diabetes
resistance MODY = maturity-onset diabetes of the young. Modified from Powers, 2012.
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Classification Scheme Used from 1986 through 1994 for
Diabetes Complicating Pregnancy Plasma
o B Over 20 < 10 None
Plasma Insulin
Glucose Level o C 10 to 19 10 to 19 None
Insulin
o A1 Gestational < o D Before 10 > 20 Benign
105 mg/dL < 120 retinopathy Insulin
mg/dL Diet o F Any Any Nephropathya
Insulin
o A2 Gestational >
o R Any Any Proliferative
105 mg/dL > 120 retinopathy Insulin
mg/dL Insulin o H Any Any Heart Insulin
aWhen diagnosed during pregnancy: proteinuria ≥ 500 mg/24 hr before 20 weeks’gestation.
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Proposed Classification System for
Diabetes in Pregnancy
• Gestational diabetes: • Type 2 Diabetes: Diabetes
diabetes diagnosed during from inadequate insulin
pregnancy that is not clearly secretion in the face of
overt (type 1 or type 2) increased insulin resistance
diabetes a. Without vascular
complications
b. With vascular complications
• Type 1 Diabetes: Diabetes (specify which)
resulting from β-cell
destruction, usually leading to
absolute insulin deficiency Other types of
a. Without vascular
complications
diabetes: genetic in
origin, associated with
b. With vascular complications pancreatic disease, drug-
(specify which) induced, or chemically
induced
Data from American Diabetes Association, 2012.
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PREGESTATIONAL DIABETES
Diagnosis
• The increasing prevalence of • Women with high plasma
type 2 diabetes in general, and glucose levels, glucosuria, and
in younger people in ketoacidosis present no
particular, has led to an problem in diagnosis. Similarly,
increasing number of affected women with a random
pregnancies (Ferrara, 2007). plasma glucose level > 200
mg/dL plus classic signs and
• In Los Angeles County, symptoms such as polydipsia,
Baraban and coworkers (2008) polyuria, and unexplained
reported that the age-adjusted weight loss or those with a
prevalence tripled from 14.5 fasting glucose level exceeding
cases per 1000 women in 1991 125 mg/dL are considered by
to 47.9 cases per 1000 in the ADA (2012) to have
2003. overt diabetes.
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Diagnosis of Overt Diabetes in
Pregnancy
• Apply to women without known
o Fasting plasma diabetes antedating pregnancy.
glucose At least 7.0 The decision to perform blood
testing for evaluation of
mmol/L (126 mg/dL) glycemia on all pregnant
o Hemoglobin A1c At women or only on women with
characteristics indicating a
least 6.5% high risk for diabetes is based
on the background frequency
o Random plasma of abnormal glucose
Glucose At least metabolism in the population
11.1 mmol/L (200 and on local circumstances.
• Modified from International Association
mg/dL) plus of Diabetes and Pregnancy Study
Groups Consensus Panel, 2010.
confirmation
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Impact on Pregnancy
• With pregestational
—or overt—diabetes,
the embryo, fetus, and
mother frequently
experience serious
complications directly
attributable to
diabetes.

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Pregnancy Outcomes of Births in Nova Scotia from 1988
to 2002 in Women with and without Pregestational Diabetes
o Gestational hypertension 28 : 9 < .001
o Preterm birth 28 : 5 < .001
o Macrosomia 45 : 13 < .001
o Fetal-growth restriction 5 : 10 < .001
o Stillbirth 1.0 : 0.4 .06
o Perinatal death 1.7 : 0.6 .004

Adapted from Yang, 2006.

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Fetal Effects
o Spontaneous Abortion.
o Preterm Delivery.
o Malformations.
o Altered Fetal Growth
(macrosomia).
o Unexplained Fetal Demise
o Hydramnios.
o Neonatal Effects.
o Respiratory Distress Syndrome
o Hypoglycemia.
o Hypocalcemia.
o Hyperbilirubinemia and
Polycythemia.
o Cardiomyopathy.
o Long-Term Cognitive
Development.
o Inheritance of Diabetes.

