What is COPD?Around 3 million people in the UK are thought to have COPD – chronic obstructive pulmonary disease. American Thoracic Society and European Respiratory Society, Standards for the Diagnosis and Management of Patients with COPD, 2004. NCI Cancer Bulletin, "Searching For Commonalities Between Two Deadly Lung Diseases," March 9, 2010. To provide even greater transparency and choice, we are working on a number of other cookie-related enhancements. Cardiovascular disease (CVD) complicates 1% to 4% of pregnancies,1 with congenital heart disease (CHD) being the most common preexisting condition and hypertension the most common acquired condition.
Major hemodynamic changes occur during pregnancy, labor and delivery, and the postpartum period (Table 1).
It should be noted that pregnancy also induces a hypercoagulable state, due to an increase in clotting factors as well as stasis induced by the compression of the inferior vena cava by the uterus. Pregnancy is also characterized by a complex series of hormonal and metabolic changes that govern glucose regulation. These marked hemodynamic changes during pregnancy account for signs and symptoms during normal pregnancy that can mimic that of heart disease. It is advised that individuals with structural cardiac disease who have undergone surgical or catheter-based repair should not be considered "corrected," as some residual disease almost always remains and the responses to the physiology of pregnancy can be unpredictable. Specific congenital or acquired cardiac lesions are classified as low, intermediate, or high risk during pregnancy (Box 1).
Ostium secundum atrial septal defect (ASD), the most common congenital cardiac lesion encountered during pregnancy, is usually well tolerated. Isolated ventricular septal defects (VSD) are low-risk lesions that are usually well tolerated during pregnancy. The presence of a PDA during pregnancy is not associated with additional maternal risk, provided the shunt is small to moderate and the pulmonary artery pressures are normal. Women with pre-existing severe mitral regurgitation may develop heart failure symptoms during pregnancy, particularly during the third trimester. Like chronic mitral regurgitation, chronic aortic regurgitation is generally well tolerated during pregnancy. The development of atrial fibrillation in the pregnant patient with mitral stenosis can result in rapid decompensation.
The most common etiology of aortic stenosis in women of childbearing age is a congenitally bicuspid valve.
Coarctation of the aorta is a narrowing in the region of the ligamentum arteriosum, just distal to the origin of the left subclavian artery, usually presenting with resistant hypertension in childhood.
If at all possible, coarctation of the aorta should be corrected prior to pregnancy with standard surgical repair or balloon angioplasty with endovascular stent placement.
It is estimated that pregnancy in patients with Marfan syndrome carries a 1% risk of serious cardiac complications. Medical management involves the use of beta-blockers throughout pregnancy to reduce the risk of aortic rupture, careful control of blood pressure, and consideration of general anesthesia and cesarean section at the time of delivery to maximize hemodynamic control. The high-risk conditions listed in Box 1 are associated with increased maternal and fetal mortality, and pregnancy is not advised. The Eisenmenger syndrome is a consequence of uncorrected long-standing left-to-right shunting. Because of the considerable risk to both the mother and the fetus, pregnancy is contraindicated in women with Eisenmenger syndrome. Women with heart failure of any etiology and an ejection fraction (EF) <40% or NYHA class III-IV symptoms should be counseled to avoid pregnancy. A group of disorders collectively known as maternal placental syndromes (MPS) have been associated with increased risk of maternal premature CVD. Hypertensive disorders can complicate 12% to 22% of pregnancies and are a major cause of maternal morbidity and mortality.
Gestational hypertension is defined as hypertension developing after 20 weeks gestation not associated with proteinuria or other features of preeclampsia that resolves by 42 days postpartum. Preeclampsia occurs in 3% to 8% of pregnancies in the United States but increases in incidence in patients with preexisting hypertension.
Peripartum cardiomyopathy (PPCM) is defined as new-onset idiopathic LV systolic dysfunction in the interval between the last month of pregnancy and the first 5 months postpartum. PPCM has long been regarded as a disease of unknown etiology, with possible triggers including viral infection and autoimmunity. Acute myocardial infarction (AMI) during pregnancy is rare, occurring in approximately 1 in 35,000 pregnancies.
Premature atrial or ventricular complexes are the most common arrhythmias during pregnancy. Supraventricular tachyarrhythmia (SVT) is also common and often diagnosed with the aid of an event or Holter monitor.
De novo atrial fibrillation and atrial flutter are rare during pregnancy, although women with a history of prepregnancy tachyarrhythmias have a high likelihood of recurrence during pregnancy.
Ventricular tachycardia is rare during pregnancy, but when it arises, it most commonly originates from the right ventricular outflow tract with a left bundle morphology and inferior axis.
