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  1. Methods: This study was conducted at a tertiary care teaching institute in north# India. Seventy consecutive patients with PD diagnosed as per the modified UK Brain Bank criteria were included. Various striatal (hand & foot) and postural (antecollis, camptocormia, scoliosis & Pisa syndrome) deformities and their relation with  Missing: pokie ‎tarantula.:
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  2. Abramson and co-workers, and Burt deinonstiated increased flow through the hands. Palmar reddening is a commonly obsersed antenatal phenomenon. In gravid patients, spider angiomas appear fretjuentl), and almost invariably pre-existent hemangiomas increase in sire. Super- ficial veins of the breasts and abtlomen.:
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Dietary instructions which refer specifically to salt rather than to sodium are inadequate, for some p. Diels cosering the nuiritise aliosvances for pregnane and containing to mg. McCartnc and associates studied toxemic water and sodium reten- tion in relation to gross bod composition.

Their findings are reproduced m Table 2 Chapter 1 de Alvarez and co-workers observed that the exaggerated, positive water and sodium balances in toxemic pregnancy resulted from a super- normal depression of the glomcnilar filtration rate Chapter 7. MacGillivray and Buchanan, however, observed that the amount of sodium retained in preeclamptic women was the same as in normal pregnant women, although retention of water was greater in the former than in the latter.

A classic example of fluid retention often is observed in the presence of hydatidiform mole. Here the basic disturbance is due to humoral iniluences. The incidence of toxemia m rheumatic and in congenital heart dis- ease is no higher than in the general clinic population However, the incidence of toxemia is increased in hypertension, chorea, heart block, kyphoscoliosis, sickle cell anemia, sickle cell-hemoglobin C disease, and in th Totoxicosis.

Except in heart block, the causative factor is the iinder- l ing disease process rather than the actual cardiac involvement In progressive kidney disease, impaired sodium excretion also leads to water retention and hypervolemia.

Although cortisone and corticotropin ACTH are known to disrupt gestation in laboratory animals, these drugs have been used in pregnant women for a wide variety of conditions vvithout similar adverse elTeci. Furthermore, during pregnancy, the rarity of clinically active rheumatic carditis, the spontaneous improvement of rheumatoid arthritis, lupus crylhematosus, sarcoidosis, and allergic diseases; and the development of hypervolemia have been attributed to physiologic gestatory adrenocor- ticoid elaboration.

Nevertheless, steroid therapy may produce untoward effects in preg- nancy which merit special oinsideration in cardiac patients.

It is recog- nized that jjrolonged administration of cortisone may not only depress corticotropin formation, but may, in some instances, lead to atrophy of the adrenal cortex. Under these circumstances, the stresses of anesthesia and of obstetric surgery may precipitate acute adrenal insufficiency.

Newborn infants, whose mothers receive cortisone for prolonged periods throughout pregnancy, also may demonstrate symptoms of adrenal insufficiency. Accordingly, if steroids are administered to pregnant car- diacs, special precautions sliould be taken to combat fluid retention, and to prescribe appropriate cortisone fortification for mother and baby.

Overactivity Overactivity is an important cause of severe heart failure. Patients ivJjose cartliac reserve js limited should compemate lor the burden of pregnancy by obtaining adequate rest and by avoiding undue physical and emotional stresses. The therapeutic classification page 49 of the New York Heart Association is a useful guide to the amount of physical activity which should be permitted. In some instances, it is advisable to hospitalize functional Class III patients as they approach the peak antepartum circulatory burden.

The policy of hospitalizing such patients two vveeks prior to term is illogic, for at this relatively late stage the cardiac output usually has retuined to or near normal. Complete betl rest is a twoedged sword, for if this regimen is enforced in the presence of significant dependent edema, mobilization of fluid from the lower extremities may precipitate severe left-sided heart failure.

In patients with limited functional leserve, it is also especially important to interdict specifically all sexual activities once the ante- partum hemodynamic burden is at hand. Furthermore, unless the cardiac reason for abstinence is outlined clearly to both husband and wife, they may assume that advice is intended only to prevent physical harm through coitus, and that it does not apply to other forms of eiotic excitement which can bunieii the heart similarly.

Disorders of the Ifeart Deat Tachycaidia, atrial fibrillation, or atrial flutter may precipitate severe failure rn-the presence of structural heart damage. If these disorders are diagnosed correctly and treated properly, there is no need to alter accepted concepts relating to management of the underlying cardiac dis- ease see Chapter Apparently, pregnancy increases susceptibility to sinus tachycardia and to paroxysmal supraventricular tachycardia.

The resultant burden imposed upon a damaged heart maj lead to severe failure of the high output variet. In pregnane , heart disease due primarily to anemia is encountered rarely, but cardiovascular complications occur in a significant number of patients with sickle cell anemia and sickle cell-hemoglobin C disease Chapter 9. However, where anemia aggravates other etiologic types of heart disease, the over-all burden may cause decompensation.

On the other hand, severe faihire has been precipitated by admm- istialion of whole blood transfusions to pregnant cardiac patients In the second and third trimesters, physiologic hemodiUition lowers the red blood cell count, hematocrit and hemoglobin readings, so that normo chromic nonnoc tic anemia h dreinia must be distinguished from true anemia. Hypochromic anemia— the most common variety— is treated with iron and cobalt preparations Macrocytic anemias are relatively uncommon in pregnancy.

Pernicious anemia is treated with liver extract and vitamin B,,. Other macrocytic anemias respond to folic acid. When profound anemia necessitates transfusion, it is prudent, in severe heart disease, to use packed red cells rather than vv'hole blood. With proper diet- ary supervision, the pregnant woman can lose weight and at the same time maintain her basic muruiona!

Hyperthyroidism is discussed m Chapter Cor pulmonale is discussed in Chapter 9. Thromboembolic phenomena are associated with thrombophlebitis, coronary occlusion, sickle cell anemia, sickle cell-hemoglobin C disease, polycytlieniia, myocarditis, endocardial fibroelastosis, heart block, atrial fibrillation, and bacterial endocarditis Although these diseases are cov 66 CARDIAC DISEASE IN PREGNANCY ered separately in later chapters, it is appropriate here to consider the use of anticoagulant drugs, svhich except in bacterial endocarditis may be used for prevention and treatment of thromboembolic com- plications.

Anticoagulant Drugs in Pregnancy. Heparin acts in several ways, diiefly by preventing the elfca of thrombin upon fibrinogen.

It acts also as an antiprothromhin, and reduces Iwih platelet conglutination and liberation of blood-clotting enzymes. The resultant prolongation of clotting time begins within a matter of minutes foifowing injection of the drug into the blood stream. Protamine sulfate or toliiidine blue neutralizes heparin effect immediately, and senes as an effective antidote.

Coumarin drugs prevent hepatic synthesis of prothrombin from vita- min K, and their anticoaguLint action is measured in terms of prothrom- bin time prolongation. These agents are administered orally, and require forty-eight to seventy-two hours for full effect. There is some evidence that the relatively large heparin molecule does not traverse the placental barrier, and that it is not excreted in breast milk.

It is known definitely, on the other hand, th. In some instances, curettage, vaginal delivery, cesarean section, or manual removal of the placenta was performctl without excessive bleeding despite ther- apeutic levels of anticoagulalion.

The most important consideration in the use of anticoagulants during pregnancy is that adequate laboratory facilities should be avail- able for testing the blood fiequenily'.

Heparin is employed initially when immediate anticoagulant effect Is required, but in less urgent situations therapy may be started with coumarin drugs.

The choice between coumann derivatives and heparin for subsequent maintenance of antepartum antico. Both coumann drugs and heparin have other advantages and dis advantages Heparin must be administered parenieralh, and repeated at least once in tvventy four hours, but the daily determination of coagula- tion time IS not absolutely necessary once proper dosage has been worked out. Whereas coumann diugs arc given orally in one daily dose, pio- thrombin values must be determined every twenty-four hours if fetal complications are to be avoided through careful regulation T he necessity for managing parturition under conditions of normal coagulation rcm.

This may he accomplished m several ways The stopping of long-term treatment prior to term may predispose to thromboembolic recurrences. These phenomena provide increased muscular tension during systole. This policy has been criticized frequently from hvo standpoints. First, such antepartum digitalization has been described as "pro pliylaxis against heart faihiie. In pregnancy, functional incapacity is due generally to pul- monary congestion since iieart failure is most often left-sided.

TJie pur- pose of digitalization is to treat this degree of heart failure, and to prevent pulmonary edema. Nor is the issue purely one of semantics, for second, it has been con- tended that, in mitral stenosis, digitalis is ineffectise prior to the develop- ment of right-sided failure or the onset of atrial librillation.

However, it has been demonstrated that striking results may be obtained in left- sided heart failure associated with normal sinus rhythm. Digitalization relieves dyspnea and attacks of cardiac asthma, and coincidentally increases the vital capacity and speed of circulation.

Hemodynamic improvement can be verified by cirdiac caiheiert ration. Most important of all from tbe practical as Kct, the fulminating and frequently intract- able nature of pulmonary edema lias causevl death while the pros and cons of digitalization were being debated.

In other words, for equal weights of fetal and maternal heart tissue, the former contains mote glycoside because it is comiirised of a greater num- ber of myocardial cells, and this docs not imply necessarily that the baby IS in danger from overdigitalization.

Mendelson ami Engel uupiibJished data studied babies bom of fully digitalized mothers. Clinically evident disturbances of the infant heart beat were not detected in uicro or neonatally. Electrocardiographic findings throughout the first week of life did not diffei significantly fiom those noted in normal babies delivered of imdigitalizcd mothers These data indicate that maternal digitalization does not harm the baby.

If digitalis concentration actually is higher in the fetal heart, one can postulate only that the Immature myocardium is less sensitive to the glycoside than is the adult myocardium.

Cardiovascular and Other Surgery It is quite understand. There are patients whose cardiac status is compromised so severely tliai existence is maintained barely even in the nonpregnant stale. If the condition is not amenable to sur- gical correction, it is illogic to expect cardiac tolerance for the gestatory burden despite tlie highest quality ol supportive care There have, in fact, been seven deaths due to heart failure at the New York Lymg-In Hos- pital in such patients managed by absolute bed rest.

However, when religious or other special considerations interdict therapeutic abortion and cardiovascular surgery is not feasible, one must rely upon supportive measures. Tiie current low figure rtUo reflects further inroads made by cardiovascular surgery.

However, there are certain exceptions to this general rule. Frequently, such premature induction produced a complicated and desultory labor, with loss of the mother due to severe heart failure, and loss of the baby due to piemaiiirity.

These poor results prompted the adoption of cesarean section for premature delivery. Subsequent knowledge of the late physiologic amelioration in hemodynamic burden led to virtual abandonment of all premature obstetric intervention intended as cardiac therapy, but until recent years cesarean section was advocated for term delivery. The data showed a significantly higher maternal mortality rate in the cesarean series.

Although since then die general risVs of cesarean section have been reduced significantly through the introduction of blood banks, antibiotics, and modern technics of anesthesia, the hazards of vaginal delivery too have decreased by virtue of these same factors rurthermore, it is recognued that the vast majority of cardiac patients, including those most seriously disabled, ilo tolerate term sjjon- taneous labor which is considerably more efficient and less burdensome upon the heart than induced premature labor.

As pointed out in Chap- ter 1, the circulatory strain of labor and vaginal delivery is discontinuous and nonnccumulative, and ihe total cardiac burden imposed does not equal levels attained previously in late second and early third trimesters.

Accordingly, the real problem is not that of surviving vaginal delivery, but rather of preventing earlier severe heart failure and death asso ciated wall the antepartum hemodynamic burden. Premature delivery and cesarean section may be required for appro- piiate management of specific obstetric complications However, except m certain cases of kyph oscoUotic h eart disease, co arctation of th e aorta, a neurys m, and ureviotis s ubarachnoid hemorrhage, these procedures are not employed on cardiovascular indications Nevertheless, postmortem cesarean section should always be performed if the mother dies undeliv- ered ami the baby is viable The popular notion that severe cardiacs liave short, easy labors has been dispelled by observations which indicate the average duration of labor in large series of patients with licart disease is no different than in the general clinic population.

Intrapartum pulse and respiratory rates Figures 35, 36, 37, and 38 provide a valuable guide to the cardiac status, for Mendelson and Pardee observed that elevation of pulse rate above per minute between uterine contractions during the first srage of labor, precedes severe intra- partum cardiac failure by a long enough jieriod to afford ample warning of its approach, and to institute appropri.

Deseloped pulmonary edema postpartum. These and other severe cardiac patients are kept upright in bed, given o'cygen as indicated, and delivered as soon as feasible after full cervical dilatation in order to shoiten the period of bearing down in the second stage. Prolonged straining to achieve the esoteric ecstasy of natural child- birth is not advocated in the presence of serious heart disease.

The author believes these patients should be taught that a safe outcome for mother and baby is facilitated through all the skills and niceties of obstetric surgery. Maintenance of the patients confidence and a pleasant soothing atmosphere are important adjuncts during labor.

Alt oral feeding, including liquid as well as solid, is withheld once the Rrst stage begins see section on acid aspiration syndrome. Demerol in suitable doses 50 to mg. One injection of scopolamine may be combined with Demerol, In com- parable doses, scopolamine produces less tachycardia than docs atropine.

Restlessness, excitement, respiratory depression, and hypoxia from over- sedation are avoided. Generally, barbiturates are omitted. Aneslliesin The choice of anesthetic technic and of agents depends not only upon the maternal and fetal states, but also largely upon the training and competency of the anesthesiologist.

The functions and responsibil- ities of the anesthesiologist cannot be assumed safely by the obstetrician or by unqualified persons. The following discussion is intended to apply generally. Specific situations in individual c. In most instances, anesthesia should not be administered when the maternal condition is extremely poor or understood inadequately.

In some multiparae, the rapidity of labor and the ease of delivery may render anesthesia unnecessary. However, as peviously noted, the cardiac status does not, by itself, affect the duration or meclianics of labor.

Some of the adiantages of inhalation anesthesia include: Among its disadsaniages are the possibilities of hypoxia, aspiration, derangement of acid-base balance, and postoperatne nausea or vomiting The agent of choice is ether, administered with a high concentration of oxygen b the CO, absorption technic Since induction with ethei is slow and unpleasant, the agent is employed following induction with less irritating and more rapidly acting gasses as nitrous oxide or cyclo- propane.

A smooth, effortless, sltort induction is encouraged, an ade- quate ainvay is maintained at all times, and hypoxia is avoided. H postoperative rebreathing is carried out with per cent oxygen, and if antibiotics are employed, the incidence of pulmonary complications can be minimired Often, cyclopropane has been malignetl erroneously.

Nevertheless, improper and injudicious use of this agent may produce arrhythmias and cardiac arrest. The presence of hypoxia and of excitement predisposes to these disturbances. Trichlorethylene and chloroform carry even greater risks of derang- ing cardiac mechanisms, and these agents slioiiJd not be employed. Local infiUiaiion, held block, and regional block subarachnoid and extradural have been employed in pregnant cardiac patients, and the obstetric nteraiuie is replete with conflicting reports of favorable and unfavorable results in each of these methods.

Death, or varying degrees and types of sublethal toxic reactions, may result from idiosyncrasy to the drug. The presence of varicosities and venous engorgement associated with pregnancy increases these haz- ards because of the greater chance of intravenous injection Bacterial contamination from the bladder, vagina, or rectum may lead to serious infection osieomyeHtis, meningitis.

The falls in blood pressure and cardiac output are tlangerous in all etiologic types of heart disease. In the presence of anomalous communication between the venous and arterial circulations, tliere are special harards associaletl with venoarterial shunt and post- partum vascular collapse Chapter 5. The customary mcasuies employed to correct the drop in blood pres- sure include placing the body in Trendelenburg position after the drug has been fixed, and administering intravenous fluids and vasopressor chugs.

In cardiac patients bordering upon pulmonary edema, the salutory elTeci of a decreased venous return is overbalanced by the coexistent hypoxia and by the burden imposed through treatment of the hypotension. Uterine contractions and beating-down efforts may raise the anes- thetic level, and produce respiratory paralysis. Disturbance of ceiebro- spinal dynamics in the face of increased intracranial pressure has been followed by herniation of the brain into the foramen magnum.

Extrusion of the nucleus pulposits has been reported following spinal puncture. In addition, the recognhed incidence of posianesthctic headache and neurologic disorders iletractv from the desirability of using spinal tcdmics. As pointed out in Chapter I.

Those who advocate spina! The use of inhalation anesthesia may be contraindicated because of respiratory infection, chronic cor pulmonale, coarctation of the aorta, aneurysm, or-il feeding during l. Under these circumstances, the author recommends local infiltration or field block. Since toxicity increases in geometric propor- tion, the le. Meticulous c-are is exercised to avoid bjcterial contamination and intravenous injection.

Penlothal is not an anesthetic agent. Ancillary agents must be added in order to abolish pain and produce rehixation effectively. Sevcie cardiorespiratory depression may occur with over- dosage. Rapid placental transmission and slow detoxifica- tion by the fetus are additional undesirable factors.

The various risks of analgesia. Although some authors assert that moderate hemorrhage may reduce the circulatory burden of hypervolemia temporarily, it is advisable to keep blood loss at a minimum and thereby avoid secondary circulatory strains of anemia Ergotraie is omuted becavise of its tcntlcncy to raise the venous pres- sure.

Pituitrm should not be used since it contains relatively large amounts of vasopressor hormone which produces marked constriction of coronary and pulinoiidry aricriolcs. Unlike natural Pito- cin, which is said to have a pressor activity of about 5 per cent, synthetic Syntocinon is free of vasopressor hormone All intravenous therapy of volumetric proportions is avoided Infu- sions of glucose solution, saline solution, or plasma expanders may serve primarily to aggravate the cardiac burden.