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Congenital Anomalies in Fetuses of 91 Women with
Type 1 Diabetes between 1999 and 2004 in Norway

o Cardiovascular 47 (52) MATERNAL EFFECT


o Musculoskeletal 11 (12) 1. Preeclampsia.
o Urogenital 8 (9) 2. Diabetic
Nephropathy.
o CNS 4 (4)
3. Diabetic Retinopathy.
o Gastrointestinal 2 (2)
4. Diabetic Neuropathy.
o Chromosomal 3 (3)
5. Diabetic
o Others 9 (10)
Ketoacidosis.
o Multiorgan 7 (8)
6. Infections.
CNS = central nervous system.
Data from Eidem, 2010.
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Diabetic Ketoacidosis.
o This serious complication develops in approximately 1 percent of
diabetic pregnancies (Hawthorne, 2011). It is most often encountered in
women with type 1 diabetes. It is increasingly being reported in
women with type 2 or even those with gestational diabetes
(Sibai, 2014).

o Diabetic ketoacidosis (DKA) may develop with hyperemesis


gravidarum, β-mimetic drugs given for tocolysis, infection, and
corticosteroids given to induce fetal lung maturation.

• The ketone body β-hydroxybutyrate is synthesized at a much


greater rate than acetoacetate, which is preferentially detected
by commonly used ketosis detection methodologies. Therefore,
serum or plasma assays for β-hydroxybutyrate more accurately
reflect true ketone body levels.
• The incidence of fetal loss can be as high as 20 percent with
DKA.
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Management of Diabetes in
Pregnancy
Preconceptional Care
First Trimester
• Insulin Treatment
• Monitoring.
• Diet.
• Hypoglycemia.
Second Trimester
Third Trimester and
Delivery
Puerperium
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GESTATIONAL DIABETES
o In the United States, Screening and
5 to 6 percent Diagnosis
of pregnancies— Plasma glucose mmol/L mg/dL
almost 250,000
o FASTING 5.1 92 8.3
women—are
affected annually by o 1-hr OGTT 10.0 180 14.0
various forms of o 2-hr OGTT 8.5 153 6.1
gestational
diabetes.

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Fifth International Workshop Conference on Gestational
Diabetes: Diagnostic Criteria of Gestational Diabetes by Oral
Glucose Tolerance Testing

Time 100-g Glucose 75-g Glucose


Fasting 95 mg/dL 5.3 mmol/L 95 mg/dL 5.3 mmol/L
1-hr 180 mg/dL 10.0 mmol/L 180 mg/dL 10.0 mmol/L
2-hr 155 mg/dL 8.6 mmol/L 155 mg/dL 8.6 mmol/L
3-hr 140 mg/dL 7.8 mmol/L ——
The test should be performed in the morning after an overnight fast of at
least 8 hr but not more than 14 hr and after at least 3 days of
unrestricted diet (≥ 150 g/d) and physical activity. The subject should
remain seated and should not smoke during the test.
Two or more of the venous plasma glucose concentrations listed must be met or
exceeded for a positive diagnosis.

Data from Metzger, 2007.


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Maternal and Fetal Effects
Management
oFetal o Diabetic Diet
o Exercise
Macrosomia o Glucose Monitoring
oNeonatal o Insulin Treatment
Hypoglycemia o Oral
Hypoglycemic
oMaternal Agents (glyburide
Obesity (Micronase) or
metformin
(Glucophage)

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GESTATIONAL DIABETES
Obstetrical • Elective cesarean
Management delivery to avoid brachial
plexus injuries in overgrown fetuses
• In general, for women with is also an important issue. The
American College of Obstetricians
gestational diabetes who do not and Gynecologists (2013) has
require insulin, early delivery or suggested that cesarean delivery
other interventions are seldom should be considered in women with
gestational diabetes whose fetuses
required. have a sonographically estimated
weight ≥ 4500 g.
• The American College of
Obstetricians and Gynecologists • Postpartum Evaluation
(2013) endorses fetal surveillance in • Recurrent Gestational
women with gestational diabetes Diabetes
and poor glycemic control. • Contraception
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WASSALAMU’ALAIKUM WW

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