Patients with refractory tachycardia despite drug therapy can be considered for catheter ablation. Fetal tachycardia complicates about 0.5% of all pregnancies and is a significant cause of fetal morbidity and mortality, including fetal congestive heart failure, hydrops fetalis, and fetal demise. Commonly used cardiovascular drug classes and their potential adverse effects during pregnancy are shown in Table 3. The American Heart Association no longer recommends antibiotic prophylaxis for the prevention of bacterial endocarditis during genitourinary procedures, including vaginal delivery and cesarean section.
Several conditions require the initiation or the maintenance of anticoagulation during pregnancy, including mechanical valves, certain prothrombotic conditions, history of venous thromboembolism, acute deep venous thrombosis or thromboembolism during pregnancy, antiphospholipid antibody syndrome, and atrial fibrillation. The Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy has recommended three potential strategies for anticoagulation during pregnancy (Figure 3).17 In women with venous thromboembolism, LMWH has become the anticoagulant of choice. Warfarin crosses the placental barrier freely and can result in warfarin embryopathy (abnormalities of fetal bone and cartilage formation).
LMWH produces a more predictable anticoagulant response than UFH and is less likely to cause HITT. Blood volume and cardiac output rise during normal pregnancy, reaching a peak during the late second trimester. Preexisting cardiac lesions should be evaluated for the degree of risk to both the mother and the fetus during pregnancy. Contraindications to pregnancy include severe pulmonary hypertension or Eisenmenger's syndrome, cardiomyopathy with NYHA class III or IV symptoms, history of peripartum cardiomyopathy, severe uncorrected valvular stenosis, unrepaired cyanotic congenital heart disease, and Marfan syndrome with an abnormal aorta. Awareness of major cardiac drug classes contraindicated in pregnancy is important for the treatment of cardiovascular conditions during pregnancy.
Anticoagulation during pregnancy presents unique challenges stemming from maternal and fetal side effects of warfarin, unfractionated heparin, and LMWH. Siu SC, Sermer M, Colman JM, et al; on behalf of the Cardiac Disease in Pregnancy (CARPREG) Investigators.
Controlled placebo-studies shown that adding this method to the set of restorative treatment methods and rehabilitation of patients with chronic bronchopulmonary pathology in the phase of recovery and stabilization enables to achieve the best clinical effect with 82 – 96% of patients with the most appropriate doses of medication, and contribute to the improvement of the quality of life. HT is effective in  rehabilitation of patients after acute pulmonary diseases with prolonged sluggish and inflammatory processes, typical for protracted acute bronchitis and pneumonia, chronic bronchitis, bronchiectasis, after surgery, etc.
In pediatrics, HT is most commonly used for treatment and rehabilitation of kids with asthma (efficiency 75-85%), high efficiency is also achieved in the treatment of kids with recurrent bronchitis, especially in cases of obstructive forms.
HT has a good track record as a method of prevention and rehabilitation for kids when used in pre-school and educational institutions. The use of prevention treatments for tobacco smokers and those with exogenous risk factors enable to restore mucociliary clearance, eliminates early manifestations of obstruction and restore protection for respiratory tract. With only two weekly HT prevention courses within three-month time-period, a 1.5-2 times reduction of acute viral respiratory infections was achieved both with the pulmonary patients and relatively healthy persons, however exposed to the development of COPD. Application of special salt aerosol concentration modes enables to apply HT not only for respiratory diseases, but also for ENT-pathology, as well as in the field of dermatology. Controlled HT is successful for the treatment of skin diseases (atopic dermatitis, allergic dermatitis, eczema, psoriasis, etc.).
Dry sodium chloride aerosol provides a therapeutic anti-inflammatory, anti-edema impact on the mucosa of the pharynx, nose and paranasal sinuses in chronic pharyngitis, rhinitis and sinusitis. The use of HT for many years, that has proved the safety of the method in terms of adverse effects on the cardiovascular system, enables the method to be applied for patients with COPD who have concomitant cardiovascular disease, including the groups of aged people. However, the NHS says that only about 900,000 people been diagnosed with COPD, the remainder being unaware that they have the disease. It is intended for general information purposes only and does not address individual circumstances. These changes begin in the first 5 to 8 weeks of gestation and peak late in the second trimester. This is likely an evolutionary means by which to protect against maternal hemorrhage, and in fact, the most hypercoagulable time is the peripartum period. Typically, a state of maternal insulin resistance develops during the second and third trimesters. Relief of inferior vena caval compression results in an increase in venous return, which in turn augments cardiac output and causes a brisk autodiuresis. Normal pregnancy is typically associated with fatigue, dyspnea, and decreased exercise capacity. Noninvasive cardiac testing may include an electrocardiogram, plasma brain natriuretic peptide (BNP) testing, and an echocardiogram.
Whenever possible, women with known pre-existing cardiac lesions should receive preconception counseling. The CARdiac disease in PREGnancy (CARPREG) risk score has been shown to predict the risk of adverse cardiac complications during pregnancy (Table 2).
An uncorrected ASD does carry a small increased risk of paradoxical embolism, and therefore, deep vein thrombosis (DVT) prevention should be meticulous.