In the event of massive hemorrhage requiring transfusion, packed red cells are used rather than whole blood. Because of the dangers of bacterial endocarditis Chapter 6 from puerperal infection and from mastitis, rheumatic and congenital cardiac patients are given hroad-specinim antibiotics during labor and the puer- perium provided there is no known idiosyncrasy to these drugs , and are discouraged from nursing.

Increased fluid and metabolic demands in breast feeding render nursing undesirable for Class III and Class IV cases in all etiologic types of heart disease. The occurrence of severe heart failure during the first twenty-four hours following delivery has received considerable attention in the literature. Roviiinc employment of anticoagulants is not advocated, but these drugs are prescribed where specifically indicated page Tubal sterilization has been recommended when severe heart fail- ure ocairred during pregnancy.

The author opposes this policy for several reasons In the first place, it is agreed generally that cesarean section should not be performed to facilitate sterilization. Reasoning along similar lines, sterilization need no longer be considered a corol- lary to therapeutic abortion. Accordingly, contraception is preferable to sterilization in almost all instances where future pregnancies may be contraindicated.

In clinic practice, follow-up is insured through Social Service visits to tlie home. All patients are urged to report for re-evalualion prior to undertaking another pregnancy, or, failing his, to register for prenatal care as soon as a menstrual period is missed. The onset of severe decompensation and the time of death are related most often to the hemodynamic burden of pregnancy rather than to the natural course of underlying heart disease.

Ordinarily, heart failure during pregnancy is left-sided, and the greatest number of deaths is due to fulminating pulmon. In respect to this problem, the New York Heart Association's functional classification provides the most important clinical guide to prognosis. Maternal deaths may result from other cardiovascular complications such as vascular accident, bacterial endocarditis, and postpartum venoarterial shunt with vascular collapse.

The incidence of these com- plications bears no lelation to functional classification. Eacli plays a definite role, and none is a panacea.

Generally, maternal cardiac disease does not, by itself, affect incidence of spontaneous abortion or of premature labor, duration of labor or blood loss at delivery. Tetal morbidity and fetal mortality result mainly from obstetric intervention, antepartum death of the mother, and other underlying medical or obstetric complications.

However, postmortem cesarean section shovild always be performed if the mother dies undelivered and the baby is V table. Fatalities from spinal anesthesia South Surgeon lt50d, Awvu. E ramilial octuTrenee of congenital heart disease. New England J Med A S, and Cohen. J Pregnancy subsequent to ligation of the inlenor vena cava and ovarian vessels. Gynec 77 , oe Alvarfz, R. The renal handling of sodium and vvater m normal and toxemic pregnancy.

Z, and MiciitoN R J Effects of lanaioside C on cardiovascular hemodynamics acute digiialmng doses m subjects with normal hearts and with heart disease. Cardiol 4 83, Ellxstao, M. K Use of sniravenously given ganglionic blocking agents for acute pulmonary edema. Am J Obst 8. Heart disease complicated by pregnancy Trans Edinburgh Obst. Drown fk Co Hervhensen. B Obstetrical anrsihesu Its principles and practice Springfield Illinois, Mechanism of radiation anencephaly.

H ; Congenital defctls. If , Gorlin, R. Danger of Diciimarot treatment in preg- nane. Chloroihiuide in edema of pregnancy. Postmortem cesarean section Obst. C The anesthetic harards in olistetrics Am. Total exchangeable sodium and potassium in nonpregnant women and in normal and preeclamptic pregnancy.

Thromboembolic conditions and their treatment with anticoagulants. Charles C Thomas McCartney. E, and Harroo, J. Alterations in body com- position duting pregnancy.

The pulse and respiratory variations duting Tabor as a guide to the onset of cardiac failure in women with rheiimalic heart disease. The management of delivery in pregnancy complicated by serious rheumatic heart disease. The aspiration of stomach contents into the lungs during obsietnc anesthesia Am J. Supportive care, imemiption of pregnancy, and mitral valvulotomy in the management of mitral stenosis complicating pregnancy.

Venous ligation in obstetrics Am. Effect of pregnancy on the course of heart disease Reevaluation of cardiac paiients three to five years after pregnancy. Circula- tion 13 Biol SL Med 80 , E Placental transfer of radioaaive digitoxin in pregnant women and its fetal distribution. Congestive heart fadurc in pregnancy. A , and Gray, M. C Coagulation defects m severe iittrapartiim and post partiim hemorrhage. G ncc 63 Coagulation defects in obstetric cbocV. ThromlsoetsiboUe disease complicating ptegnancs and the puerpcriwm Am J Obst.

E Elfect of acute dtgicali zation in patients with rheumatic heart disease Cardiologia 53 B Routine hsprsosvs for ohstetfical delivers Am J Obst.

Exper Therap TTie importance of this evolutionary rheumatic process will be emphasized repeatedly in the ensuing sections of this chapter. At the onset, several important generalizations may be made. Heart disease during phases 1 and 2 is due primarily to pancarditis, whereas during phases 3 and 4 it is due primarily to chronic valvular disease.

Phases 1 and 2 are uncommon during the childbearing age. However, phase 4 may develop earlier than the fourth decade, and under these circumstances maternal mortality due to severe heart failure presents a major challenge.

This complica- tion occurred in 3. Sixteen 70 per cent of these twenty-three fatalities were due to heart failure and all sixteen of these patients had mitral stenosis as the sole or predominant lesion. Deaths due to causes other than severe heart failure seldom are encountered in present-day obstetric experiences. Frequently, bacterial endocarditis Chapter 6 is preventable or amenable to treatment LiuboUc deaths are in a large measure avoidable. From tliese data, it has been concluded erroneously that maternal rheumatic cardiac deaths are due to the natural course of heart disease, and that the circulatory burdens imposed upon a woman by the pregnant state are no greater than other cardiac burdens she might encounter normally during a comparable nine-month span of time in the nongmvid state.

Indeed, this is a devious approach to the problem,, for by analogous misinietpretatiou of the same figures, one might con- clude just as well that prosiaiic carcinoma is never fatal m rheumatic males. In order to evaluate logically the relation of death to pregnancy. It is essential that fatalities be analyzed carefully rather than disiegarded summarily. If maternal deaths represent natural evolution of rheumatic heart disease, they should he disirlbuted evenly throughout pregnancy.

It is, in fact, this burden rather than the natural evolution of rheumatic heart disease which accounts for the vast nvajority of maternal deaths. Gorenberg and Chesley reported only two deaths 0. The validity of these statistic cor- rections is open to serious question.

For example, the patient who dies of appendiceal rupture and peritonitis following an ill-. The same fifteen patients are no less dead than tJie twenty-three reported in the New York Lying-In Hospital series, and tlie latter includes all fatalities— registered and nonregistered, rule- adherents and rule-violators, private and ward— yet the mortality is only 0 76 pet cent. Their conclusions were based upon identification of. Now, it is acceptetl generally that rheumatic activity indi- cated solely by Aschoff bodies is not clinically important, and further- more, doubt has arisen whether these lesions invariably signify any degree of active carditis Figure The cases reported by the above- mentioned British authors were documented incompletely, and mitral stenosis cannot he excluded as the primary cause of maternal decom- pensation and death.

Many of the laboratory criteria ordinarily employed to determine rheumatic activity are unrefiablc tluring pregnancy. Normally, the white blood count, se dimenta tion rate, and gamma glo bulin level rise ante- partum. Positiv e C-Vca ctive protein responses have been reported in uncomplicated pregnancy. Sheliar and associates found 37 per cent positive responses in the third trimester. Tyler and Roess found positive responses antepartum and postpartum: Active rheumatic fever has been diagnoseti in only ten New York Lying-In Hospital patients, and in five of these the picture was obscure.

All ten patients survived, and tight mitral stenosis appears to have been responsible for the two instances of severe heart failure that developed. Rheumatic activity could not be demonstrated in pregnancies com- plicated by chorea or atrial fibrillation. No death occurred in the cases of first-degree heart block, rericarditis, skin nodules, new diastolic mur- murs, and severe right-shied heart failure are most uncommon in preg- nant rheumatic cardiacs.

One must, therefore, conclude that clinically active rheumatic fever is exceedingly rare tluring pregnancy, and that carditis is not an important cause of severe heart failure or death in the childbearing woman. The author suggests that gestatory steroid elabora- tion may prevent or suppress rheumatic carditis. Maternal outcome depends mainly upon prevent- ing death from severe heart failure.

Clinical and laboratory observations are employed in determining the prognosis. As pointed out in Chapter 2, circulatory experiences in a prior preg- nancy may aid in appraising the cardiac reserve. Severe antepartum heart failure due to mitral stenosis is likely to recur in successive pregnancies. The current functional classification is of primary significance, and due allowances must be made both for improsement e.

Table H summarizes maternal mortality, according to functional classification, in rheumatic heart disease at the New York Lying-fn Hos- pital. There uere six deaths in the Class I and Class II cases, and none of the fatalities was due to heart failure. There tvere seventeen deaths in the Class and Class IV cases, and sixteen of the fatalities rvere due to heart failure. For example, the elderly Class 1 nuthipara with generalized cardiac enlargement, tiouble mitral and double aortic valvular involvement may have a distinctly better chance of avoiding severe heart failure and of surviving pregnancy than the younger Class priinigravida with a smaller heart and isolated mitral stenosis.

In obscure cases, cardiac catheterization provides a direct method for evaluating the under- lying lesion and its hemodynamic significance. Except in the piesence of atrial fibrillation or a history of embolism, this laboratory procedure can be performed withcmi undue risk ihiring pregnancy.

However, the uterus should be shielded horn radiational exposure so as not to endanger the fetus Chaptei 2. Goilin and associates found an abnormal lesponse in patients with left or right ventricular failure, or tight mitral or aortic stenosis calculated oi oieasured valve area equal to 1 stj. The initial rise of the systemic, systolic, and pulse pressures was sustained throughout the straining phase, and an overshoot did not develop during the release phase Fig 34, p.

It docs not increase the nonnal incidence of spontaneous abortion, premature labor, toxemia, or of other obstetric complications. Increased fetal losses in ihenmatic heart disease result primarily from therapeutic mteiruption of pregnancy and from ante- partum cardiac sleaih of the mother.

However, susceptibility to rheu- matic fever in later life is inherited apparently tlirough a recessive hictor. Anothei 10 to 15 per cent have combined mitral ancf aortic lesions.

Tfie remafnder have isofaietl aortic valve disease, or tiicuspid involvement associated with mitral or with aortic and mitral lesions. In the preceding sections, it has been intimated that mitral stenosis creates the main problem of rheumatic heart disease complicating preg- nancy. In the vast majority of cases, it is the sole or significant lesion. Tlie ensuing disaission will, therefore, be devoted largely to mitral stenosis Specific implications of other valve lesions arc covered toward the end of the chapter.

Significant hemodynamic clianges do not occur until the mural orifice area is reduced by fiO per cent. Increased left atrial juessurc then is requited to overcome the obstiuction, and this elevation of pressure is reHectctl in all segments of the pulmonary vascular bed venous, capillary, and arterial , resulting m dyspnea, cough, hemop tysis, and pulmonary edema Later, as the orifice decreases to less than one-tliird normal size, increased left atrial pressuie is insufficient to over- come the obstiuction, and the raidiac output decreases progressively as valvular narrowing increases.

Patients with long-standing tight mitral stenosis develop sclerotic changes in the smail pulmonary arteries, which increase the blockage to blood flow through the lungs, raise the pul- monary artery pressure out of proportion to the increase in left atrial pressure, and eventually lead to right ventiiculai failure. Clinical Features The clinical features of mitral stenosis have been correlated with three stages of hemodynamic evolution' stage 1. Most of these manifestations are attributable directly to pulmonary congestion.

Stage 5, whicli generally is terminal, is accompanied by venous engorgement, hepatomegaly, edema, tiansudation, and atrial thrombosis. The physical signs of mitral stenosis aie well defined Palpation discloses a rapid, slapping apical impulse, a presystolic thrill, a dilfuse precordial heave, and a shock over the pulmonary region and apex The classic murimii is a low-pitched early diastolic or presystolic rumble, located at the c.

The presystolic element, due to atrial con traction, disappears once atrial fibrillation replaces normal sinus rhythm Owing to fibiotic changes in the valve cusps and chordae tendineae, the apical first sound is loud and snapping. Pulmonary hypertension pro- duces accentuation and icdupVicaiion of the pulmonary second sound Functional pulmonic insufficiency develops in the face of extremely high pressures, and a soft, blowing diastolic Graham Steell murmur is heard over the incompetent valve.

Positive roentgenologic findings are observed with significant mitral stenosis The left atrium and right ventricle are enlarged, and the pulmonary artery shadow is prominent and widened. Right anteiior oblique views show left atrial encroachment on the retrocardiac syvace, ami posterior displacement of tlve bariunwconlaining esophagus.

Calci- fication may he detected m the mittal valve. Generate a file for use with external citation management software. Pandey S 1 , Kumar H 1. Comment in Understanding of skeletal deformities in Parkinson's disease. Images from this publication. See all images 5 Free text.

Striatal hand showing flexion at metacarpophalangeal joint with extension at interphalangeal joint and ulnar deviation of the left hand A , which was confirmed by hand X-rays B , striatal toe showing lateral flexion of the great toe with flexion of other toes C , which was confirmed by foot X-rays D. Pisa syndrome in a patient with Parkinson's disease characterized by leaning towards left side A , which was confirmed by spine X-rays B.

A patient with Parkinson's disease with scoliosis with concavity towards left side A , which was confirmed by spine X-rays B. The number of patients having Pisa syndrome and scoliosis was less in our study, so proper assessment regarding their sidedness could not be done.

In conclusion, our study showed that striatal and postural deformities were common in Indian patients with PD. These were more frequent in advanced stage of disease as reflected by significantly higher UPDRS, and H and Y scores in these patients.

Striatal foot and striatal hand were more likely to be ipsilateral to the side of PD symptom onset. National Center for Biotechnology Information , U. Indian J Med Res. Sanjay Pandey and Hitesh Kumar. Received May This article has been cited by other articles in PMC.

Camptocormia, dyskinesias, Pisa syndrome, scoliosis, striatal foot. Results A total of 79 patients with a possible diagnosis of PD were included. Analysis of variables between patients with Parkinson's disease PD with and without deformity.

Striatal hand showing flexion at metacarpophalangeal joint with extension at interphalangeal joint and ulnar deviation of the left hand A , which was confirmed by hand X-rays B , striatal toe showing lateral flexion of the great toe with flexion of Pisa syndrome in a patient with Parkinson's disease characterized by leaning towards left side A , which was confirmed by spine X-rays B.

A patient with Parkinson's disease with scoliosis with concavity towards left side A , which was confirmed by spine X-rays B. Camptocormia in a patient with Parkinson's disease A and B , which was corrected by pushing against wall C and while lying down D. Antecollis in a patient with Parkinson's disease A which was confirmed by cervical spine X-rays B and relieved completely on lying supine C. Discussion In our study, striatal foot was the most common deformity observed, followed by camptocormia in patients with PD.

Footnotes Conflicts of Interest: Ashour R, Jankovic J. Joint and skeletal deformities in Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy. Striatal deformities of the hand and foot in Parkinson's disease. Srivanitchapoom P, Hallett M. Camptocormia in Parkinson's disease: J Neurol Neurosurg Psychiatry. Melamed E, Djaldetti R. Camptocormia in Parkinson's disease. Dropped head syndrome in Parkinson's disease. Jankovic J, Tintner R.

The pharmacology of foot dystonia in Parkinsonism. Deformities of the hands and feet in Parkinsonism and their reversibility by operation. Striatal hand in Parkinson's disease: A specific clinical pattern of camptocormia in Parkinson's disease.

Camptocormia in Parkinson disease: Dropped head in Parkinson's disease. Botulinum toxin treatment of lateral axial dystonia in Parkinsonism. Pisa syndrome in Parkinson's disease:

factor for certain

These deformities we more common in patients with advanced stage of PD. Propensity to bend forward is an important clinical feature in patients with Parkinson's disease PD. As the disease progresses, many patients develop striatal and postural deformities which include striatal hands, striatal foot, antecollis, camptocormia, Pisa syndrome and scoliosis 1. However, these deformities are seen more commonly among atypical Parkinsonism such as multisystem atrophy, progressive supranuclear palsy and drug-induced Parkinsonism.

The pathogenesis of these deformities is a combination of ongoing Parkinsonian symptoms such as rigidity and bradykinesia, musculoskeletal changes, dystonia and use of dopaminergic medications 2 , 3.

These deformities increase the morbidity of patients by postural instability, gait problems, increased falls and reduced dexterity leading to disability in the activities of daily living 1. These deformities are frequently misdiagnosed as rheumatoid arthritis, Dupuytren's contracture, trigger finger, equinovarus deformity, etc 2.

The objective of this study was to describe the clinical features of these deformities in Indian patients with PD. The study was approved by institute's Review and Ethical Committee. A written informed consent was taken from all patients. Over a period of three years, 70 consecutive patients with PD fulfilling the United Kingdom Brain Bank criteria 4 were evaluated in detail for symptomatology, side of onset, duration, drug history along with the duration of levodopa intake, dyskinesia and family history of PD 4.

All patients were clinically examined for various striatal and postural deformities antecollis, camptocormia, Pisa syndrome, scoliosis, striatal hands and striatal foot. Those patients having postural deformities were evaluated by a locally made goniometer for quantitative measurement of deformity.

All patients having clinically appreciable deformities underwent radiological evaluation by X-ray. Scoliosis was measured by Cobb angle radiologically. Needle electromyography was done to rule out myopathy in patients having antecollis, camptocormia and Pisa syndrome. Clinical criteria for striatal and postural deformities were taken as described elsewhere 2 , 5 , 6. Pearson's chi-square test and Student's t test were used for univariate analysis and ANOVA test was used for multivariate analysis.