Percutaneous closure is now considered first-line therapy, and it is reasonable to close even asymptomatic small PDAs.
MVP is specifically stated as a low-risk condition for endocarditis in the American Heart Association 2007 guidelines and is not an indication for antibiotic prophylaxis at delivery.
In chronic mitral regurgitation, the physiologic reduction in SVR partially compensates for the additional volume overload generated by the regurgitant valve. In general, these symptoms can be managed medically with judicious use of diuretics and afterload-reducing agents.
In addition to the physiologic fall in SVR, the tachycardia of pregnancy shortens diastole and reduces the aortic regurgitant fraction.
Severe, symptomatic pulmonary stenosis may be treated with percutaneous pulmonary valvuloplasty prior to conception. Patients with moderate-to-severe mitral stenosis often experience hemodynamic deterioration during the third trimester or at the time of labor and delivery. Digoxin and beta blockers can be used to reduce heart rate and diuretics to gently reduce the blood volume and left atrial pressure. In contrast, patients with moderate-to-severe mitral stenosis should be referred to a cardiologist. However, patients with symptoms of congestive heart failure or moderate-to-severe mitral stenosis may need close hemodynamic monitoring during labor and delivery and for several hours into the postpartum period.
Mild-to-moderate aortic stenosis with preserved LV function usually is well tolerated during pregnancy. The valvuloplasty balloon is inserted across the aortic valve over a stiff wire into the left ventricle. Ideally, the patient should undergo correction of the valvular abnormality before conception. Coarctation is well tolerated during pregnancy, although hypertension, heart failure, angina, and aortic dissection are possible complications. Correction of coarctation during pregnancy is indicated in patients with severe uncontrollable hypertension, heart failure, or uterine hypoperfusion.
Thus, women with Marfan syndrome should receive genetic counseling well in advance of pregnancy.
Women with Marfan syndrome with no identifiable cardiac abnormalities have a low rate of complications and can usually tolerate a normal vaginal delivery. If pregnancy should occur, the risk of maternal mortality and morbidity must be assessed on an individual basis. Over time, pulmonary artery pressures approach and can exceed systemic pressures, resulting in cyanosis due to reversal of the shunt flow direction from right to left. PPCM and its implications for subsequent pregnancies are discussed further in the following section.
In CHAMPS (Controlled High-Risk Avonex Multiple Sclerosis Study),10 MPS were defined as the presence of preeclampsia, eclampsia, gestational hypertension, placental abruption, or placental infarction during pregnancy. The incidence of PPCM in the United States is estimated to be 1 in 3,000 to 1 in 4,000 live births; the incidence appears to be highest in Africa and Haiti (occurring in 1 in 300 pregnancies). Recent mouse models have demonstrated a role for a 16kDa protein derived from proteolytic cleavage of prolactin under oxidative stress.11 This derivative is cardiotoxic, anti-angiogenic, proapoptotic, proinflammatory, and is observed in higher levels in PPCM patients.
Approximately 50% of women completely recover normal heart size and function, usually within 6 months of delivery.12 The remainder either experience stable LV dysfunction or experience clinical deterioration. Independent predictors of AMI during pregnancy include chronic hypertension, hyperlipidemia, smoking, advanced maternal age, diabetes, and preeclampsia. Although thrombolytic agents increase the risk of maternal hemorrhage substantially (8%), their use is permitted in situations where cardiac catheterization facilities are not available. They are not associated with adverse maternal or fetal outcomes and do not require antiarrhythmic therapy. It is important that underlying conditions such as hyperthyroidism or structural heart disease be ruled out. Other etiologies include PPCM, long QT syndrome, thyrotoxicosis, or hyperemesis gravidarum. If at all possible, ablation should be postponed until the second trimester and performed at an experienced center.
Therapy includes transplacental therapy, direct fetal therapy, or early delivery and neonatal therapy. The three most common agents considered for use during pregnancy are unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and warfarin.
In women with mechanical heart valves, data are more limited and there has been concern regarding the efficacy of heparin products with respect to preventing valve thrombosis.


The risk of warfarin embryopathy has been estimated at 4% to 10%, but is minimized when the daily dose is less than 5 mg. Its use, however, has been associated with maternal osteoporosis, hemorrhage, thrombocytopenia, thrombosis (HITT syndrome), and a high incidence of thromboembolic events with older-generation mechanical valves.
In planned pregnancies, a careful discussion regarding the risks and benefits of warfarin, UFH, and LMWH are crucial in determining an appropriate anticoagulation strategy. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Predictors of pregnancy complications in women with congenital heart disease [published online ahead of print June 28, 2010]. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study.
Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation.
Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. Acute myocardial infarction in pregnancy: a United States population-based study [published online ahead of print March 13, 2006].
Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes [published online ahead of print March 3, 2006]. Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Therapeutic impact of HT enables to significantly reduce the prescription of antibacterial agents that helps prevention of dysbacteriosis and allergic reactions with kids. Prevention courses for frequently ill kids reduce the risk of recurrent disease by 1.5-2 times and accelerate recovery. Stay in halocomplex provides a positive cleaning action, restores skin biocenosis, enhance microcirculation, which is used in cosmetic applications. The use of HT for the patients with asthma and COPD older than 60 years with coronary heart disease, dyscirculatory encephalopathy enabled to achieve a positive clinical effect with the absence of any adverse reactions.
It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Studies suggest that pregnancy-related mortality has also increased over the last several decades, with deaths attributable to CVD increasing over the same time period.2 Given the potential complications associated with maternal CVD, the ability to both counsel patients prior to pregnancy and appropriately manage patients during pregnancy is of vital importance. Insulin resistance is a physiologic response that favors a shift in the glucose supply to the fetus.
Stroke volume increases, with a resultant rise in cardiac output by an additional 50% with each contraction.
The hemodynamic changes return to the prepregnancy baseline within 2 to 4 weeks following vaginal delivery and 4 to 6 weeks following cesarean section. The electrocardiogram may reveal a leftward axis deviation, especially during the third trimester when the uterus pushes the diaphragm upward.
This should include contraceptive advice, quantification of maternal and fetal risks during pregnancy, and discussion of possible long-term morbidity and mortality after pregnancy. VSD can occur in conjunction with other congenital cardiac lesions, including ASD, patent ductus arteriosus (PDA), mitral regurgitation, and transposition of the great arteries.
Following repair of more significant PDAs, women are at no additional risk for complications during pregnancy. However, the development of new atrial fibrillation or severe hypertension can disrupt this balance and precipitate hemodynamic deterioration. Nitrates, hydralazine and dihydropyridine calcium channel-blocking agents can serve as relatively safe afterload-reducing agents in pregnant women.
Marfan syndrome should be considered as an etiology, given the implications of aortic root instability during pregnancy.
If necessary during pregnancy, percutaneous pulmonary valvuloplasty should be delayed until after the first trimester to avoid fetal radiation exposure during early development. The physiologic increase in blood volume and rise in heart rate lead to an elevation of left atrial pressure, resulting in pulmonary edema. The development of atrial fibrillation increases the risk of stroke, necessitating the initiation of anticoagulation (see "Medication Guidelines During Pregnancy"). In these patients, epidural anesthesia is usually better tolerated hemodynamically than general anesthesia. Treatment options include surgical valve repair, surgical valve replacement, or percutaneous balloon valvotomy but require a multidisciplinary approach to determine the appropriate treatment option. Coarctation can be associated with intracerebral aneurysms, which may rupture during pregnancy.
The clinical manifestations of Marfan syndrome include skeletal abnormalities, ectopia lentis, and cardiovascular abnormalities such as aortic root dilatation with or without aortic regurgitation, aortic dissection, and MVP. There is some evidence that pregnancy in women with Marfan syndrome may be relatively safe up to 4.5 cm.
If deemed extremely high, consideration of medical termination of pregnancy is advised to safeguard the mother's health. Eisenmenger syndrome is a possible common endpoint of multiple congenital lesions, including ASD, VSD, and PDA. Women who choose to continue with pregnancy are advised to restrict physical activity, use continuous oxygen for at least the third trimester and consider use of pulmonary vasodilating drugs such as iloprost and prostacyclin.
Studies show that a low maternal oxygen saturation (<85%) correlates with a very low rate of live-born infants (12%). Hypertension during pregnancy is classified into three main categories: chronic hypertension, gestational hypertension, and preeclampsia with or without preexisting hypertension. Women of childbearing age who take chronic antihypertensive medications should be counseled in regards to their safety well in advance of a potential pregnancy. Although it resolves after delivery, women with this condition may be at risk for developing hypertension or CVD in the future. Risk factors include maternal age >30 years, obesity, multiparity, multiple fetuses, pre-eclampsia, eclampsia, chronic hypertension, African descent, low socioeconomic status or tocolytic therapy with beta-agonists.
Furthermore, small numbers of postpartum women with PPCM have shown favorable cardiac outcomes with bromocriptine, a dopamine receptor agonist that inhibits prolactin secretion. Beta-blockers are generally safe, although there have been case reports of fetal bradycardia and growth retardation. Mortality at 2 years is approximately 9% in the white population and 15% in the African American population. Most myocardial infarctions occur during the third trimester and are most common in multiparous women over the age of 33. In addition, beta blockers, digoxin, or both can be useful in controlling the ventricular rate. Recurrent tachyarrhythmias during pregnancy are associated with an increased risk of adverse fetal complications, including premature birth, low birth weight, respiratory distress syndrome, and death.16 Management strategies for atrial fibrillation and flutter are similar to that of SVT. VT associated with structural heart disease is associated with a significant risk of death and should be promptly treated per ACLS guidelines. Cardioverter-defibrillator implantation should be considered if necessary to protect the mother's life. Fetal echocardiography, using M-mode and pulsed wave Doppler ultrasound, is extremely useful in diagnosing fetal arrhythmias. Digoxin is the initial drug of choice for transplacental therapy and can be delivered via direct fetal injection. Studies suggest that oral anticoagulation with warfarin throughout pregnancy is the safest regimen for the mother.