Spearman's rank correlation test was used for calculating correlation between variables. A total of 79 patients with a possible diagnosis of PD were included. Out of these, nine patients were excluded from the study as they were diagnosed as having PD-plus syndrome. Of the 70 patients with PD, 47 Mean age at presentation was Majority of the patients were in the age group of yr Mean age of onset of PD symptom was The mean duration of PD symptoms at presentation was 4. The mean duration of levodopa treatment in the remaining 52 patients was 2.

The durations of PD symptom 5. Striatal foot and striatal hand were common deformities observed in patients with PD Fig. Among striatal foot deformities, the most common deformity was toe flexion, being present in Others types of foot deformities were big toe hyperextension in four, equinovarus deformity in three and big toe lateral flexion in two patients.

Scoliosis was significantly more in female patients with PD compared to male patients with PD. Fourteen patients had camptocormia and 13 had antecollis Figs.

Dyskinesias were present in 12 Striatal foot and striatal hand were present on ipsilateral side of the PD symptom in relation to initial symptom onset in Pisa syndrome and concavity of scoliosis were on contralateral side to PD symptom onset side in In our study, striatal foot was the most common deformity observed, followed by camptocormia in patients with PD. A simple test requires that the patient climb twenty steps at a normal pace. The pulse and respiratory rates are recorded prior to the exercise.

In normal patients anti in Class I and Class II cardiacs, the rates return to original lesels by the last observation.

Such tests should not of course be perfonned in the presence of serious incapacity, as they may precipitate pulmonary etiema. In obscure cases of rheu- matic or congenital heart disease, cardiac catheterization provides a direct method for evaluating the underlying anatomic lesion and its hemodynamic significance.

Except in the presence of atrial fibrillation or a history of embolism, this laboratory procedure can be per- formed during pregnancy without undue risk. However, as previ- ously noted, the procedure should be deferred until the third month, and even then the uterus should be shielded from rachational exposure so as not to endanger the fetus. The initial rise in systolic blood pressure which accompanies a forced expiration persists throughout the period of straining, and the characteristic poststraining osershoot does not occur Figure These deviations from the normal response do not occur in dyspnea associated with obesity, in the hyperventilation syndrome, or in psychogenic dyspnea.

These special prob- lems will be discussed in later chapters. Also, hypoxia may play a role in anomalous development. Intrapartum fetal deaths hate been attributed to hypoxia associated with maternal cyanosis and with maternal paroxysmal tachycardia.

Apart from the foregoing considerations, maternal heart disease, by itself, does not affect the infant nioibiclity or mortality. Tlie incidence of spontaneous abortion and of premature labor is no dillerent in car- diac patients than in the general clinic population.

These variations will be disaissed in detail in later cliapters In most instances, however, the fundamental purpose of management is to prevent death from heart failure. In die early stages of its development, cardiac insufficiency manifests itself only when circufatory demands are increased, as with exercise. It may be absent in the resting state. The different degrees of this ability are expressed by the cardiac functional classification. Failure of the heart to circulate the requiretl volume of blood leads to venous congestion in the pulmonary or systemic circuit, or in both, and to inadequate arterial blood flow.

As a result, the circulation time is prolonged and functional changes occur in the various organs. Reten- tion of salt and water due to impaired renal function produces hyper- volemia which aggravates the congestive state. In cardiac failure asso- ciated with hyperthyroidism, beriberi, pulmonary disease, and anemia, the output is normal or increased.

However, in most other etiologic types of heart disease, failure is characterUed by low output and pro- longed circulation time.

The single, most important component of the heart is the myo- cardium. Pressure loads are created when normal or reduced stroke volumes aie ejected against liigh resistance. The left side of the heart fails more rapidly than does the right under volume loads; the right side of the heart fails more rapidly than does the left under hydrostatic pressure stiess In the early stages of cardiac insufficiency, the clinical picture may be predominantly that of left-sided or of right-sided failure, depending upon winch side of the liearl is aHected primarily Generally, the later clinical picture is that of bilateral failure Prunary heart failure is more commonly left-sided than right-sided Primary left-sided failure is seen m mitral and m aortic valvular disease, hypertension, coronary artery disease, and in left-to-right intra- cardiac shunts due to patent ductus or lentnciilar septal defect The clinical manifestations result from pulmonary congestion and increased pulmonary capillary pressure.

These include dyspnea, orthopnea, cough, hemoptysis, pulmonary rales, accentuated pulmonary second sound, and decreased vital capacity The venous pressure is normal Acute left-sided failure protluces p.

Primary right-stded failure is seen tn pulmonary hypertension, pulmonic stenosis, cor pulmonale, myocarditis, tricuspid stenosis, and in constrictive peri- carditis. The manifestations are due largely to engorgement and elevation of pressure in the systemic venous circuit These include engorgement of the superficial veins, subcutaneous edema, enlargement and tenderness of the liver, cyanosis, ascites, hydrothorax, hydropen- cardium, and disturbances of the gasiroiniesiinal.

Ordinarily, true heart failure during pregnancy is left sided, and is manifested by reduced vital capacity, persistent basal rales, prolonged circulation time, cough, hemoptysis, paroxysmal dyspnea, and paroxys- mal pulmonary edema.

The term "severe heart failure. The frequently intractable nature of this complication is responsible for many maternal deaths. The process may be initiated b a marled increase in resistance to outflow from the left cardiac chambers, sudden decrease in left ventricular or left atrial out- flow, or by excessively rapid increase in venous return and right ventricu- lar output.

Gestatoty hypervolemia predisposes to pulmonary edema in the etiologic types of heart disease characterized by primary left-sided failure.

Ph siologic antepartum increases in heart rate and cardiac out- put favor the development of pulmonary edema in mitral stenosis Chapter 3. Hamilton and Thomson contended that a decrease in vital capacity of 15 or more per cent antedated other evidences of severe antepartum heart failure. Experiences at the New York Lying-In Hospital have not corroborated this contention, for in each instance where the vital capacity fell due to cardiac insufficiency, other subjective or objective evidence of deterioration could be detected as well, provided the patient h.

This does not detract from the value of vital capacity observations, but it does indicate that the total clinical picture is just as important, if not more so, in evaluating the cardiac status. Augmentation of ph siologic antepartum hyper- volemia due to factors which produce vascular congestion Table 11 may le-id to pulmonary edema. Acute cor pulmonale may develop with massive intraluminal or extraluminal pulmonary vascular obstruction.

Acute cor pulmonale, as a specific obstetric hazard, is associated with venous air embolism, fibrin emboli, and with the "acid aspiration" syn- drome. These complications are discussed in Chapter 9. These include a regimen of digitalis, oxygen, rest, sedatives, diuretics, and restricted intake of sodium and of fluids.

Mercurial diuretics have been employed with good results. Once severe heart failure has occurred during pregnancy, it is adtis- able, in most cases, for the patient to remain under treatment in the hospital until after delivery— regardless of complete recovery from the current episode of failure, or adequacy of facilities for home super- vision and care. Compromises in this policy may prove ill-fated, unless, of covirse, the vinderlying cause of decompensation has been corrected definitively by cardiac suigery f-g.

Meanwhile, severe decompensa- tion may recur, and the associated 15 per cent mortality takes its inev- itable toll. The beneficial effects of atropine may be overshadowed by the tachycardia u produces. Aminoplj lIine is admlnisteml intravenously to maintain the car- diac output and to lower the venous pressure. If necessary, the drug may be lepeated at hourly intervals. However, since aminophylline can cause stitlden cardiac arrest, it should, at all times, be given slowly over a peiiod of minutes, and if the patient experiences distress during the administration, injection slioiild be discontinued immediately.

In undigitalized patients, rapid digitalis effect is induced to main- tain cardiac output. Ouabain or lanatoside C may be used intravenously. Antifoaming agents reduce pulmonary obstniction due to frothing of the edema fluid.

The desired effect is achieved by bubbling pressur- ized oxygen through ethyl alcohol before it enters die tent or mask. Encouraging results have been obtained following intravenous use of ganglionic blocking drugs such as hexamethonium. Tiiese agents lower the peripheral arteriolar resistance and produce a corresponding decrease in systemic and pulmonic vasadar pressures, tliereby reducing both the left ventricular load and the tendency lovvard transudation into the alveolar spaces.

Also ganglionic blockade exerts a vagolytic action which relieves liyperpnea. Occasionally, phlebot- omy becomes necessary if tourniquet treaimeni does not achieve the desired results, Obstetric intervention has absolutely no place in the tieatment of pulmonary edema. When these complications do arise, fluid is aspirated as indicated, but special precautions arc taken not to injure the uterus and tlje baby at the time of paracentesis.

This is true especially in acute cor pulmonale due to fibrin emboli complicating abruptio placentae, amnioiic fluid infusion, or retention of dead fetus, since in such cases e. Care should be exercised not to increase the cardiac embarrass- ment by overloading the circulation with infusions or transfusions Vasopressor drugs may be administered in syringe doses.

Fibrinogen may be required to correct the coagulation defect. Prevent or control coninbuiory burdens. Remove the cause of the piediciable burden by therapeutic abortion.

Prevent futuie gestatory burdens by sterilization or by contra- ception. Agents which lower blood pres- sure have reduced the occurrence of cardiovascular complications in hypertension. Appropriate medical and surgical treatment has prevented or reversed cardiac involvement in thyroid disease.

Anticoagulant dnigs have proved beneficial m preventing and controlling thromboembolic disease Studies of maternal actors including nutrition, oxygenation, exposure to radiation, and virus infection especially rubella have shed light upon antepartum influences m the genesis of congenital cardio- vascular anomalies The foregoing considerations give reason to hope that heart disease will, some day, become a rare complication of pregnancy.

However, from the practical standpoint, current emphasis must be placed upon preventing severe failure in the presenting Jieart disease.

Infection Patients are instructed carefully and repeatedly to report at once in the eient of any infectioti. Hospitalization is advised, cultures taken as indicated, and appropriate therapy rendered. Upper respiratory infections command the greatest lespect since ilicir complications, espe- cially bronchitis and pneumonia, are the most important contributory causes of severe heart failure in pregnancy.

Influenzal pneumonia is particularly dangerous in pregnant cardiacs Fiom the standpoint of prophylaxis, exposure to crowds and to known cases of respiratory infec- tion should be avoided. Difliciilties may arise In distinguishing the signs and symptoms o pulmonary infection from those of severe heart failure.

In sucli cases, it is, at all tinves, prudent to treat the patient for both conditions simul- taneously. Infections also create special hazards of bacterial endocarditis in rheumatic and in congenital licari disease. Prophylactic administration of broad-spectrum antibiotics is, therefore, recommended during labor and following delivery or abortion, unless these agents are contraindi- cated because of specific hypersensitivity. Vascular Congestion Vascular congestion is the second most common contributory cause of severe heart failure in pregnant women.

Sodium retention and hydremia of gestation are discussed in Chapter 1. As a general rule, it is advisable to limit fluid intake in the pregnant cardiac to cc.

Infusions, transfusions, and intravenous hypertonic solutions are avoided, since the hyper- volemia they produce may lead to pulmonary edema. It is also extremely important to limit the sodium intake. In the past, it was virtually im- possible to supply the b. Dietary instructions which refer specifically to salt rather than to sodium are inadequate, for some p. Diels cosering the nuiritise aliosvances for pregnane and containing to mg. McCartnc and associates studied toxemic water and sodium reten- tion in relation to gross bod composition.

Their findings are reproduced m Table 2 Chapter 1 de Alvarez and co-workers observed that the exaggerated, positive water and sodium balances in toxemic pregnancy resulted from a super- normal depression of the glomcnilar filtration rate Chapter 7. MacGillivray and Buchanan, however, observed that the amount of sodium retained in preeclamptic women was the same as in normal pregnant women, although retention of water was greater in the former than in the latter.

A classic example of fluid retention often is observed in the presence of hydatidiform mole. Here the basic disturbance is due to humoral iniluences. The incidence of toxemia m rheumatic and in congenital heart dis- ease is no higher than in the general clinic population However, the incidence of toxemia is increased in hypertension, chorea, heart block, kyphoscoliosis, sickle cell anemia, sickle cell-hemoglobin C disease, and in th Totoxicosis.

Except in heart block, the causative factor is the iinder- l ing disease process rather than the actual cardiac involvement In progressive kidney disease, impaired sodium excretion also leads to water retention and hypervolemia. Although cortisone and corticotropin ACTH are known to disrupt gestation in laboratory animals, these drugs have been used in pregnant women for a wide variety of conditions vvithout similar adverse elTeci.

Furthermore, during pregnancy, the rarity of clinically active rheumatic carditis, the spontaneous improvement of rheumatoid arthritis, lupus crylhematosus, sarcoidosis, and allergic diseases; and the development of hypervolemia have been attributed to physiologic gestatory adrenocor- ticoid elaboration.

Nevertheless, steroid therapy may produce untoward effects in preg- nancy which merit special oinsideration in cardiac patients. It is recog- nized that jjrolonged administration of cortisone may not only depress corticotropin formation, but may, in some instances, lead to atrophy of the adrenal cortex.

Under these circumstances, the stresses of anesthesia and of obstetric surgery may precipitate acute adrenal insufficiency.

Newborn infants, whose mothers receive cortisone for prolonged periods throughout pregnancy, also may demonstrate symptoms of adrenal insufficiency. Accordingly, if steroids are administered to pregnant car- diacs, special precautions sliould be taken to combat fluid retention, and to prescribe appropriate cortisone fortification for mother and baby.

Overactivity Overactivity is an important cause of severe heart failure. Patients ivJjose cartliac reserve js limited should compemate lor the burden of pregnancy by obtaining adequate rest and by avoiding undue physical and emotional stresses.

The therapeutic classification page 49 of the New York Heart Association is a useful guide to the amount of physical activity which should be permitted. In some instances, it is advisable to hospitalize functional Class III patients as they approach the peak antepartum circulatory burden. The policy of hospitalizing such patients two vveeks prior to term is illogic, for at this relatively late stage the cardiac output usually has retuined to or near normal. Complete betl rest is a twoedged sword, for if this regimen is enforced in the presence of significant dependent edema, mobilization of fluid from the lower extremities may precipitate severe left-sided heart failure.

In patients with limited functional leserve, it is also especially important to interdict specifically all sexual activities once the ante- partum hemodynamic burden is at hand. Furthermore, unless the cardiac reason for abstinence is outlined clearly to both husband and wife, they may assume that advice is intended only to prevent physical harm through coitus, and that it does not apply to other forms of eiotic excitement which can bunieii the heart similarly.

Disorders of the Ifeart Deat Tachycaidia, atrial fibrillation, or atrial flutter may precipitate severe failure rn-the presence of structural heart damage. If these disorders are diagnosed correctly and treated properly, there is no need to alter accepted concepts relating to management of the underlying cardiac dis- ease see Chapter Apparently, pregnancy increases susceptibility to sinus tachycardia and to paroxysmal supraventricular tachycardia.

The resultant burden imposed upon a damaged heart maj lead to severe failure of the high output variet. In pregnane , heart disease due primarily to anemia is encountered rarely, but cardiovascular complications occur in a significant number of patients with sickle cell anemia and sickle cell-hemoglobin C disease Chapter 9.

However, where anemia aggravates other etiologic types of heart disease, the over-all burden may cause decompensation. On the other hand, severe faihire has been precipitated by admm- istialion of whole blood transfusions to pregnant cardiac patients In the second and third trimesters, physiologic hemodiUition lowers the red blood cell count, hematocrit and hemoglobin readings, so that normo chromic nonnoc tic anemia h dreinia must be distinguished from true anemia.

Hypochromic anemia— the most common variety— is treated with iron and cobalt preparations Macrocytic anemias are relatively uncommon in pregnancy. Pernicious anemia is treated with liver extract and vitamin B,,. Other macrocytic anemias respond to folic acid. When profound anemia necessitates transfusion, it is prudent, in severe heart disease, to use packed red cells rather than vv'hole blood. With proper diet- ary supervision, the pregnant woman can lose weight and at the same time maintain her basic muruiona!

Hyperthyroidism is discussed m Chapter Cor pulmonale is discussed in Chapter 9. Thromboembolic phenomena are associated with thrombophlebitis, coronary occlusion, sickle cell anemia, sickle cell-hemoglobin C disease, polycytlieniia, myocarditis, endocardial fibroelastosis, heart block, atrial fibrillation, and bacterial endocarditis Although these diseases are cov 66 CARDIAC DISEASE IN PREGNANCY ered separately in later chapters, it is appropriate here to consider the use of anticoagulant drugs, svhich except in bacterial endocarditis may be used for prevention and treatment of thromboembolic com- plications.

Anticoagulant Drugs in Pregnancy. Heparin acts in several ways, diiefly by preventing the elfca of thrombin upon fibrinogen. It acts also as an antiprothromhin, and reduces Iwih platelet conglutination and liberation of blood-clotting enzymes.

The resultant prolongation of clotting time begins within a matter of minutes foifowing injection of the drug into the blood stream. Protamine sulfate or toliiidine blue neutralizes heparin effect immediately, and senes as an effective antidote. Coumarin drugs prevent hepatic synthesis of prothrombin from vita- min K, and their anticoaguLint action is measured in terms of prothrom- bin time prolongation. These agents are administered orally, and require forty-eight to seventy-two hours for full effect.

There is some evidence that the relatively large heparin molecule does not traverse the placental barrier, and that it is not excreted in breast milk. It is known definitely, on the other hand, th. In some instances, curettage, vaginal delivery, cesarean section, or manual removal of the placenta was performctl without excessive bleeding despite ther- apeutic levels of anticoagulalion. The most important consideration in the use of anticoagulants during pregnancy is that adequate laboratory facilities should be avail- able for testing the blood fiequenily'.

Heparin is employed initially when immediate anticoagulant effect Is required, but in less urgent situations therapy may be started with coumarin drugs. The choice between coumann derivatives and heparin for subsequent maintenance of antepartum antico.

Both coumann drugs and heparin have other advantages and dis advantages Heparin must be administered parenieralh, and repeated at least once in tvventy four hours, but the daily determination of coagula- tion time IS not absolutely necessary once proper dosage has been worked out.

Whereas coumann diugs arc given orally in one daily dose, pio- thrombin values must be determined every twenty-four hours if fetal complications are to be avoided through careful regulation T he necessity for managing parturition under conditions of normal coagulation rcm. This may he accomplished m several ways The stopping of long-term treatment prior to term may predispose to thromboembolic recurrences. These phenomena provide increased muscular tension during systole.

This policy has been criticized frequently from hvo standpoints. First, such antepartum digitalization has been described as "pro pliylaxis against heart faihiie. In pregnancy, functional incapacity is due generally to pul- monary congestion since iieart failure is most often left-sided. TJie pur- pose of digitalization is to treat this degree of heart failure, and to prevent pulmonary edema. Nor is the issue purely one of semantics, for second, it has been con- tended that, in mitral stenosis, digitalis is ineffectise prior to the develop- ment of right-sided failure or the onset of atrial librillation.

However, it has been demonstrated that striking results may be obtained in left- sided heart failure associated with normal sinus rhythm. Digitalization relieves dyspnea and attacks of cardiac asthma, and coincidentally increases the vital capacity and speed of circulation.

Hemodynamic improvement can be verified by cirdiac caiheiert ration. Most important of all from tbe practical as Kct, the fulminating and frequently intract- able nature of pulmonary edema lias causevl death while the pros and cons of digitalization were being debated.

In other words, for equal weights of fetal and maternal heart tissue, the former contains mote glycoside because it is comiirised of a greater num- ber of myocardial cells, and this docs not imply necessarily that the baby IS in danger from overdigitalization. Mendelson ami Engel uupiibJished data studied babies bom of fully digitalized mothers. Clinically evident disturbances of the infant heart beat were not detected in uicro or neonatally.

Electrocardiographic findings throughout the first week of life did not diffei significantly fiom those noted in normal babies delivered of imdigitalizcd mothers These data indicate that maternal digitalization does not harm the baby. If digitalis concentration actually is higher in the fetal heart, one can postulate only that the Immature myocardium is less sensitive to the glycoside than is the adult myocardium. Cardiovascular and Other Surgery It is quite understand.

There are patients whose cardiac status is compromised so severely tliai existence is maintained barely even in the nonpregnant stale. If the condition is not amenable to sur- gical correction, it is illogic to expect cardiac tolerance for the gestatory burden despite tlie highest quality ol supportive care There have, in fact, been seven deaths due to heart failure at the New York Lymg-In Hos- pital in such patients managed by absolute bed rest. However, when religious or other special considerations interdict therapeutic abortion and cardiovascular surgery is not feasible, one must rely upon supportive measures.

Tiie current low figure rtUo reflects further inroads made by cardiovascular surgery. However, there are certain exceptions to this general rule. Frequently, such premature induction produced a complicated and desultory labor, with loss of the mother due to severe heart failure, and loss of the baby due to piemaiiirity.

These poor results prompted the adoption of cesarean section for premature delivery. Subsequent knowledge of the late physiologic amelioration in hemodynamic burden led to virtual abandonment of all premature obstetric intervention intended as cardiac therapy, but until recent years cesarean section was advocated for term delivery. The data showed a significantly higher maternal mortality rate in the cesarean series. Although since then die general risVs of cesarean section have been reduced significantly through the introduction of blood banks, antibiotics, and modern technics of anesthesia, the hazards of vaginal delivery too have decreased by virtue of these same factors rurthermore, it is recognued that the vast majority of cardiac patients, including those most seriously disabled, ilo tolerate term sjjon- taneous labor which is considerably more efficient and less burdensome upon the heart than induced premature labor.

As pointed out in Chap- ter 1, the circulatory strain of labor and vaginal delivery is discontinuous and nonnccumulative, and ihe total cardiac burden imposed does not equal levels attained previously in late second and early third trimesters. Accordingly, the real problem is not that of surviving vaginal delivery, but rather of preventing earlier severe heart failure and death asso ciated wall the antepartum hemodynamic burden. Premature delivery and cesarean section may be required for appro- piiate management of specific obstetric complications However, except m certain cases of kyph oscoUotic h eart disease, co arctation of th e aorta, a neurys m, and ureviotis s ubarachnoid hemorrhage, these procedures are not employed on cardiovascular indications Nevertheless, postmortem cesarean section should always be performed if the mother dies undeliv- ered ami the baby is viable The popular notion that severe cardiacs liave short, easy labors has been dispelled by observations which indicate the average duration of labor in large series of patients with licart disease is no different than in the general clinic population.

Intrapartum pulse and respiratory rates Figures 35, 36, 37, and 38 provide a valuable guide to the cardiac status, for Mendelson and Pardee observed that elevation of pulse rate above per minute between uterine contractions during the first srage of labor, precedes severe intra- partum cardiac failure by a long enough jieriod to afford ample warning of its approach, and to institute appropri. Deseloped pulmonary edema postpartum.

These and other severe cardiac patients are kept upright in bed, given o'cygen as indicated, and delivered as soon as feasible after full cervical dilatation in order to shoiten the period of bearing down in the second stage. Prolonged straining to achieve the esoteric ecstasy of natural child- birth is not advocated in the presence of serious heart disease. The author believes these patients should be taught that a safe outcome for mother and baby is facilitated through all the skills and niceties of obstetric surgery.

Maintenance of the patients confidence and a pleasant soothing atmosphere are important adjuncts during labor. Alt oral feeding, including liquid as well as solid, is withheld once the Rrst stage begins see section on acid aspiration syndrome.

Demerol in suitable doses 50 to mg. One injection of scopolamine may be combined with Demerol, In com- parable doses, scopolamine produces less tachycardia than docs atropine. Restlessness, excitement, respiratory depression, and hypoxia from over- sedation are avoided.

Generally, barbiturates are omitted. Aneslliesin The choice of anesthetic technic and of agents depends not only upon the maternal and fetal states, but also largely upon the training and competency of the anesthesiologist.

The functions and responsibil- ities of the anesthesiologist cannot be assumed safely by the obstetrician or by unqualified persons. The following discussion is intended to apply generally.

Specific situations in individual c. In most instances, anesthesia should not be administered when the maternal condition is extremely poor or understood inadequately. In some multiparae, the rapidity of labor and the ease of delivery may render anesthesia unnecessary. However, as peviously noted, the cardiac status does not, by itself, affect the duration or meclianics of labor.

Some of the adiantages of inhalation anesthesia include: Among its disadsaniages are the possibilities of hypoxia, aspiration, derangement of acid-base balance, and postoperatne nausea or vomiting The agent of choice is ether, administered with a high concentration of oxygen b the CO, absorption technic Since induction with ethei is slow and unpleasant, the agent is employed following induction with less irritating and more rapidly acting gasses as nitrous oxide or cyclo- propane.

A smooth, effortless, sltort induction is encouraged, an ade- quate ainvay is maintained at all times, and hypoxia is avoided. H postoperative rebreathing is carried out with per cent oxygen, and if antibiotics are employed, the incidence of pulmonary complications can be minimired Often, cyclopropane has been malignetl erroneously.

Nevertheless, improper and injudicious use of this agent may produce arrhythmias and cardiac arrest. The presence of hypoxia and of excitement predisposes to these disturbances. Trichlorethylene and chloroform carry even greater risks of derang- ing cardiac mechanisms, and these agents slioiiJd not be employed.

Local infiUiaiion, held block, and regional block subarachnoid and extradural have been employed in pregnant cardiac patients, and the obstetric nteraiuie is replete with conflicting reports of favorable and unfavorable results in each of these methods. Death, or varying degrees and types of sublethal toxic reactions, may result from idiosyncrasy to the drug. The presence of varicosities and venous engorgement associated with pregnancy increases these haz- ards because of the greater chance of intravenous injection Bacterial contamination from the bladder, vagina, or rectum may lead to serious infection osieomyeHtis, meningitis.

The falls in blood pressure and cardiac output are tlangerous in all etiologic types of heart disease. In the presence of anomalous communication between the venous and arterial circulations, tliere are special harards associaletl with venoarterial shunt and post- partum vascular collapse Chapter 5. The customary mcasuies employed to correct the drop in blood pres- sure include placing the body in Trendelenburg position after the drug has been fixed, and administering intravenous fluids and vasopressor chugs.

In cardiac patients bordering upon pulmonary edema, the salutory elTeci of a decreased venous return is overbalanced by the coexistent hypoxia and by the burden imposed through treatment of the hypotension. Uterine contractions and beating-down efforts may raise the anes- thetic level, and produce respiratory paralysis.

Disturbance of ceiebro- spinal dynamics in the face of increased intracranial pressure has been followed by herniation of the brain into the foramen magnum. Extrusion of the nucleus pulposits has been reported following spinal puncture. In addition, the recognhed incidence of posianesthctic headache and neurologic disorders iletractv from the desirability of using spinal tcdmics. As pointed out in Chapter I. Those who advocate spina! The use of inhalation anesthesia may be contraindicated because of respiratory infection, chronic cor pulmonale, coarctation of the aorta, aneurysm, or-il feeding during l.

Under these circumstances, the author recommends local infiltration or field block. Since toxicity increases in geometric propor- tion, the le. Meticulous c-are is exercised to avoid bjcterial contamination and intravenous injection. Penlothal is not an anesthetic agent. Ancillary agents must be added in order to abolish pain and produce rehixation effectively.

Sevcie cardiorespiratory depression may occur with over- dosage. Rapid placental transmission and slow detoxifica- tion by the fetus are additional undesirable factors. The various risks of analgesia.

Although some authors assert that moderate hemorrhage may reduce the circulatory burden of hypervolemia temporarily, it is advisable to keep blood loss at a minimum and thereby avoid secondary circulatory strains of anemia Ergotraie is omuted becavise of its tcntlcncy to raise the venous pres- sure.

Pituitrm should not be used since it contains relatively large amounts of vasopressor hormone which produces marked constriction of coronary and pulinoiidry aricriolcs. Unlike natural Pito- cin, which is said to have a pressor activity of about 5 per cent, synthetic Syntocinon is free of vasopressor hormone All intravenous therapy of volumetric proportions is avoided Infu- sions of glucose solution, saline solution, or plasma expanders may serve primarily to aggravate the cardiac burden.

In the event of massive hemorrhage requiring transfusion, packed red cells are used rather than whole blood. Because of the dangers of bacterial endocarditis Chapter 6 from puerperal infection and from mastitis, rheumatic and congenital cardiac patients are given hroad-specinim antibiotics during labor and the puer- perium provided there is no known idiosyncrasy to these drugs , and are discouraged from nursing.

Increased fluid and metabolic demands in breast feeding render nursing undesirable for Class III and Class IV cases in all etiologic types of heart disease. The occurrence of severe heart failure during the first twenty-four hours following delivery has received considerable attention in the literature. Roviiinc employment of anticoagulants is not advocated, but these drugs are prescribed where specifically indicated page Tubal sterilization has been recommended when severe heart fail- ure ocairred during pregnancy.

The author opposes this policy for several reasons In the first place, it is agreed generally that cesarean section should not be performed to facilitate sterilization. Reasoning along similar lines, sterilization need no longer be considered a corol- lary to therapeutic abortion. Accordingly, contraception is preferable to sterilization in almost all instances where future pregnancies may be contraindicated.

In clinic practice, follow-up is insured through Social Service visits to tlie home. All patients are urged to report for re-evalualion prior to undertaking another pregnancy, or, failing his, to register for prenatal care as soon as a menstrual period is missed. The onset of severe decompensation and the time of death are related most often to the hemodynamic burden of pregnancy rather than to the natural course of underlying heart disease.

Ordinarily, heart failure during pregnancy is left-sided, and the greatest number of deaths is due to fulminating pulmon. In respect to this problem, the New York Heart Association's functional classification provides the most important clinical guide to prognosis. Maternal deaths may result from other cardiovascular complications such as vascular accident, bacterial endocarditis, and postpartum venoarterial shunt with vascular collapse.

The incidence of these com- plications bears no lelation to functional classification. Eacli plays a definite role, and none is a panacea.

Generally, maternal cardiac disease does not, by itself, affect incidence of spontaneous abortion or of premature labor, duration of labor or blood loss at delivery. Tetal morbidity and fetal mortality result mainly from obstetric intervention, antepartum death of the mother, and other underlying medical or obstetric complications. However, postmortem cesarean section shovild always be performed if the mother dies undelivered and the baby is V table. Fatalities from spinal anesthesia South Surgeon lt50d, Awvu.

E ramilial octuTrenee of congenital heart disease. New England J Med A S, and Cohen. J Pregnancy subsequent to ligation of the inlenor vena cava and ovarian vessels.

Gynec 77 , oe Alvarfz, R. The renal handling of sodium and vvater m normal and toxemic pregnancy. Z, and MiciitoN R J Effects of lanaioside C on cardiovascular hemodynamics acute digiialmng doses m subjects with normal hearts and with heart disease.

Cardiol 4 83, Ellxstao, M. K Use of sniravenously given ganglionic blocking agents for acute pulmonary edema. Am J Obst 8. Heart disease complicated by pregnancy Trans Edinburgh Obst.

Drown fk Co Hervhensen. B Obstetrical anrsihesu Its principles and practice Springfield Illinois, Mechanism of radiation anencephaly. H ; Congenital defctls. If , Gorlin, R. Danger of Diciimarot treatment in preg- nane. Chloroihiuide in edema of pregnancy. Postmortem cesarean section Obst. C The anesthetic harards in olistetrics Am. Total exchangeable sodium and potassium in nonpregnant women and in normal and preeclamptic pregnancy.

Thromboembolic conditions and their treatment with anticoagulants. Charles C Thomas McCartney. E, and Harroo, J. Alterations in body com- position duting pregnancy. The pulse and respiratory variations duting Tabor as a guide to the onset of cardiac failure in women with rheiimalic heart disease.

These are frequently misdiagnosed as joint or orthopaedic pathology leading to unnecessary investigations.

This study was conducted to observe the various striatal and postural deformities among patients with PD in India. This study was conducted at a tertiary care teaching institute in north India. Of the 70 patients with PD, 34 Striatal foot was the most common deformity observed Striatal deformities were more ipsilateral to PD symptom onset side agreement Pisa and scoliosis concavity were more on contralateral side to PD symptoms onset side Our results showed that striatal and postural deformities were common and present in about half of the patients with PD.

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In a study by Ashour and Jankovic 1 , these deformities were present in Among these deformities, the most common was striatal limb deformity Ashour and Jankovic 1 described the characteristics of striatal foot deformity as great toe extension or flexion, planter flexion of remaining toe and equinovarus foot ankle inversion.

The relative frequency of various components of striatal foot may indicate the severity of striatal foot deformity. Big toe lateral flexion and equinovarus foot may indicate severe form of striatal foot deformity. Jankovic and Tintner 7 found striatal hand and foot deformities in up to 10 per cent of untreated patients with advanced PD. In another study foot dystonia was found to develop in per cent of the patients with PD receiving sustained levodopa treatment 8. Ashour and Jankovic 1 found that patients with striatal deformity were younger and had earlier disease onset than patients without deformity.

Gortvai 9 suggested that MP flexion and IP extension, due to contraction of lumbricals and interossei, respectively, could be the earliest signs of striatal hand. In our study, among striatal hand deformities, flexion at MP joint and extension of IP joint were most common. Spagnolo et al 10 concluded that striatal hand was significantly worse on the side of PD onset and on the side having more PD symptoms. In our study, camptocormia was present in 20 per cent patients and they had higher UPDRS and H and Y scores compared to patients without camptocormia.

Camptocormia has been reported to be present in 3- 7 per cent patients with PD 11 , Abe et al 13 reported camptocormia in In a recent review, authors have classified camptocormia as upper and lower types and reported its prevalence in patients with PD ranging from 3 to 18 per cent 3. Antecollis was seen in 7. In a study by Kashihara et al 6 , dropped head syndrome was found in six per cent patients.

Fujimoto 14 found that seven of the 5. In our study, Pisa syndrome was found in five 7. Tassorelli et al 16 found Pisa syndrome in 20 6.

Ashour and Jankovic 1 found scoliosis in 8. Duvoisin and Marsden 19 analyzed 19 patients of PD with scoliosis and found that 16 of them had scoliosis concavity towards contralateral side to the initial parkinsonian symptomatology and three towards ipsilateral side.

There has been debate about the direction of trunk leaning Pisa syndrome or scoliosis towards or away from predominant parkinsonian symptom side 6. Ashour and Jankovic 1 found that side of striatal deformity correlated with the side of initial parkinsonian symptom in all patients with striatal hand and in Baik et al 18 found no correlation between PD symptom laterality and scoliosis.

The number of patients having Pisa syndrome and scoliosis was less in our study, so proper assessment regarding their sidedness could not be done. In conclusion, our study showed that striatal and postural deformities were common in Indian patients with PD.

These were more frequent in advanced stage of disease as reflected by significantly higher UPDRS, and H and Y scores in these patients. Striatal foot and striatal hand were more likely to be ipsilateral to the side of PD symptom onset. National Center for Biotechnology Information , U. Indian J Med Res. Sanjay Pandey and Hitesh Kumar. Received May This article has been cited by other articles in PMC.

Camptocormia, dyskinesias, Pisa syndrome, scoliosis, striatal foot. Results A total of 79 patients with a possible diagnosis of PD were included. Analysis of variables between patients with Parkinson's disease PD with and without deformity. More recently, both Sims and Krantz, and dc Alvarez and Braivold performed "serial" determina- tions throughout the pregnancies of normal women.