Although the highest risk period is during the first trimester (weeks 6-12), warfarin use during the second and third trimesters has been associated with fetal central nervous system abnormalities, such as optic atrophy, microencephaly, mental retardation, spasticity, and hypotonia. UFH may be administered parenterally or subcutaneously throughout pregnancy; when used subcutaneously for anticoagulation of mechanical heart valves, the recommended starting dose is 17,500 to 20,000 units twice daily.
The use of HT as a method of conservative treatment of nose pathology diseases enables to achieve positive results in 72 – 87%% cases with the greatest efficiency for vasomotor and allergic rhinitis. Clinical observation and experience of controlled HT application showed a general favorable effect of HT on the cardiovascular system. Never ignore professional medical advice in seeking treatment because of something you have read on the BootsWebMD Site.
The complexity of these patients requires a multidisciplinary approach with the involvement of obstetricians, cardiologists, anesthesiologists, and internists who are experienced in caring for these patients.
Blood volume increases 40% to 50% during normal pregnancy and outweighs the increase in red blood cell mass, contributing to the fall in hemoglobin concentration otherwise known as anemia of pregnancy. In normal women, this is countered by a steady increase in basal insulin secretion and a marked increase in insulin secretion immediately after a glucose load (first phase).
Most pregnant women have audible physiologic systolic murmurs as a result of augmented blood flow. Unfortunately, many women with pre-existing heart disease are not aware of the risks of pregnancy. While the CARPREG study included both acquired and CHD, the more recent ZAHARA predictors were developed based on a population of CHD patients.6 The predictors included history of arrhythmia, baseline NYHA class III-IV, left heart obstruction, mechanical valve prosthesis, moderate-to-severe atrioventricular valve regurgitation, moderate-to-severe subpulmonary atrioventricular valve regurgitation, use of cardiac medication prior to pregnancy, and repaired or unrepaired cyanotic heart disease. Although rare during the childbearing years, the presence of pulmonary hypertension substantially increases the risk of cardiac complications during pregnancy.
The risk associated with a VSD repaired prior to the development of pulmonary hypertension is negligible. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are strictly contraindicated during pregnancy. Aortic regurgitation is generally medically managed during pregnancy with diuretics and afterload reduction. Pulmonary stenosis frequently coexists with other congenital cardiac lesions that may cause cyanotic heart disease.
Additional displacement of blood volume into the systemic circulation during contractions makes labor particularly hazardous. With hemodynamically unstable atrial fibrillation, electrocardioversion can be performed safely. If severe mitral stenosis is discovered during pregnancy, medical therapy with diuretics and digoxin is preferred. Symptoms such as dyspnea, angina pectoris, or syncope usually become apparent late in the second trimester or early in the third trimester.
When severe symptomatic aortic stenosis is diagnosed during pregnancy, maximal medical therapy is preferred over intervention. Hypotension in vascular beds distal to the coarctation can compromise uteroplacental blood flow, resulting in intrauterine growth retardation. If the pregnancy is continued, patients are best managed with the assistance of a cardiologist and a maternal-fetal medicine specialist at a center with high-risk obstetrical facilities and a level three neonatal unit.
Maternal mortality in women with Eisenmenger syndrome ranges from 30% to 50%, with a 50% risk of fetal loss if the mother survives. The most common cyanotic congenital defect, tetralogy of Fallot, is characterized by a VSD, pulmonic stenosis, right ventricular outflow tract obstruction, and an overriding aorta.
Although an increase in blood volume helps to reduce intracavitary or LV outflow tract gradients, tachycardia and a reduction in SVR can exacerbate outflow tract obstruction. Risk factors, such as smoking, diabetes, hypertension, hyperlipidemia, and thrombophilia, are associated with increased risk of spontaneous abortion, maternal placental syndromes ([MPS] see next section), preterm labor or premature rupture of membranes, and acute arterial or venous thromboses during pregnancy. Interestingly, traditional cardiovascular risk factors were more prevalent in women with MPS as compared to women without MPS. Most notably, women who are treated with ACE inhibitors should be made aware of the potential teratogenic effects.
Therefore, they should undergo physical examination and screening for traditional cardiovascular risk factors annually after pregnancy. Symptoms usually begin in the third trimester and occur more frequently during the first pregnancy. Women with PPCM who attempt a subsequent pregnancy face high risk of complications, including deterioration of LV function, symptomatic heart failure, and death. Coronary spasm, in situ coronary thrombosis, and spontaneous coronary artery dissection occur more often than classic obstructive atherosclerosis.