The data reported by Sims and Kraniz confirm the observations of earlier investigators, lltc glomerular filtration rate was increased approximately 50 per tent throughout pregnancy The estimated renal plasma flow and renal blood flow were approximately 25 per cent higher than control values throughout early and midprcgnancy, and declined to control values during the last trimester The filtration fraction the relation of the glomerular filtration to the renal plasma flow was elevated significantly throughout pregnancy, and rose to approximately 40 per cent above control values as term was ap preached.

As a result of the increase in filtration rate, the concentra- tions of urea and creatinine in the plasma were reduced to approxi- mately one-half and two-thirds, respectively, of the concentrations in nonnal nonpregnani subjects. Sims and Krantz pointed out that coincident with the increase in renal function during pregnancy, there was an increase both in total body water and m plasma volume. However, by the time plasma volume had reached its peak, the renal plasma flow had declined well toward the nonpregnani range.

Hence, it seems unlikely that the increase in renal plasma flow is merely a passive reflection of some correlate of hypervolemia. The authors contended lliere is no evidence tliat the kidneys hypertrophy during pregnancy. Figures 14, 15, and 16 are reproduced from their article.

During the first trimester, the glomerular filtration rate was increased by 50 to 60 per cent above the normal nonpregnani level. Beginning early in the second trimester, the rate declined pro- gressively, and gradually reached a level below that of the normal nonpregnant state.

Riistcii R de Ah: Accordingly, the filtration ftaction was reduced during the first two trimesters, and increased during the last trimester. According to de Alvarez, the jiositive sodium and water balances of nomial pregnancy are related to a progressive de ression of tlie glomerular filtration rate.

Thus, the kidneys alone may be responsible for most of the observed modifications of fluid vohime anti soduini. General metabolic, placental, and additional humoral influences contribute to these alterations of renal function. Judging from the conflicting results obtained in these two recent serial tyjie studies, it is impossible, at piescnt, to state definitely whether renal unction increases or decreases during pregnanes Nevertheless, tiiere are certain areas of agreement, for in both articles a correlation is observed beivveen the renal plasma flow and the cardiac output.

Uterine blood flow at term averaged 15 cc. Uterine oxygen consunvjvtion at term averaged 1. Uterine vascular resistance at term averaged 6 mm. Total uterine blood flow at term was estimated to be cc. Metcalfe and associates found an average term total uterine blood flow of cc per minute, and the average oxygen consumption of the uterus and its contents wms calculated to be 25 cc. Their results arc not directly comparable with those of the Assali study since different methods for determination were employed.

Nevertheless, it is dear that uterine circulation increases markedly during pregnancy see posipanum values, page In the thirty-sixth and thirty-sesenlli weeks, peripheral circulatory adjust- ments developed. From the tlurty-eiglith stcek until term, a gradual decrease was noted in the peripheral circulation to all extremities. Abramson and co-workers, and Burt deinonstiated increased flow through the hands.

Palmar reddening is a commonly obsersed antenatal phenomenon. In gravid patients, spider angiomas appear fretjuentl , and almost invariably pre-existent hemangiomas increase in sire. Super- ficial veins of the breasts and abtlomen may become greatly engorged.

The reduction was associated with increased arteriolar motor activity vvhicit cvilminated in true spasm at term. McCausland and Holmes fountl a normal cerebrospinal fluid pressure at term. Fine atelectatic lusal rales may develop from uterine encroachment upon the diaphragm. However, these adventitious sounds disappear after coughing or deep breathing. Decreased height of the thoracic cavity is compensated for by increase in its anteroposterior and transverse diameters.

The subcostal angle is widened by flaring of the lower ribs. Before discussing pulmonary function, it is helpful to define certain terms which only recently have been standardized: Vital Capacilys The maximal volume of gas that can be expelled from the lungs by forceful effort following a maximal inspiration. Expiratory Rcsersc Volume; Tlic maximal volume of gas tliat can be expired from the resting expiratory level. The volume of gas remaining in the lungs in the resting expiratory position.

Residual Volimici The volume of gas remaining in the lungs at the end of a maximal expiration. Viial capant in pregnane Tidal Volume: The volume of air that moves in or out of the nose and moiitli with each inspiration or expiration Minute Volume: The volume of air which moves in or out of the nose and mouth per minute tidal volume times frequency of breathing per minute.

The maximal volume of gas that can be breathed per minute by voluntary effort. Increased inspiratory capacity of pregnancy compensates for decreased expiratory reserve volume, and vital capacity rigtire 17 remains un- changed.

Observations in over cases at the New York Lying-In Hospital have not confirmed the slight increase of vital capacity reported by other investigators who studied mudi smaller senes of patients.

Decreases in residual volume and expiratory resene reduce the func- tional residual capacity. Maximal breathing capacity remains unchanged. Hyper- veniihition and tlyspnca are encountered eomnionly in pregnant women.

Augmentation ol minute solume leads lo an increase in the amount of carbon dioxide expired per minute, and this in turn lowers the carbon dioxide in ahcnl.

Howeser, the plasma pH remains normal, since reduction of carbon dioxide in the plasma is compensated for by loss of bicarbonate through the urine. Mendehon and Weinbaum performed stand. Serial detenninations in each patient failed to demonsiiaie significant changes during pregnancy in the responses to exercise as measured by the pulse and respiratory rates, oxygen debt, or subjective symptoms.

Severe exercise did produce a slightly greater increase of oxygen debt than occurs in nongravid females. Robbe studied the "physical working capacity" in nomial and in cardiac, subjects.

The capacity in normal patients and in the groups with septal defects, pulmonary stenosis, and aortic valvular disease re- mained approximately constant during and after pregnancy, except in two cases complicated by toxemia. In the mitral disease gioup pure or combined with aortic valvular disease , there was a suggestion of higher mean pulse rate resjionse to any partiadar vvoik load during pregnancy than in the postpartum state. Judging from the afoTemeniioned observations, it remains lo be proved that the additional weight of pregnancy imposes an added burden to physical activity.

The normal response to this maneincr is ditidcd into four phases. Since the Valsalva maneuver also impedes thoracic venous inflow, stroke output falls, and consequently aitenal, sysiolic, and pulse pressures decrease. Invariably, this reduction in pressure begins within one to two seconds after onset of the acute rise in syscenue arterial pressure.

In phase 2, systemic arterial pressure and pulse pressure decline to a relatively steady low point. If positive pressure is held long enough, systemic vasoconstriction occurs, with a resultant rise m mean arterial pressure toward the end of phase 2. Phase 3 occurs as forced expiration is terminated and is characterized by a sudden fall in systemic arterial pressure.

Phase 4 occurs after the release of forcet! Eventually, all parameters return to original baseline levels Figure 18 sliows the typical arterial systolic blood pressvire response to the Valsalva maneuver This normal pattern of response to the V. Gorlin and associates found normal responses during the antepartum months of pregnancy. The Valsalva maneuver is performed in the following manner. Tlie subject blows forcibly into a mouthpiece connected to the aneroid attachment of a clinical blood pressure cull with sufflcieni strength to maintain the pressure at 40 mm.

Hg for approximately ten seconds. The resting systolic blood pressure is determined by the use of an orcli nary sphygmomanometer. Hg above the resting systolic pressure. Similarly, by next maintaming the cuff tension at about 10 to 15 mm. Hg abote the baseline systolic pressure, the overshoot in phase 4 is deter- mined by the reappearance of auscultatory sounds after release of the forced expiration.

Tables 3 and 4, and Figures 19 and 20 are reproduced from their article. The cardiac output rose appioximately 20 per cent during eadi eilcctite uterine conirdcison o! Significant increases during contraction developed also in the pulse rate, blood pressure, and left ventricular worV.. SlToVe tohime, circulation time, and total peripheral resistance were not altered appreciably.

The virtual complete absence of positive changes, following saddle block or caudal anesthesia, suggested to the authors that individual response to pain, anxiety, and niusciil. Crapl'ic illuMralion of average values for cardiac ouiput, heart rate, and stroke volume between contractions and at height ol contraction.

The cartihic output, heart rate, stroke rohime, and left ventricular work, between contniaions were ttnehanged by normal first stage labor. Hendricks conducted a similar study using the blootl pressure mcthotl to calculate cardiac output. The oiicptit Figures 21 and 22 rose about 30 per cent during each uterine contraction of first stage labor.

Blood pressure Figures 23, 21, and 25 rose quite consistently during contrac- Tjo. Alteration in canliac ouipiit duniig uterine contracUon The mean cartiiac output as tndicaietl liy the putw pressure method for issent eompleie roiicracdon cycles shows a nsc extremely early in the contraction, and readies an apex alMstil eishteen seconds berore the maxi- mum amnioiic fluid pressure is reached Counesj of Dr. Charles H Hendricks tions, the systolic level by 10 to 20 mm.

Hg and the diastolic level some- what less. The heart rate and stroke volume Figure 26 maintained a reciprocal iclaiionship throughout each contraction cycle. The heart rate rose during the initial phase, fell below base level at the peak of contraction, and returned to its original value. The stroke volume dropped slightly jn the early phase of contraction, and then rose sig- nificantly above base level before returning to its original value. Central and femoral venous pressures rose dnrmg contractions, but brachial venous pressure did not change Figure An rsaggerated blood pressure respimse to uierine coniraction Tlie rise in blood pressure is from 20 lo 30 mm.

H", and Ihc mavimutn pressure is attained Iiefore the apex of the contraction is re. B, Intrathoracic venous pres- sure, recorded at 3 cm per minute The pressure rises significantly in assoctalion mth he incrcave In amniotic fluid prenurc C.

The brachial venous pressure shows little or no alteration In response to the merine contractions. The femoral venous pressure rises sharply by as much as 20 mm Ug during the earl part of the contraction cycle, then drops to a "plateau level" until the completion of llie acme pan of the con traction, when it subsides further to the basdine noncontraetde level Courtesy of Dr.

Anxiety, pain, and physical effort affected the findings markedly. A, Supine position l, On the right side Courtesy of Dr. The initial jreak of femoral venous pressure is not sustained, but some elevation persists until the uterus relaxes com- pletely. Consistent alterations in femoral venous pressure disappear when pelvic venous obstruction is overcome by turning the patient on her side or by raising her legs into the lithotomy position.

Initially, the heart responds to increased venous pressure by acceler- ating its beat. Subsequently, however, as blood pressure rises, the rale declines and the stioke volume increases. When redistribution is com- pleted, all parameters return to their original baseline levels of the relaxed myometrial phase, and remain there until onset of the ensuing contraction Aithoiigli the actual volume of blood contained in the human gravid uterus at term has not been detcrminetl, evidence translated from animal experiments suggests that fiOO to cc may be present.

Accoiding to McCausland and Holmes, tlie cerebrospinal fluid pressure increases slightly to moderately during uterine contractions. Pardee and Mcndclson found that the pulse and respiratory rates between uterine contrartions remain fairly constant throughout the first stage of labor Figures 29, 30, 31, 32, and Basically, these eflorts reproduce the Valsalva maneuver page To the author's knowledge, Valsalva phenomena have not been studied during labor.

Normally, straining efToris should impede venous reitim to the heart. EfTective uterine contractions, on the other hand, normally should increase tlie venous return.

Thcorelically, the over-all hemodynamic response to bearing down m association with a uterine contraction will vary with effectiveness and timing of the opposing processes. Throughout the earlier part ol labor the pulse had reniained at!

X anil the respirations at Second, venous return to the heart may be decreased by Valsalva impedance when: Third, venous return to the heart may remain unaltered where the effects of contraction and of bearing down are balanced. Seldom did the respirations increase more than eight per minute, but the rate exceeded twenty-four in 19 per cent of cases.

There was no correlation of pulse and respiratory rates with either the use of analgesia or the particular analgesic employed. Prolonged labor and prolonged second sLige increased the liability to atceleration of pulse nnd respirations. During actual deliscry, there is a s-ariable increase in cardiac output and pulse rate. Accoiding to Atlams, tliis increase, contrasted with that accom- panying first stage uterine contractions, is accomplished by an increase in stroke volume.

In the third stage, the pulse rate falls, pain and anxiety are alleviated, ami pliysical efforts are no longer expended. Augmented venous return is, therefore, the primary factor involved in raising the cardiac output postpartum. Repayment of maternal oxygen debt incurred throughout labor may contribute to elevated output during the first twenty-four liours following delivery.

The rise in cardiac output is accompanied by an increase in left ventricular woik. The augmented venous return derives from expansion of plasma voUiiue and from release of pelvic venous obstruction. A brief but srg- nificint rise in plasma volume coincides with initial uterine contraction following birth of the baby. Third stage blood loss next is reflected by a transient decrease in plasma volume, usually to a subnormal value for pregnancy Within a matter of hours, however, the plasma volume returns to higher than normal levels.

This elevation, which persists approximately two weeks, is aitribiued to reabsorption of fluids lost to the tissues during labor, and to removal of extracellular water which has accumulated throughout pregnancy. Brown and co-workers imcstigatetl the effects of routine oxytocic agents administered at childbirth, and demonstrated that ergot prepara- tions raised venous pressure markedly during the first twenty-four hours after delivery.

The leukocyte count rises to an average of 14, to 15, on the second postp-artiim day, and returns graduaUy to normal tn the next two to four weeks. The corrected sedimentation rate reaches a peak averaging 37 mni. Renal jilasma flow returns to the nonnal nonpregnant level b the third postpartiiin da.

Sims and Kranu observed a postpartum elepression in renal plasma flow which lasted several months. In the postpartum period, pcrtplicral blood flow cliaiiges begin witii ambulation, reripheral blood flow and skm temperatures arc normal within siv to ten weeks after parturition.

Assali and co-uorkers observed the following cliangcs in luerme metabolism: The fall vloes not produce sub- jective symptoms, and hyperventilation is not observed.

Additional variables are introduced by the character of labor itself, not only in resjicet to strength, frequency, anil duration of uterine contractions, but also m terms of associated conditions such as dehydration, acidosis, and hemor- rhage.

Tatum studied eight cesarean cases and vvas unable to demonstrate any immediate rise in plasma volume after enrptying tlte utervis, although a later rise devel- oped as seen following vaginal delivery.

Absence of the immediate rise may be explained by failure of initial contractions to squeeze a significant volume of blood into circulation owing to the large amount lost through the myometrial incision.

Infusions and transfusions— administered commonly during cesarean section— increase volumetric return to the right side of the heart. Post- operative complications suclr as fever and abdominal distention augment the cardiac burden of cesarean section. SUMMARY Pregnancy imposes a significant and predictable circulatory burden which is due mainly to Increases in oxygen consumption, cardiac output, and blood volume.

This burden starts in the first trimester, increases progressively throughout the second trimester, and decreases subse- quently toward term. Transient rises occur during labor and immediately following delivery, but not to the previous high antepartum levels. A return to the normal nonpregnani heniotlynamic state is acliieved by the second postpartum week. The pattern of cardiac output and of related cardiovascular phe- nomena may be due to an arteriovenous fistul.

The added metabolic demands of pregnancy cannot account primarily for the rise in cardiac output. The normal pregnant woman exhibits physiologic deviations which easily can be misinterpreted to indicate organic heart disease.

S M- Peripheral blood flow during preg- nane. Alicralions in tardiovavciilar physiolog during labor. Obst S; C nec.

A , Jr , Baird. Measurement of urine blood flow and utenne metabolism Am J. Gynec 61 , Heinodjnamics at rest and during exercise in normal pregnancy as siiidied by cardiac caiheieriration J ain Invest. L O Ginriifincfr B t and Gixnsir. Rntiv C C Rrm. C E Renal glomerulotubular mech. C R Studies of blood in normal pregnant , hemo- globin. G nec 63 1, Elisbebc. The Iwari in pregnancy and the chiltlhearing age. Bril Imp 56 The hemodyiiamica of a utennc coniraciion.

A , aoil Wawm. II- Rociugenologic and electrocardiographic cli. Supine hypotensisc syndrome late in pregnanq. Ohst I Gynec I MA , JinsoN, W. I , and U'iimss. Blood pressure responses to the Valsalva maneuver in cardiac patients utih and wuhoiii congestive failure Circula tion n SHO. F Tlie bulbar eon- junclival vascular bed in normal pregnanq.

Am J Obst A Gynec. N U'j Corfdttion of bloosl loss ujth blood volume and other hematological studies before, during and after childliirth Am. J Total exchangeable sodium and potassium in nonpregnant women and in normal and piv eclamptic pregnancy Lancet 2 Alterations in body compo- sition dtinng p r egnancy.

Am J Obst i Gynec Uest J Surg 65 , E Plasma vofiimc fate in pregnancy. H C , Booth. J iiemodymmic changes associated with the Vaisilva maoeuser in normal adult male and female sub jects Abstract.

D rsiimaiion of iiieniic blood How in normal human pregnanq at term. Jm- liver flow in pregnancy hepatic vein catheterization. IUrms, a C ami ItRit.

Gvnec 78 1G5, Rvmsfv, F. U' N, and Str. Gy nee 77 J , and Auuit. C Ihc csnmatwm of ch. Maternal and fetal circulation m the human placenta 7lschr f Anat u Fntwicklungshesb Jtnsox W L and U'li kins. II C, Jr The niiraiion rate. J Clm Invest 21 Pregnancy and heart disease Acta obst et gynec.

The lardio pidmoiul fuiiciion during jireginiic a clinical expen- menial stud uiili parliiulir respect to tnililaiion and oxygen comnropuoi among normal ciscs ai rest and after tsork tests Acta obst. Relationship between abdominal uterine and arternl pressures during lalxir Am.

The cloctrocardiogiam in pregnanq and the piierperiiim Am Heart J 12 These data and all published reports indicate that over 90 per cent of pregnant cardiac cases are of rheumatic origin. A complete diagnosis should include one or more titles from each of the mam headings of this nomenclature There should be a statement as to the etiology of the disease.

Tliere should be a statement indicating he cardiac meclianism and any disturbance of cardiac physiology which may Ime arisen, particularly a diagnosis to indicate the patient's symptomatology.

A diagnosis of the cardiac functional capacity and a statement of the patient's therapeutic classiBcation com- plete the list.

Certain patients may have symptoms or abnormal physi- cal signs, and yet it may not be ossiIile to make a diagnosis of struc- tural disease or of a disturbance of canliac physiology. Predisposing Etiologic Fartor,' and there should be a statement of the etiologic factor. Ordinary physical activity docs not cause undue fatigue, palpitation, dyspnea, or anginal pain.

They are comfortable at rest. Ordinary physical activity results m fatigue, palpitation, dyspnea, or anginal pain. Class in-patients with cardiac disease resulting in marked limita- tion of physical activity. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain Class IV— patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency, or of the anginal syndrome, may be present even at rest.

If any physical activity is undertaken, discomfort is increased. The following therapeutic classifications arc, therefore, useful: Class A— patients with cardiac disease whose physical activity need not be restricted. This is seldom the case in pregnancy because of the added burdens involved.

Close B— patients with cardiac disease wliose ordinary physical activ- ity need not be restricted, but who should be advised against severe or competitive physical efforts.

Class C— patients with cardiac disease whose ordinary physical activ- ity should be restricted moderately and wliose more strenuous effort should be discontinued.

Class D— patients with cardiac disease whose ordinary physical activ- ity should be restricted markedly. Class E— patients vvilh cardiac disease who should be at complete rest, confined to bed or chair.

Routine studies for complete diagnosis include anteroposterior and lateral x-rays of the heart, eleclrocardiogtaiin. Special determinations including circulation time, exercise tolerance tests, cardiac catheterization, angiography, and response to the Valsalva maneuver may be required. In pregnant women, cardiac catheterization and angiography should be reserved for serious problems which urgently require clarification to insure proper management.

Occasionally, serious and even fatal reac- tions have resulted from the test materials used in angiography, and venous thrombosis occurs fairly commonly at the injection site. The uterus should be shielded from radiational exposure so as not to endanger the fetus.

Even with utmost care, scatter may create a potential hazard. Frac- tionation of exposure does not, as may he thought, reduce the incidence of anomalies; in fact, exposure to fractional doses leads to malforma- tions of much greater sexerity than those caused by a single dose. This may be due to more organ primordia being subjected to radiation insult during their rcspecthe critical stages of dexelopment. It is important that this also is the period when pregnancy might not be suspected by the patient or her physician.

There are three basic reasons for cautioning against unnecessary fetal irradiation. First, the prj mitise germ cells an? Second, it is probable that leratoiogic effects of ionizing radia- tion begin simultaneously with development of the central nervous S stem. Third, there is an increased probability that leukeniia xvill appear in young children as a sequela to prenatal irradiation.

In addi- tion, some harmful effects of x-rays upon the fetus may not appear for many years follosving birth, and although gross abnormalities are not evident, subtle deficiencies may be manifested in intelligence. There is less danger of inducing gross teratism after the fortieth day except at higher levels of exposure.

Angiocardiography and cardiac catheterization siioufd, therefore, be deferred until the third month. Other institutions report mortalities tvhich range from I to 5 per cent. Acute endocarditis, thromboHS of sagilUi sinus. Arteriosclerotic coronary arler " , , J. The mortality in setere heart failure is 15 per cent. On the other hand, there is no evidence to indicate that ordinarily childbearing causes permanent deterioration of the canliac status, or that childbearing shortens life expectancy, provided the patient sursites each pregnancy.

D g 6 5 0 2 0 1 Coronary atherosclerosii. Although only 12 per cent of the cardiac patients are in the Class and Class lY groujis, this small number accounts for most of the maternal fatalities. It should be emphasized that favorable statistics concerning results in heart disease complicating pregnancy hate little significance unless they refer specifically to the Class III and Class IV patients Obstetric clinics which do noi handle large numbers of cardiac patients will have relatively few of these unfavorable cases, and are apt to develop an overoptimisiic atiitmie regarding tlie problems of heart disease in pregnancy.

Similarly— in patients with adequate cardiac reserve— chronic atnal fibrillation in rheumatic heart disease, cy'anosis in congenital heart dis- ease, previous coronary occlusion jn hypertensive disease, and previous bacterial endocarditis in rheumatic or congenital heart disease are not by themselves necessarily incompatible with childbearing Circulatory experiences in a prior pregnancy may aid in appraising the cardiac reserve Severe antepartum heart failure due to mitral stenosis is likely to recur in successive pregnancies This is not neces- sarily true in all other types of heart disease.

In fact, it has been learned that reactions to exercise tests provide a reliable guide to func- tional classification esjjecially where the history is equivocal.

A simple test requires that the patient climb twenty steps at a normal pace. The pulse and respiratory rates are recorded prior to the exercise. In normal patients anti in Class I and Class II cardiacs, the rates return to original lesels by the last observation. Such tests should not of course be perfonned in the presence of serious incapacity, as they may precipitate pulmonary etiema.

In obscure cases of rheu- matic or congenital heart disease, cardiac catheterization provides a direct method for evaluating the underlying anatomic lesion and its hemodynamic significance. Except in the presence of atrial fibrillation or a history of embolism, this laboratory procedure can be per- formed during pregnancy without undue risk. However, as previ- ously noted, the procedure should be deferred until the third month, and even then the uterus should be shielded from rachational exposure so as not to endanger the fetus.

The initial rise in systolic blood pressure which accompanies a forced expiration persists throughout the period of straining, and the characteristic poststraining osershoot does not occur Figure These deviations from the normal response do not occur in dyspnea associated with obesity, in the hyperventilation syndrome, or in psychogenic dyspnea.

These special prob- lems will be discussed in later chapters. Also, hypoxia may play a role in anomalous development. Intrapartum fetal deaths hate been attributed to hypoxia associated with maternal cyanosis and with maternal paroxysmal tachycardia. Apart from the foregoing considerations, maternal heart disease, by itself, does not affect the infant nioibiclity or mortality.

Tlie incidence of spontaneous abortion and of premature labor is no dillerent in car- diac patients than in the general clinic population. These variations will be disaissed in detail in later cliapters In most instances, however, the fundamental purpose of management is to prevent death from heart failure.

In die early stages of its development, cardiac insufficiency manifests itself only when circufatory demands are increased, as with exercise. It may be absent in the resting state. The different degrees of this ability are expressed by the cardiac functional classification. Failure of the heart to circulate the requiretl volume of blood leads to venous congestion in the pulmonary or systemic circuit, or in both, and to inadequate arterial blood flow.

As a result, the circulation time is prolonged and functional changes occur in the various organs. Reten- tion of salt and water due to impaired renal function produces hyper- volemia which aggravates the congestive state.

In cardiac failure asso- ciated with hyperthyroidism, beriberi, pulmonary disease, and anemia, the output is normal or increased. However, in most other etiologic types of heart disease, failure is characterUed by low output and pro- longed circulation time. The single, most important component of the heart is the myo- cardium. Striatal deformities were more ipsilateral to PD symptom onset side agreement Pisa and scoliosis concavity were more on contralateral side to PD symptoms onset side Our results showed that striatal and postural deformities were common and present in about half of the patients with PD.

These deformities we more common in patients with advanced stage of PD. National Center for Biotechnology Information , U. Didn't get the message?

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Pisa and scoliosis concavity were more on contralateral side to PD symptoms onset side Our results showed that striatal and postural deformities were common and present in about half of the patients with PD.

These deformities we more common in patients with advanced stage of PD. National Center for Biotechnology Information , U. Didn't get the message? Add to My Bibliography. Generate a file for use with external citation management software. Pandey S 1 , Kumar H 1. Comment in Understanding of skeletal deformities in Parkinson's disease.

Images from this publication. See all images 5 Free text. Striatal hand showing flexion at metacarpophalangeal joint with extension at interphalangeal joint and ulnar deviation of the left hand A , which was confirmed by hand X-rays B , striatal toe showing lateral flexion of the great toe with flexion of other toes C , which was confirmed by foot X-rays D.

Pisa syndrome in a patient with Parkinson's disease characterized by leaning towards left side A , which was confirmed by spine X-rays B. Class D— patients with cardiac disease whose ordinary physical activ- ity should be restricted markedly. Class E— patients vvilh cardiac disease who should be at complete rest, confined to bed or chair. Routine studies for complete diagnosis include anteroposterior and lateral x-rays of the heart, eleclrocardiogtaiin.

Special determinations including circulation time, exercise tolerance tests, cardiac catheterization, angiography, and response to the Valsalva maneuver may be required. In pregnant women, cardiac catheterization and angiography should be reserved for serious problems which urgently require clarification to insure proper management. Occasionally, serious and even fatal reac- tions have resulted from the test materials used in angiography, and venous thrombosis occurs fairly commonly at the injection site.

The uterus should be shielded from radiational exposure so as not to endanger the fetus. Even with utmost care, scatter may create a potential hazard. Frac- tionation of exposure does not, as may he thought, reduce the incidence of anomalies; in fact, exposure to fractional doses leads to malforma- tions of much greater sexerity than those caused by a single dose.

This may be due to more organ primordia being subjected to radiation insult during their rcspecthe critical stages of dexelopment.

It is important that this also is the period when pregnancy might not be suspected by the patient or her physician. There are three basic reasons for cautioning against unnecessary fetal irradiation. First, the prj mitise germ cells an? Second, it is probable that leratoiogic effects of ionizing radia- tion begin simultaneously with development of the central nervous S stem.

Third, there is an increased probability that leukeniia xvill appear in young children as a sequela to prenatal irradiation. In addi- tion, some harmful effects of x-rays upon the fetus may not appear for many years follosving birth, and although gross abnormalities are not evident, subtle deficiencies may be manifested in intelligence. There is less danger of inducing gross teratism after the fortieth day except at higher levels of exposure.

Angiocardiography and cardiac catheterization siioufd, therefore, be deferred until the third month. Other institutions report mortalities tvhich range from I to 5 per cent. Acute endocarditis, thromboHS of sagilUi sinus.

Arteriosclerotic coronary arler " , , J. The mortality in setere heart failure is 15 per cent. On the other hand, there is no evidence to indicate that ordinarily childbearing causes permanent deterioration of the canliac status, or that childbearing shortens life expectancy, provided the patient sursites each pregnancy. D g 6 5 0 2 0 1 Coronary atherosclerosii.

Although only 12 per cent of the cardiac patients are in the Class and Class lY groujis, this small number accounts for most of the maternal fatalities. It should be emphasized that favorable statistics concerning results in heart disease complicating pregnancy hate little significance unless they refer specifically to the Class III and Class IV patients Obstetric clinics which do noi handle large numbers of cardiac patients will have relatively few of these unfavorable cases, and are apt to develop an overoptimisiic atiitmie regarding tlie problems of heart disease in pregnancy.

Similarly— in patients with adequate cardiac reserve— chronic atnal fibrillation in rheumatic heart disease, cy'anosis in congenital heart dis- ease, previous coronary occlusion jn hypertensive disease, and previous bacterial endocarditis in rheumatic or congenital heart disease are not by themselves necessarily incompatible with childbearing Circulatory experiences in a prior pregnancy may aid in appraising the cardiac reserve Severe antepartum heart failure due to mitral stenosis is likely to recur in successive pregnancies This is not neces- sarily true in all other types of heart disease.

In fact, it has been learned that reactions to exercise tests provide a reliable guide to func- tional classification esjjecially where the history is equivocal. A simple test requires that the patient climb twenty steps at a normal pace.

The pulse and respiratory rates are recorded prior to the exercise. In normal patients anti in Class I and Class II cardiacs, the rates return to original lesels by the last observation.

Such tests should not of course be perfonned in the presence of serious incapacity, as they may precipitate pulmonary etiema. In obscure cases of rheu- matic or congenital heart disease, cardiac catheterization provides a direct method for evaluating the underlying anatomic lesion and its hemodynamic significance.

Except in the presence of atrial fibrillation or a history of embolism, this laboratory procedure can be per- formed during pregnancy without undue risk. However, as previ- ously noted, the procedure should be deferred until the third month, and even then the uterus should be shielded from rachational exposure so as not to endanger the fetus.

The initial rise in systolic blood pressure which accompanies a forced expiration persists throughout the period of straining, and the characteristic poststraining osershoot does not occur Figure These deviations from the normal response do not occur in dyspnea associated with obesity, in the hyperventilation syndrome, or in psychogenic dyspnea. These special prob- lems will be discussed in later chapters. Also, hypoxia may play a role in anomalous development.

Intrapartum fetal deaths hate been attributed to hypoxia associated with maternal cyanosis and with maternal paroxysmal tachycardia. Apart from the foregoing considerations, maternal heart disease, by itself, does not affect the infant nioibiclity or mortality. Tlie incidence of spontaneous abortion and of premature labor is no dillerent in car- diac patients than in the general clinic population.

These variations will be disaissed in detail in later cliapters In most instances, however, the fundamental purpose of management is to prevent death from heart failure. In die early stages of its development, cardiac insufficiency manifests itself only when circufatory demands are increased, as with exercise. It may be absent in the resting state. The different degrees of this ability are expressed by the cardiac functional classification.

Failure of the heart to circulate the requiretl volume of blood leads to venous congestion in the pulmonary or systemic circuit, or in both, and to inadequate arterial blood flow. As a result, the circulation time is prolonged and functional changes occur in the various organs.

Reten- tion of salt and water due to impaired renal function produces hyper- volemia which aggravates the congestive state. In cardiac failure asso- ciated with hyperthyroidism, beriberi, pulmonary disease, and anemia, the output is normal or increased.

However, in most other etiologic types of heart disease, failure is characterUed by low output and pro- longed circulation time. The single, most important component of the heart is the myo- cardium.

Pressure loads are created when normal or reduced stroke volumes aie ejected against liigh resistance. The left side of the heart fails more rapidly than does the right under volume loads; the right side of the heart fails more rapidly than does the left under hydrostatic pressure stiess In the early stages of cardiac insufficiency, the clinical picture may be predominantly that of left-sided or of right-sided failure, depending upon winch side of the liearl is aHected primarily Generally, the later clinical picture is that of bilateral failure Prunary heart failure is more commonly left-sided than right-sided Primary left-sided failure is seen m mitral and m aortic valvular disease, hypertension, coronary artery disease, and in left-to-right intra- cardiac shunts due to patent ductus or lentnciilar septal defect The clinical manifestations result from pulmonary congestion and increased pulmonary capillary pressure.

These include dyspnea, orthopnea, cough, hemoptysis, pulmonary rales, accentuated pulmonary second sound, and decreased vital capacity The venous pressure is normal Acute left-sided failure protluces p. Primary right-stded failure is seen tn pulmonary hypertension, pulmonic stenosis, cor pulmonale, myocarditis, tricuspid stenosis, and in constrictive peri- carditis.

The manifestations are due largely to engorgement and elevation of pressure in the systemic venous circuit These include engorgement of the superficial veins, subcutaneous edema, enlargement and tenderness of the liver, cyanosis, ascites, hydrothorax, hydropen- cardium, and disturbances of the gasiroiniesiinal. Ordinarily, true heart failure during pregnancy is left sided, and is manifested by reduced vital capacity, persistent basal rales, prolonged circulation time, cough, hemoptysis, paroxysmal dyspnea, and paroxys- mal pulmonary edema.

The term "severe heart failure. The frequently intractable nature of this complication is responsible for many maternal deaths. The process may be initiated b a marled increase in resistance to outflow from the left cardiac chambers, sudden decrease in left ventricular or left atrial out- flow, or by excessively rapid increase in venous return and right ventricu- lar output.

Gestatoty hypervolemia predisposes to pulmonary edema in the etiologic types of heart disease characterized by primary left-sided failure. Ph siologic antepartum increases in heart rate and cardiac out- put favor the development of pulmonary edema in mitral stenosis Chapter 3. Hamilton and Thomson contended that a decrease in vital capacity of 15 or more per cent antedated other evidences of severe antepartum heart failure. Experiences at the New York Lying-In Hospital have not corroborated this contention, for in each instance where the vital capacity fell due to cardiac insufficiency, other subjective or objective evidence of deterioration could be detected as well, provided the patient h.

This does not detract from the value of vital capacity observations, but it does indicate that the total clinical picture is just as important, if not more so, in evaluating the cardiac status. Augmentation of ph siologic antepartum hyper- volemia due to factors which produce vascular congestion Table 11 may le-id to pulmonary edema. Acute cor pulmonale may develop with massive intraluminal or extraluminal pulmonary vascular obstruction. Acute cor pulmonale, as a specific obstetric hazard, is associated with venous air embolism, fibrin emboli, and with the "acid aspiration" syn- drome.

These complications are discussed in Chapter 9. These include a regimen of digitalis, oxygen, rest, sedatives, diuretics, and restricted intake of sodium and of fluids. Mercurial diuretics have been employed with good results. Once severe heart failure has occurred during pregnancy, it is adtis- able, in most cases, for the patient to remain under treatment in the hospital until after delivery— regardless of complete recovery from the current episode of failure, or adequacy of facilities for home super- vision and care.

Compromises in this policy may prove ill-fated, unless, of covirse, the vinderlying cause of decompensation has been corrected definitively by cardiac suigery f-g. Meanwhile, severe decompensa- tion may recur, and the associated 15 per cent mortality takes its inev- itable toll.

The beneficial effects of atropine may be overshadowed by the tachycardia u produces. Aminoplj lIine is admlnisteml intravenously to maintain the car- diac output and to lower the venous pressure.

If necessary, the drug may be lepeated at hourly intervals. However, since aminophylline can cause stitlden cardiac arrest, it should, at all times, be given slowly over a peiiod of minutes, and if the patient experiences distress during the administration, injection slioiild be discontinued immediately.