Short-term heparin administration has not been associated with increased maternal or fetal adverse effects. Adenosine and direct-current cardioversion are both safe during pregnancy and can be used to treat SVT. Most antiarrhythmic medications used to treat ventricular tachycardia are safe during pregnancy, although amiodarone is not recommended given fetotoxic effects (iodine component may cause neonatal goiter).
Bradyarrhythmias are uncommon during pregnancy, but if necessary, pacemaker support is recommended in complete heart block, symptomatic bradyarrhythmia, or hemodynamic deterioration. Warfarin's anticoagulant effect is more potent for the fetus than the mother given the fetus has lower levels of vitamin K-dependent clotting factors. Today the controlled HT is added to the rehabilitation programs for patients with cardiovascular pathology. Similarly, cardiac output rises 30% to 50% above baseline, peaking at the end of the second trimester and reaching a plateau until delivery. In contrast, women with gestational diabetes exhibit impaired pancreatic β-cell secretory function and demonstrate a blunted first-phase insulin secretion response to glucose loading. A physiologic third heart sound (S3), reflecting increased blood volume, can sometimes be auscultated. In one questionnaire-based study of 116 adult females with CHD, of which 55% had been pregnant at least once, 37% of respondents reported that they had never been informed that they were at increased risk for maternal cardiac complications during pregnancy.
Although such scores serve as an overall assessment of risk, pre-pregnancy counseling should be tailored according to specific cardiac lesions. A secundum ASD that has been repaired prior to pregnancy is not associated with any increased risk of cardiac complications. The most common causes of mitral regurgitation are rheumatic heart disease and myxomatous degeneration. Women with severe symptomatic mitral regurgitation prior to pregnancy should consider operative repair prior to conception. Operative repair prior to pregnancy is feasible in certain patients, especially when the valve is anatomically bicuspid. If symptoms cannot be controlled with medical therapy, percutaneous valvuloplasty can be performed in the second or third trimester to prevent fetal radiation exposure during the first trimester. However, if the patient has refractory symptoms and hemodynamic deterioration despite maximal medical therapy, percutaneous balloon valvotomy may be performed (Figure 2).
Coarctation of the aorta is often associated with a congenitally bicuspid aortic valve, which increases the risk of infective endocarditis.


It is thought that oxytocin stimulation during breast-feeding may activate the ERK pathway, which has been recently implicated in the pathophysiology of this condition.
The most vulnerable period for the mother is labor and delivery and the first week postpartum.
Women with tetralogy of Fallot who have undergone successful repair in childhood may tolerate pregnancy, provided they have little or no residual right ventricular outflow tract gradient, no pulmonary hypertension, and preserved ventricular function.
Furthermore, the presence of such risk factors also predicts future development of coronary artery disease, chronic hypertension, stroke, and peripheral arterial disease in the mother.
Women with MPS were two times as likely to experience a hospital admission or revascularization procedure for coronary, cerebrovascular, or peripheral vascular disease compared to women without MPS. Women with chronic hypertension have an increased risk of developing preeclampsia and should be made aware of the signs and symptoms of preeclampsia.
ACE inhibitor fetopathy includes oligohydramnios, intrauterine growth retardation, hypocalvaria, renal dysplasia, anuria, and death.
Given the recurrence risk of 30% to 50%, some experts counsel affected women against subsequent pregnancies.13 It should be noted that the majority of maternal deaths have occurred in women whose LV function remained abnormal prior to future pregnancies and LVEF at first PPCM diagnosis seems to be a major prognostic indicator. Spontaneous coronary artery dissection is more common in pregnant than non-pregnant women and often effects the left main trunk or the left anterior descending artery.
If patients do not respond to rate control, antiarrhythmic agents such as sotalol, fleicanide, or propafenone can be used. If the patient is started on LMWH, this should be switched to intravenous UFH at least 36 hours before delivery, stopped 4 to 6 hours before deliver, and restarted 4 to 6 hours after delivery. Warfarin can cause spontaneous abortion, prematurity, stillbirth, neonatal intracranial hemorrhage or retroplacental hematoma. High doses of UFH are often required to achieve the goal aPTT due to the hypercoagulable state associated with pregnancy. There are data to support the use of LMWH in pregnant women with deep venous thrombosis, but data on the safety and efficacy of LMWH in pregnant patients with mechanical valve prostheses are limited.
COPD tends to get worse over time, but diagnosing it early, along with good care, can help many people stay active and may slow progression of the disease. The increase in cardiac output is achieved by three factors: an increase in preload due to greater blood volume, reduced afterload due to a fall in systemic vascular resistance (SVR), and a rise in the maternal heart rate by 10 to 15 beats per minute. The cardiovascular consequences of gestational diabetes can include macrosomia, shoulder dystocia, future development of maternal type 2 diabetes and an increased risk of obesity and type 2 diabetes in the offspring. Blood loss during delivery (300-400 mL for a vaginal delivery and 500-800 mL for a cesarean section) can contribute to hemodynamic stress. Abnormal signs and symptoms during pregnancy include exertional chest pain, paroxysmal nocturnal dyspnea, orthopnea, sustained atrial or ventricular arrhythmias, pulmonary edema, severe obstructive systolic murmurs, diastolic murmurs, and an S4 gallop. Elevations in BNP are a useful guide in managing early cardiac dysfunction and the hypertensive disorders of pregnancy. Device or operative repair of hemodynamically significant ASDs should be performed prior to conception.
Hypertrophic cardiomyopathy (HCM) and mitral annular dilatation secondary to dilated cardiomyopathy can also result in mitral regurgitation. Although repair is strongly preferred to valve replacement before pregnancy, the success of operative repair is dependent on suitable valve anatomy. Spinal and epidural anesthesia are discouraged during labor and delivery because of their vasodilatory effects. The aortic wall adjacent to an area of coarctation has histologic features of cystic medial necrosis, which renders it vulnerable to dissection. In addition, women with Marfan syndrome may be more prone to spontaneous abortion and preterm labor. Vaginal delivery, facilitated by vacuum or low forceps extraction, is the delivery method of choice. Genetic counseling and screening for the 22q11 deletion should be offered as its transmission is autosomal dominant.
Emerging risk factors for future CVD in women include maternal obesity and gestational diabetes. The growing body of evidence linking cardiovascular risk factors, MPS, and future CVD might indicate underlying vascular pathology that predates pregnancy and can manifest as MPS during pregnancy or chronic CVD later in life. Hydralazine is an effective afterload-reducing agent, although it is currently listed as a category C agent (adequate and well-controlled studies in pregnant patients are lacking and should be used only when the expected benefit outweighs the potential risk to the fetus). Dissections have been successfully treated medically, and if refractory to medical management, with coronary stenting or coronary artery bypass grafting.
It is typically necessary to use higher doses of digoxin and other antiarrhythmic medications in pregnant women due to decreased plasma concentrations of drug caused by increased blood volume and higher glomerular filtration rates.
Lower doses of UFH may be appropriate when using anticoagulation for the prevention of venous thromboembolism during pregnancy. Symptoms of COPDInside the lungs, COPD can clog the airways and damage the tiny, balloon-like sacs (alveoli) that absorb oxygen. Stroke volume increases during the first and second trimesters but declines in the third trimester due to compression of the inferior vena cava by the uterus, at which point heart rate is the major factor in the increase in cardiac output. Echocardiography is an invaluable tool for the diagnosis and evaluation of suspected cardiac disease in the pregnant patient.
There is evidence that patients with secundum ASDs are at elevated risk of bacterial endocarditis. During pregnancy, surgical intervention for both mitral and aortic regurgitation is rarely undertaken and performed only for refractory heart failure. Thus, women who have previously undergone surgical repair of an aortic coarctation remain at risk for complications during pregnancy.
Fetal risk due to maternal hypoxemia is substantial, with a high incidence of fetal loss, premature delivery, intrauterine growth retardation, and perinatal death.
Cesarean delivery is associated with a substantially higher mortality than the vaginal route. Whenever possible, women should receive genetic counseling prior to conception, given the heritability of certain forms of HCM approaches 50%.
It should be noted that methyldopa alone has been studied in trials of treatment of hypertension during pregnancy.
In even mild preeclampsia, elevation of BNP can precede other laboratory abnormalities, such as platelet and liver function abnormalities.
Therefore, clopidogrel should be used for the shortest period of time possible, favoring bare metal stenting.
However, data show that for mechanical valves the risk of valve thrombosis is substantially less with warfarin versus UFH (3.9% vs.
Blood pressure typically falls approximately 10 mm Hg below baseline by the end of the second trimester due to reduction in SVR and addition of new blood vessels in the uterus and placenta. Normal changes attributable to pregnancy include increased left ventricular (LV) mass and dilatation. Holt-Oram syndrome, a rare heart–upper limb malformation complex that most commonly includes ASD, requires additional consideration given the potential for autosomal dominant transmission of the TBX5 gene defect to offspring. Anesthetic management includes central venous and arterial pressure monitoring, with maintenance of adequate SVR and intravenous volume and prevention of sudden increases in pulmonary vascular resistance.
Pregnancy can precipitate supraventricular arrhythmias that may rapidly conduct over the accessory pathway.
Although definitive treatment includes delivery of the baby, many women with preeclampsia require treatment with antihypertensive medications before delivery and for some period of time after. Percutaneous coronary intervention with either balloon angioplasty or stenting has been successfully performed in pregnant patients with AMI.15 Studies suggest that the dose of radiation during percutaneous intervention do not reach levels that are harmful to the fetus, particularly if the procedure is performed greater than 12 weeks after conception.