In undigitalized patients, rapid digitalis effect is induced to main- tain cardiac output. Ouabain or lanatoside C may be used intravenously. Antifoaming agents reduce pulmonary obstniction due to frothing of the edema fluid. The desired effect is achieved by bubbling pressur- ized oxygen through ethyl alcohol before it enters die tent or mask. Encouraging results have been obtained following intravenous use of ganglionic blocking drugs such as hexamethonium.

Tiiese agents lower the peripheral arteriolar resistance and produce a corresponding decrease in systemic and pulmonic vasadar pressures, tliereby reducing both the left ventricular load and the tendency lovvard transudation into the alveolar spaces. Also ganglionic blockade exerts a vagolytic action which relieves liyperpnea. Occasionally, phlebot- omy becomes necessary if tourniquet treaimeni does not achieve the desired results, Obstetric intervention has absolutely no place in the tieatment of pulmonary edema.

When these complications do arise, fluid is aspirated as indicated, but special precautions arc taken not to injure the uterus and tlje baby at the time of paracentesis. This is true especially in acute cor pulmonale due to fibrin emboli complicating abruptio placentae, amnioiic fluid infusion, or retention of dead fetus, since in such cases e.

Care should be exercised not to increase the cardiac embarrass- ment by overloading the circulation with infusions or transfusions Vasopressor drugs may be administered in syringe doses. Fibrinogen may be required to correct the coagulation defect. Prevent or control coninbuiory burdens. Remove the cause of the piediciable burden by therapeutic abortion. Prevent futuie gestatory burdens by sterilization or by contra- ception.

Agents which lower blood pres- sure have reduced the occurrence of cardiovascular complications in hypertension. Appropriate medical and surgical treatment has prevented or reversed cardiac involvement in thyroid disease. Anticoagulant dnigs have proved beneficial m preventing and controlling thromboembolic disease Studies of maternal actors including nutrition, oxygenation, exposure to radiation, and virus infection especially rubella have shed light upon antepartum influences m the genesis of congenital cardio- vascular anomalies The foregoing considerations give reason to hope that heart disease will, some day, become a rare complication of pregnancy.

However, from the practical standpoint, current emphasis must be placed upon preventing severe failure in the presenting Jieart disease. Infection Patients are instructed carefully and repeatedly to report at once in the eient of any infectioti.

Hospitalization is advised, cultures taken as indicated, and appropriate therapy rendered. Upper respiratory infections command the greatest lespect since ilicir complications, espe- cially bronchitis and pneumonia, are the most important contributory causes of severe heart failure in pregnancy.

Influenzal pneumonia is particularly dangerous in pregnant cardiacs Fiom the standpoint of prophylaxis, exposure to crowds and to known cases of respiratory infec- tion should be avoided. Difliciilties may arise In distinguishing the signs and symptoms o pulmonary infection from those of severe heart failure.

In sucli cases, it is, at all tinves, prudent to treat the patient for both conditions simul- taneously. Infections also create special hazards of bacterial endocarditis in rheumatic and in congenital licari disease.

Prophylactic administration of broad-spectrum antibiotics is, therefore, recommended during labor and following delivery or abortion, unless these agents are contraindi- cated because of specific hypersensitivity. Vascular Congestion Vascular congestion is the second most common contributory cause of severe heart failure in pregnant women. Sodium retention and hydremia of gestation are discussed in Chapter 1. As a general rule, it is advisable to limit fluid intake in the pregnant cardiac to cc.

Infusions, transfusions, and intravenous hypertonic solutions are avoided, since the hyper- volemia they produce may lead to pulmonary edema. It is also extremely important to limit the sodium intake. In the past, it was virtually im- possible to supply the b. Dietary instructions which refer specifically to salt rather than to sodium are inadequate, for some p. Diels cosering the nuiritise aliosvances for pregnane and containing to mg. McCartnc and associates studied toxemic water and sodium reten- tion in relation to gross bod composition.

Their findings are reproduced m Table 2 Chapter 1 de Alvarez and co-workers observed that the exaggerated, positive water and sodium balances in toxemic pregnancy resulted from a super- normal depression of the glomcnilar filtration rate Chapter 7.

MacGillivray and Buchanan, however, observed that the amount of sodium retained in preeclamptic women was the same as in normal pregnant women, although retention of water was greater in the former than in the latter.

A classic example of fluid retention often is observed in the presence of hydatidiform mole. Here the basic disturbance is due to humoral iniluences. The incidence of toxemia m rheumatic and in congenital heart dis- ease is no higher than in the general clinic population However, the incidence of toxemia is increased in hypertension, chorea, heart block, kyphoscoliosis, sickle cell anemia, sickle cell-hemoglobin C disease, and in th Totoxicosis.

Except in heart block, the causative factor is the iinder- l ing disease process rather than the actual cardiac involvement In progressive kidney disease, impaired sodium excretion also leads to water retention and hypervolemia. Although cortisone and corticotropin ACTH are known to disrupt gestation in laboratory animals, these drugs have been used in pregnant women for a wide variety of conditions vvithout similar adverse elTeci.

Furthermore, during pregnancy, the rarity of clinically active rheumatic carditis, the spontaneous improvement of rheumatoid arthritis, lupus crylhematosus, sarcoidosis, and allergic diseases; and the development of hypervolemia have been attributed to physiologic gestatory adrenocor- ticoid elaboration. Nevertheless, steroid therapy may produce untoward effects in preg- nancy which merit special oinsideration in cardiac patients.

It is recog- nized that jjrolonged administration of cortisone may not only depress corticotropin formation, but may, in some instances, lead to atrophy of the adrenal cortex. Under these circumstances, the stresses of anesthesia and of obstetric surgery may precipitate acute adrenal insufficiency. Newborn infants, whose mothers receive cortisone for prolonged periods throughout pregnancy, also may demonstrate symptoms of adrenal insufficiency.

Accordingly, if steroids are administered to pregnant car- diacs, special precautions sliould be taken to combat fluid retention, and to prescribe appropriate cortisone fortification for mother and baby.

Overactivity Overactivity is an important cause of severe heart failure. Patients ivJjose cartliac reserve js limited should compemate lor the burden of pregnancy by obtaining adequate rest and by avoiding undue physical and emotional stresses.

The therapeutic classification page 49 of the New York Heart Association is a useful guide to the amount of physical activity which should be permitted.

In some instances, it is advisable to hospitalize functional Class III patients as they approach the peak antepartum circulatory burden. The policy of hospitalizing such patients two vveeks prior to term is illogic, for at this relatively late stage the cardiac output usually has retuined to or near normal.

Complete betl rest is a twoedged sword, for if this regimen is enforced in the presence of significant dependent edema, mobilization of fluid from the lower extremities may precipitate severe left-sided heart failure.

In patients with limited functional leserve, it is also especially important to interdict specifically all sexual activities once the ante- partum hemodynamic burden is at hand. Furthermore, unless the cardiac reason for abstinence is outlined clearly to both husband and wife, they may assume that advice is intended only to prevent physical harm through coitus, and that it does not apply to other forms of eiotic excitement which can bunieii the heart similarly.

Disorders of the Ifeart Deat Tachycaidia, atrial fibrillation, or atrial flutter may precipitate severe failure rn-the presence of structural heart damage. If these disorders are diagnosed correctly and treated properly, there is no need to alter accepted concepts relating to management of the underlying cardiac dis- ease see Chapter Apparently, pregnancy increases susceptibility to sinus tachycardia and to paroxysmal supraventricular tachycardia.

The resultant burden imposed upon a damaged heart maj lead to severe failure of the high output variet. In pregnane , heart disease due primarily to anemia is encountered rarely, but cardiovascular complications occur in a significant number of patients with sickle cell anemia and sickle cell-hemoglobin C disease Chapter 9. However, where anemia aggravates other etiologic types of heart disease, the over-all burden may cause decompensation.

On the other hand, severe faihire has been precipitated by admm- istialion of whole blood transfusions to pregnant cardiac patients In the second and third trimesters, physiologic hemodiUition lowers the red blood cell count, hematocrit and hemoglobin readings, so that normo chromic nonnoc tic anemia h dreinia must be distinguished from true anemia.

Hypochromic anemia— the most common variety— is treated with iron and cobalt preparations Macrocytic anemias are relatively uncommon in pregnancy.

Pernicious anemia is treated with liver extract and vitamin B,,. Other macrocytic anemias respond to folic acid.

When profound anemia necessitates transfusion, it is prudent, in severe heart disease, to use packed red cells rather than vv'hole blood. With proper diet- ary supervision, the pregnant woman can lose weight and at the same time maintain her basic muruiona!

Hyperthyroidism is discussed m Chapter Cor pulmonale is discussed in Chapter 9. Thromboembolic phenomena are associated with thrombophlebitis, coronary occlusion, sickle cell anemia, sickle cell-hemoglobin C disease, polycytlieniia, myocarditis, endocardial fibroelastosis, heart block, atrial fibrillation, and bacterial endocarditis Although these diseases are cov 66 CARDIAC DISEASE IN PREGNANCY ered separately in later chapters, it is appropriate here to consider the use of anticoagulant drugs, svhich except in bacterial endocarditis may be used for prevention and treatment of thromboembolic com- plications.

Anticoagulant Drugs in Pregnancy. Heparin acts in several ways, diiefly by preventing the elfca of thrombin upon fibrinogen. It acts also as an antiprothromhin, and reduces Iwih platelet conglutination and liberation of blood-clotting enzymes.

The resultant prolongation of clotting time begins within a matter of minutes foifowing injection of the drug into the blood stream. Protamine sulfate or toliiidine blue neutralizes heparin effect immediately, and senes as an effective antidote. Coumarin drugs prevent hepatic synthesis of prothrombin from vita- min K, and their anticoaguLint action is measured in terms of prothrom- bin time prolongation. These agents are administered orally, and require forty-eight to seventy-two hours for full effect.

There is some evidence that the relatively large heparin molecule does not traverse the placental barrier, and that it is not excreted in breast milk. It is known definitely, on the other hand, th. In some instances, curettage, vaginal delivery, cesarean section, or manual removal of the placenta was performctl without excessive bleeding despite ther- apeutic levels of anticoagulalion.

The most important consideration in the use of anticoagulants during pregnancy is that adequate laboratory facilities should be avail- able for testing the blood fiequenily'. Heparin is employed initially when immediate anticoagulant effect Is required, but in less urgent situations therapy may be started with coumarin drugs.

The choice between coumann derivatives and heparin for subsequent maintenance of antepartum antico. Both coumann drugs and heparin have other advantages and dis advantages Heparin must be administered parenieralh, and repeated at least once in tvventy four hours, but the daily determination of coagula- tion time IS not absolutely necessary once proper dosage has been worked out.

Whereas coumann diugs arc given orally in one daily dose, pio- thrombin values must be determined every twenty-four hours if fetal complications are to be avoided through careful regulation T he necessity for managing parturition under conditions of normal coagulation rcm.

This may he accomplished m several ways The stopping of long-term treatment prior to term may predispose to thromboembolic recurrences. These phenomena provide increased muscular tension during systole. This policy has been criticized frequently from hvo standpoints. First, such antepartum digitalization has been described as "pro pliylaxis against heart faihiie.

In pregnancy, functional incapacity is due generally to pul- monary congestion since iieart failure is most often left-sided. TJie pur- pose of digitalization is to treat this degree of heart failure, and to prevent pulmonary edema. Nor is the issue purely one of semantics, for second, it has been con- tended that, in mitral stenosis, digitalis is ineffectise prior to the develop- ment of right-sided failure or the onset of atrial librillation.

However, it has been demonstrated that striking results may be obtained in left- sided heart failure associated with normal sinus rhythm. Digitalization relieves dyspnea and attacks of cardiac asthma, and coincidentally increases the vital capacity and speed of circulation.

Hemodynamic improvement can be verified by cirdiac caiheiert ration. Most important of all from tbe practical as Kct, the fulminating and frequently intract- able nature of pulmonary edema lias causevl death while the pros and cons of digitalization were being debated. In other words, for equal weights of fetal and maternal heart tissue, the former contains mote glycoside because it is comiirised of a greater num- ber of myocardial cells, and this docs not imply necessarily that the baby IS in danger from overdigitalization.

Mendelson ami Engel uupiibJished data studied babies bom of fully digitalized mothers. Clinically evident disturbances of the infant heart beat were not detected in uicro or neonatally. Electrocardiographic findings throughout the first week of life did not diffei significantly fiom those noted in normal babies delivered of imdigitalizcd mothers These data indicate that maternal digitalization does not harm the baby.

If digitalis concentration actually is higher in the fetal heart, one can postulate only that the Immature myocardium is less sensitive to the glycoside than is the adult myocardium. Cardiovascular and Other Surgery It is quite understand. There are patients whose cardiac status is compromised so severely tliai existence is maintained barely even in the nonpregnant stale.

If the condition is not amenable to sur- gical correction, it is illogic to expect cardiac tolerance for the gestatory burden despite tlie highest quality ol supportive care There have, in fact, been seven deaths due to heart failure at the New York Lymg-In Hos- pital in such patients managed by absolute bed rest.

However, when religious or other special considerations interdict therapeutic abortion and cardiovascular surgery is not feasible, one must rely upon supportive measures. Tiie current low figure rtUo reflects further inroads made by cardiovascular surgery.

However, there are certain exceptions to this general rule. Frequently, such premature induction produced a complicated and desultory labor, with loss of the mother due to severe heart failure, and loss of the baby due to piemaiiirity.

These poor results prompted the adoption of cesarean section for premature delivery. Subsequent knowledge of the late physiologic amelioration in hemodynamic burden led to virtual abandonment of all premature obstetric intervention intended as cardiac therapy, but until recent years cesarean section was advocated for term delivery. The data showed a significantly higher maternal mortality rate in the cesarean series. Although since then die general risVs of cesarean section have been reduced significantly through the introduction of blood banks, antibiotics, and modern technics of anesthesia, the hazards of vaginal delivery too have decreased by virtue of these same factors rurthermore, it is recognued that the vast majority of cardiac patients, including those most seriously disabled, ilo tolerate term sjjon- taneous labor which is considerably more efficient and less burdensome upon the heart than induced premature labor.

As pointed out in Chap- ter 1, the circulatory strain of labor and vaginal delivery is discontinuous and nonnccumulative, and ihe total cardiac burden imposed does not equal levels attained previously in late second and early third trimesters. Accordingly, the real problem is not that of surviving vaginal delivery, but rather of preventing earlier severe heart failure and death asso ciated wall the antepartum hemodynamic burden.

Premature delivery and cesarean section may be required for appro- piiate management of specific obstetric complications However, except m certain cases of kyph oscoUotic h eart disease, co arctation of th e aorta, a neurys m, and ureviotis s ubarachnoid hemorrhage, these procedures are not employed on cardiovascular indications Nevertheless, postmortem cesarean section should always be performed if the mother dies undeliv- ered ami the baby is viable The popular notion that severe cardiacs liave short, easy labors has been dispelled by observations which indicate the average duration of labor in large series of patients with licart disease is no different than in the general clinic population.

Intrapartum pulse and respiratory rates Figures 35, 36, 37, and 38 provide a valuable guide to the cardiac status, for Mendelson and Pardee observed that elevation of pulse rate above per minute between uterine contractions during the first srage of labor, precedes severe intra- partum cardiac failure by a long enough jieriod to afford ample warning of its approach, and to institute appropri.

Deseloped pulmonary edema postpartum. These and other severe cardiac patients are kept upright in bed, given o'cygen as indicated, and delivered as soon as feasible after full cervical dilatation in order to shoiten the period of bearing down in the second stage.

Prolonged straining to achieve the esoteric ecstasy of natural child- birth is not advocated in the presence of serious heart disease. The author believes these patients should be taught that a safe outcome for mother and baby is facilitated through all the skills and niceties of obstetric surgery.

Maintenance of the patients confidence and a pleasant soothing atmosphere are important adjuncts during labor. Alt oral feeding, including liquid as well as solid, is withheld once the Rrst stage begins see section on acid aspiration syndrome.

Demerol in suitable doses 50 to mg. One injection of scopolamine may be combined with Demerol, In com- parable doses, scopolamine produces less tachycardia than docs atropine. Restlessness, excitement, respiratory depression, and hypoxia from over- sedation are avoided.

Generally, barbiturates are omitted. Aneslliesin The choice of anesthetic technic and of agents depends not only upon the maternal and fetal states, but also largely upon the training and competency of the anesthesiologist.

The functions and responsibil- ities of the anesthesiologist cannot be assumed safely by the obstetrician or by unqualified persons. The following discussion is intended to apply generally. Specific situations in individual c. In most instances, anesthesia should not be administered when the maternal condition is extremely poor or understood inadequately. In some multiparae, the rapidity of labor and the ease of delivery may render anesthesia unnecessary.

However, as peviously noted, the cardiac status does not, by itself, affect the duration or meclianics of labor. Some of the adiantages of inhalation anesthesia include: Among its disadsaniages are the possibilities of hypoxia, aspiration, derangement of acid-base balance, and postoperatne nausea or vomiting The agent of choice is ether, administered with a high concentration of oxygen b the CO, absorption technic Since induction with ethei is slow and unpleasant, the agent is employed following induction with less irritating and more rapidly acting gasses as nitrous oxide or cyclo- propane.

A smooth, effortless, sltort induction is encouraged, an ade- quate ainvay is maintained at all times, and hypoxia is avoided.

H postoperative rebreathing is carried out with per cent oxygen, and if antibiotics are employed, the incidence of pulmonary complications can be minimired Often, cyclopropane has been malignetl erroneously. Nevertheless, improper and injudicious use of this agent may produce arrhythmias and cardiac arrest.