If the frequency of SVT episodes decreases over several months after delivery, the arrhythmia can be managed medically. Surgical correction reduces the maternal risk of pregnancy but does not reduce the risk of congenital anomalies in the fetus. When medical therapy is not successful, women with PPCM may ultimately require advanced mechanical support or cardiac transplantation. If SVT continues to occur frequently and with rapid rates, it may be best treated with electrophysiologic ablation. There are data that warfarin doses greater than 5 mg daily pose the greatest risk to the fetus.
Individuals with a single functional ventricle will often have a palliative version of the Fontan procedure during childhood. For these patients, substitution of oral anticoagulant therapy with UFH or LMWH in weeks 6 to 12 decreases the risk. Heart failure, thromboembolism and atrial arrhythmias occur in 10% to 20% pregnant patients with this anomaly, and fetal loss can reach 50%. The patient must understand that while this decreases the risk of embryopathy (see below), it does increase the risk of valve thrombosis.
Inside the lungs, the small airways have swollen walls, constant oozing of mucus and scarring. Experience with pregnancy in women with surgically corrected D-transposition of the great arteries, truncus arteriosus, or tricuspid atresia is limited.
As with pregnancy-induced hypertension, women with these conditions should receive annual cardiovascular evaluation. Women with congenitally corrected transposition (L-transposition) and no cyanosis, heart failure or conduction disease should tolerate pregnancy well.
Pre-term delivery rates in these complex conditions range from 22% to 65%, and an elevated rate of premature rupture of membranes has been associated with Fontan patients and transposition.
COPD: EmphysemaEmphysema damages the tiny air sacs in the lungs, which inflate when we take in a breath and move oxygen into the blood. In time, the damage destroys the air sacs, leaving large spaces in the lungs, which trap stale air. Diagnosis: Physical examinationFirst, a doctor will ask about your smoking history and whether you have a family history of COPD, then will listen to your chest as you breathe.
The amount of oxygen in your blood may be measured with a blood test or a pulse oximeter, a painless device that clips to a finger. You might repeat the test after inhaling a puff of a bronchodilator drug that opens up your airways. Diagnosis: Chest x-rayA chest X-ray isn't used to diagnose COPD but it may help rule out conditions that cause similar symptoms, such as pneumonia.
Treatment: BronchodilatorsBronchodilators are drugs that relax the muscles of the airways to help keep them open and make it easier to breathe. Short-acting bronchodilators last about four to six hours and are used on an as-needed basis.
Longer-acting bronchodilators can be used every day for people with more persistent symptoms. Treatment: Lung trainingMany hospitals offer pulmonary rehabilitation (PR) courses that teach people ways to keep up with their daily activities without as much shortness of breath. Classes also focus on education, psychological support, advice on quitting smoking and nutritional advice. Breathe in normally through your nose, then slowly blow the air out through your mouth with your lips in a whistle or kissing position. Treatment: Oxygen therapyCOPD reduces the oxygen in your blood, so extra oxygen may be needed for your body. It can help you stay active without feeling as tired or out of breath and help protect your brain, heart and other organs. If you have COPD and need supplemental oxygen, you will typically get the oxygen through tubing from an oxygen cylinder to the nostrils. If your cough and shortness of breath get worse, or you develop a high temperature, seek medical advice.
These are signs that a lung infection may be taking hold and your doctor may prescribe medicine to help treat it as quickly as possible.
Treatment: SurgeryA small number of people with significant lung damage from COPD may benefit from surgery.
Bullectomy and lung volume reduction surgery remove the diseased parts of the lung, allowing the healthy tissue to perform better and making breathing easier. A lung transplant may help some people with the most severe COPD who have lung failure, but it can have serious complications. Start with just five or 10 minutes at a time, three to five days a week, or whatever you can manage or your doctor advises. What causes COPD?The vast majority of people with COPD are current or former smokers and their disease usually appears after age 40. Secondhand smoke and exposure to environmental irritants and pollution can also increase your risk of COPD. In rare cases the DNA passed down through a family can lead to COPD, even in "never smokers". Tobacco smoke destroys the tiny hair-like cilia that normally clean the airways, and harms the lungs in other ways too. Quitting will slow, or possibly prevent, further damage and is simply the most important step you can take for COPD.
Talk to a registered dietitian or a respiratory specialist nurse about the best eating plan for you. COPD and cancerMany people with COPD also develop lung cancer -- probably due to a history of smoking cigarettes. Researchers are studying whether specific genes make some people more vulnerable to COPD, or cancer, or both diseases. Chronic inflammation, caused by smoking or other lung irritants, could play a role in COPD and cancer as well. You may need to pace yourself or use oxygen therapy but staying active will make you stronger. Avoid secondhand smoke, chemical fumes and other lung irritants.  Be sure to get vaccinated against the flu and pneumococcal disease. Wash your hands frequently and avoid people who are coughing and sneezing, especially during the cold and flu season.
Organisations like the British Lung Foundation can also provide support and practical tips about COPD to get the most out of every day.



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