The presence of hypoxia and of excitement predisposes to these disturbances. Trichlorethylene and chloroform carry even greater risks of derang- ing cardiac mechanisms, and these agents slioiiJd not be employed. Local infiUiaiion, held block, and regional block subarachnoid and extradural have been employed in pregnant cardiac patients, and the obstetric nteraiuie is replete with conflicting reports of favorable and unfavorable results in each of these methods. Death, or varying degrees and types of sublethal toxic reactions, may result from idiosyncrasy to the drug.

The presence of varicosities and venous engorgement associated with pregnancy increases these haz- ards because of the greater chance of intravenous injection Bacterial contamination from the bladder, vagina, or rectum may lead to serious infection osieomyeHtis, meningitis. The falls in blood pressure and cardiac output are tlangerous in all etiologic types of heart disease. In the presence of anomalous communication between the venous and arterial circulations, tliere are special harards associaletl with venoarterial shunt and post- partum vascular collapse Chapter 5.

The customary mcasuies employed to correct the drop in blood pres- sure include placing the body in Trendelenburg position after the drug has been fixed, and administering intravenous fluids and vasopressor chugs.

In cardiac patients bordering upon pulmonary edema, the salutory elTeci of a decreased venous return is overbalanced by the coexistent hypoxia and by the burden imposed through treatment of the hypotension. Uterine contractions and beating-down efforts may raise the anes- thetic level, and produce respiratory paralysis.

Disturbance of ceiebro- spinal dynamics in the face of increased intracranial pressure has been followed by herniation of the brain into the foramen magnum. Extrusion of the nucleus pulposits has been reported following spinal puncture.

In addition, the recognhed incidence of posianesthctic headache and neurologic disorders iletractv from the desirability of using spinal tcdmics. As pointed out in Chapter I. Those who advocate spina! The use of inhalation anesthesia may be contraindicated because of respiratory infection, chronic cor pulmonale, coarctation of the aorta, aneurysm, or-il feeding during l.

Under these circumstances, the author recommends local infiltration or field block. Since toxicity increases in geometric propor- tion, the le. Meticulous c-are is exercised to avoid bjcterial contamination and intravenous injection. Penlothal is not an anesthetic agent. Ancillary agents must be added in order to abolish pain and produce rehixation effectively.

Sevcie cardiorespiratory depression may occur with over- dosage. Rapid placental transmission and slow detoxifica- tion by the fetus are additional undesirable factors.

The various risks of analgesia. Although some authors assert that moderate hemorrhage may reduce the circulatory burden of hypervolemia temporarily, it is advisable to keep blood loss at a minimum and thereby avoid secondary circulatory strains of anemia Ergotraie is omuted becavise of its tcntlcncy to raise the venous pres- sure. Pituitrm should not be used since it contains relatively large amounts of vasopressor hormone which produces marked constriction of coronary and pulinoiidry aricriolcs.

Unlike natural Pito- cin, which is said to have a pressor activity of about 5 per cent, synthetic Syntocinon is free of vasopressor hormone All intravenous therapy of volumetric proportions is avoided Infu- sions of glucose solution, saline solution, or plasma expanders may serve primarily to aggravate the cardiac burden. In the event of massive hemorrhage requiring transfusion, packed red cells are used rather than whole blood.

Because of the dangers of bacterial endocarditis Chapter 6 from puerperal infection and from mastitis, rheumatic and congenital cardiac patients are given hroad-specinim antibiotics during labor and the puer- perium provided there is no known idiosyncrasy to these drugs , and are discouraged from nursing. Increased fluid and metabolic demands in breast feeding render nursing undesirable for Class III and Class IV cases in all etiologic types of heart disease.

The occurrence of severe heart failure during the first twenty-four hours following delivery has received considerable attention in the literature. Roviiinc employment of anticoagulants is not advocated, but these drugs are prescribed where specifically indicated page Tubal sterilization has been recommended when severe heart fail- ure ocairred during pregnancy.

The author opposes this policy for several reasons In the first place, it is agreed generally that cesarean section should not be performed to facilitate sterilization.

Reasoning along similar lines, sterilization need no longer be considered a corol- lary to therapeutic abortion. Accordingly, contraception is preferable to sterilization in almost all instances where future pregnancies may be contraindicated.

In clinic practice, follow-up is insured through Social Service visits to tlie home. All patients are urged to report for re-evalualion prior to undertaking another pregnancy, or, failing his, to register for prenatal care as soon as a menstrual period is missed.

The onset of severe decompensation and the time of death are related most often to the hemodynamic burden of pregnancy rather than to the natural course of underlying heart disease. Ordinarily, heart failure during pregnancy is left-sided, and the greatest number of deaths is due to fulminating pulmon.

In respect to this problem, the New York Heart Association's functional classification provides the most important clinical guide to prognosis. Maternal deaths may result from other cardiovascular complications such as vascular accident, bacterial endocarditis, and postpartum venoarterial shunt with vascular collapse. The incidence of these com- plications bears no lelation to functional classification. Eacli plays a definite role, and none is a panacea.

Generally, maternal cardiac disease does not, by itself, affect incidence of spontaneous abortion or of premature labor, duration of labor or blood loss at delivery.

Tetal morbidity and fetal mortality result mainly from obstetric intervention, antepartum death of the mother, and other underlying medical or obstetric complications. However, postmortem cesarean section shovild always be performed if the mother dies undelivered and the baby is V table. Fatalities from spinal anesthesia South Surgeon lt50d, Awvu. E ramilial octuTrenee of congenital heart disease. New England J Med A S, and Cohen. J Pregnancy subsequent to ligation of the inlenor vena cava and ovarian vessels.

Gynec 77 , oe Alvarfz, R. The renal handling of sodium and vvater m normal and toxemic pregnancy. Z, and MiciitoN R J Effects of lanaioside C on cardiovascular hemodynamics acute digiialmng doses m subjects with normal hearts and with heart disease. Cardiol 4 83, Ellxstao, M. K Use of sniravenously given ganglionic blocking agents for acute pulmonary edema.

Am J Obst 8. Heart disease complicated by pregnancy Trans Edinburgh Obst. Drown fk Co Hervhensen. B Obstetrical anrsihesu Its principles and practice Springfield Illinois, Mechanism of radiation anencephaly. H ; Congenital defctls. If , Gorlin, R. Danger of Diciimarot treatment in preg- nane. Chloroihiuide in edema of pregnancy. Postmortem cesarean section Obst. C The anesthetic harards in olistetrics Am. Total exchangeable sodium and potassium in nonpregnant women and in normal and preeclamptic pregnancy.

Thromboembolic conditions and their treatment with anticoagulants. Charles C Thomas McCartney. E, and Harroo, J. Alterations in body com- position duting pregnancy. The pulse and respiratory variations duting Tabor as a guide to the onset of cardiac failure in women with rheiimalic heart disease. The management of delivery in pregnancy complicated by serious rheumatic heart disease. The aspiration of stomach contents into the lungs during obsietnc anesthesia Am J. Supportive care, imemiption of pregnancy, and mitral valvulotomy in the management of mitral stenosis complicating pregnancy.

Venous ligation in obstetrics Am. Effect of pregnancy on the course of heart disease Reevaluation of cardiac paiients three to five years after pregnancy. Circula- tion 13 Biol SL Med 80 , E Placental transfer of radioaaive digitoxin in pregnant women and its fetal distribution. Congestive heart fadurc in pregnancy. A , and Gray, M. C Coagulation defects m severe iittrapartiim and post partiim hemorrhage. G ncc 63 Coagulation defects in obstetric cbocV.

ThromlsoetsiboUe disease complicating ptegnancs and the puerpcriwm Am J Obst. E Elfect of acute dtgicali zation in patients with rheumatic heart disease Cardiologia 53 B Routine hsprsosvs for ohstetfical delivers Am J Obst.

Exper Therap TTie importance of this evolutionary rheumatic process will be emphasized repeatedly in the ensuing sections of this chapter. At the onset, several important generalizations may be made. Heart disease during phases 1 and 2 is due primarily to pancarditis, whereas during phases 3 and 4 it is due primarily to chronic valvular disease. Phases 1 and 2 are uncommon during the childbearing age.

However, phase 4 may develop earlier than the fourth decade, and under these circumstances maternal mortality due to severe heart failure presents a major challenge. This complica- tion occurred in 3. Sixteen 70 per cent of these twenty-three fatalities were due to heart failure and all sixteen of these patients had mitral stenosis as the sole or predominant lesion. Deaths due to causes other than severe heart failure seldom are encountered in present-day obstetric experiences.

Frequently, bacterial endocarditis Chapter 6 is preventable or amenable to treatment LiuboUc deaths are in a large measure avoidable. From tliese data, it has been concluded erroneously that maternal rheumatic cardiac deaths are due to the natural course of heart disease, and that the circulatory burdens imposed upon a woman by the pregnant state are no greater than other cardiac burdens she might encounter normally during a comparable nine-month span of time in the nongmvid state.

Indeed, this is a devious approach to the problem,, for by analogous misinietpretatiou of the same figures, one might con- clude just as well that prosiaiic carcinoma is never fatal m rheumatic males.

In order to evaluate logically the relation of death to pregnancy. It is essential that fatalities be analyzed carefully rather than disiegarded summarily. If maternal deaths represent natural evolution of rheumatic heart disease, they should he disirlbuted evenly throughout pregnancy. It is, in fact, this burden rather than the natural evolution of rheumatic heart disease which accounts for the vast nvajority of maternal deaths.

Gorenberg and Chesley reported only two deaths 0. The validity of these statistic cor- rections is open to serious question. For example, the patient who dies of appendiceal rupture and peritonitis following an ill-. The same fifteen patients are no less dead than tJie twenty-three reported in the New York Lying-In Hospital series, and tlie latter includes all fatalities— registered and nonregistered, rule- adherents and rule-violators, private and ward— yet the mortality is only 0 76 pet cent.

Their conclusions were based upon identification of. Now, it is acceptetl generally that rheumatic activity indi- cated solely by Aschoff bodies is not clinically important, and further- more, doubt has arisen whether these lesions invariably signify any degree of active carditis Figure The cases reported by the above- mentioned British authors were documented incompletely, and mitral stenosis cannot he excluded as the primary cause of maternal decom- pensation and death.

Many of the laboratory criteria ordinarily employed to determine rheumatic activity are unrefiablc tluring pregnancy. Normally, the white blood count, se dimenta tion rate, and gamma glo bulin level rise ante- partum. Positiv e C-Vca ctive protein responses have been reported in uncomplicated pregnancy.

Sheliar and associates found 37 per cent positive responses in the third trimester. Tyler and Roess found positive responses antepartum and postpartum: Active rheumatic fever has been diagnoseti in only ten New York Lying-In Hospital patients, and in five of these the picture was obscure.

All ten patients survived, and tight mitral stenosis appears to have been responsible for the two instances of severe heart failure that developed. Rheumatic activity could not be demonstrated in pregnancies com- plicated by chorea or atrial fibrillation.

No death occurred in the cases of first-degree heart block, rericarditis, skin nodules, new diastolic mur- murs, and severe right-shied heart failure are most uncommon in preg- nant rheumatic cardiacs. One must, therefore, conclude that clinically active rheumatic fever is exceedingly rare tluring pregnancy, and that carditis is not an important cause of severe heart failure or death in the childbearing woman.

The author suggests that gestatory steroid elabora- tion may prevent or suppress rheumatic carditis. Maternal outcome depends mainly upon prevent- ing death from severe heart failure.

Clinical and laboratory observations are employed in determining the prognosis. As pointed out in Chapter 2, circulatory experiences in a prior preg- nancy may aid in appraising the cardiac reserve. Severe antepartum heart failure due to mitral stenosis is likely to recur in successive pregnancies. The current functional classification is of primary significance, and due allowances must be made both for improsement e.

Table H summarizes maternal mortality, according to functional classification, in rheumatic heart disease at the New York Lying-fn Hos- pital. There uere six deaths in the Class I and Class II cases, and none of the fatalities was due to heart failure. There tvere seventeen deaths in the Class and Class IV cases, and sixteen of the fatalities rvere due to heart failure. For example, the elderly Class 1 nuthipara with generalized cardiac enlargement, tiouble mitral and double aortic valvular involvement may have a distinctly better chance of avoiding severe heart failure and of surviving pregnancy than the younger Class priinigravida with a smaller heart and isolated mitral stenosis.

In obscure cases, cardiac catheterization provides a direct method for evaluating the under- lying lesion and its hemodynamic significance. Except in the piesence of atrial fibrillation or a history of embolism, this laboratory procedure can be performed withcmi undue risk ihiring pregnancy.

However, the uterus should be shielded horn radiational exposure so as not to endanger the fetus Chaptei 2. Goilin and associates found an abnormal lesponse in patients with left or right ventricular failure, or tight mitral or aortic stenosis calculated oi oieasured valve area equal to 1 stj. The initial rise of the systemic, systolic, and pulse pressures was sustained throughout the straining phase, and an overshoot did not develop during the release phase Fig 34, p.

It docs not increase the nonnal incidence of spontaneous abortion, premature labor, toxemia, or of other obstetric complications. Increased fetal losses in ihenmatic heart disease result primarily from therapeutic mteiruption of pregnancy and from ante- partum cardiac sleaih of the mother. However, susceptibility to rheu- matic fever in later life is inherited apparently tlirough a recessive hictor.

Anothei 10 to 15 per cent have combined mitral ancf aortic lesions. Tfie remafnder have isofaietl aortic valve disease, or tiicuspid involvement associated with mitral or with aortic and mitral lesions.

In the preceding sections, it has been intimated that mitral stenosis creates the main problem of rheumatic heart disease complicating preg- nancy.

In the vast majority of cases, it is the sole or significant lesion. Tlie ensuing disaission will, therefore, be devoted largely to mitral stenosis Specific implications of other valve lesions arc covered toward the end of the chapter. Significant hemodynamic clianges do not occur until the mural orifice area is reduced by fiO per cent. Increased left atrial juessurc then is requited to overcome the obstiuction, and this elevation of pressure is reHectctl in all segments of the pulmonary vascular bed venous, capillary, and arterial , resulting m dyspnea, cough, hemop tysis, and pulmonary edema Later, as the orifice decreases to less than one-tliird normal size, increased left atrial pressuie is insufficient to over- come the obstiuction, and the raidiac output decreases progressively as valvular narrowing increases.

Patients with long-standing tight mitral stenosis develop sclerotic changes in the smail pulmonary arteries, which increase the blockage to blood flow through the lungs, raise the pul- monary artery pressure out of proportion to the increase in left atrial pressure, and eventually lead to right ventiiculai failure.

Clinical Features The clinical features of mitral stenosis have been correlated with three stages of hemodynamic evolution' stage 1. Most of these manifestations are attributable directly to pulmonary congestion. Stage 5, whicli generally is terminal, is accompanied by venous engorgement, hepatomegaly, edema, tiansudation, and atrial thrombosis. The physical signs of mitral stenosis aie well defined Palpation discloses a rapid, slapping apical impulse, a presystolic thrill, a dilfuse precordial heave, and a shock over the pulmonary region and apex The classic murimii is a low-pitched early diastolic or presystolic rumble, located at the c.

The presystolic element, due to atrial con traction, disappears once atrial fibrillation replaces normal sinus rhythm Owing to fibiotic changes in the valve cusps and chordae tendineae, the apical first sound is loud and snapping.

Pulmonary hypertension pro- duces accentuation and icdupVicaiion of the pulmonary second sound Functional pulmonic insufficiency develops in the face of extremely high pressures, and a soft, blowing diastolic Graham Steell murmur is heard over the incompetent valve.

Positive roentgenologic findings are observed with significant mitral stenosis The left atrium and right ventricle are enlarged, and the pulmonary artery shadow is prominent and widened.

Right anteiior oblique views show left atrial encroachment on the retrocardiac syvace, ami posterior displacement of tlve bariunwconlaining esophagus. Calci- fication may he detected m the mittal valve. Prognosis In former jears, mitral stenosis carried a relatively unfavorable prog- nosis. The average age at death ranged between forty and forty-five jears, and onlj 25 per cent of patients survived past the fiftieth jear.

In general, the outlook was determined by the severity of stenosis, as reflected by the presence or absence of cantiac enlargement and of severe heart fail- ure. Persistent or recurrent carditis, bacterial endocarditis, atrial fibrillation, and embolization alTected the prognosis adversely.

Recent advances in medicine and in cardiovascular surgery have brightened the picture. Penicillin prevents or controls streptococcal infections, thereby decreasing the incidence of acute rheumatic fever. Antibiotics reduce the devaswting effects of bacterial endocarditis. Steroid therap appears to modify the course of carditis favorably. The occurrence of thromboembolic complications is reduced by surgical removal of intracardiac thrombi, and by judicious use of anticoagulant drugs.

Comnihsuroiom relieves the hemodjnamic disturbances of val- vular obstruction. Mitral CommiMurotomy Although the long-term results of commissurotomy still are forth- coming, evidence, accumulated to date, indicates that the operation plays a logical and important role in the management of tight mitral stenosis. The historic aspects and technical details of commissurotomy are be ond the scope of this book.

The operative indications and contra- indications are listed in Table Refinements in case selection and surgical technics have reduced the operative mortality so that it is cur- rently between 1 and 5 per cent. Excellent results for at least one year are obtained in 70 to 90 per cent of cases.

Approximately 50 per cent of the patients demonstrate sustained improvement. Unsuccessful results are due generally to improper case selection, inadequate surgery, or recurrent stenosis. Even though the mitral orifice is widened at operation, progressive deterioration is likely to continue if irreversible pulmonary vascular changes have developed.

In the presence of advanced calcification, the valve may be completely unyielding, or it may tear and produce significant mitral insufficiency. Most of these unfavorable cases can be detected by careful preoperative studies includ- ing cardiac catheterization and roentgenography, so that unsuitable can- didates for commissurotomy can be rejected. Recently, open heart sur- gery with direct vision valvuloplasty has been applied to advanced cases.

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