CARDIAC DISEASE IN

PREGNANCY
Mohd Hafis Zul Arif Bin Awang
Ward 24
 Fetal & Maternal Cardiovascular
Physiology
• CARDIAC OUTPUT increases dramatically in pregnancy.
The average increase is from 4.5 L/min to 6.0 L/min.
• The greatest increase is seen within the first trimester
although further rises lead to a peak at around 24
weeks.
• This increase results from an increase in both HEART
RATE and STROKE VOLUME.
• Heart rate increases from 70 bpm in the non-pregnant
state to 78 bpm at 20 weeks gestation with a peak of
around 85 bpm in late pregnancy.
• Stroke volume increases from 64 ml to 70 ml in mid-
pregnancy. It reduces towards term.
CO = SV x HR
• Reduced
pulmonary
vascular resistance
results in:
 40% increase in
pulmonary blood
flow.
 Renal blood flow
increases by 35%
and
 uterine blood
flow by around
250%. Blood
volume
and organ
perfusion increase.
 Introduction
• HD Incidence 1% of pregnancies.

CAUSES
• Rheumatic heart (75%): mitral valve affection is the
commonest followed by aortic valve then both or others.
• Congenital heart diseases (10%):
 Acyanotic (left to right shunt): more common, includes
septal defects and patent ductus arteriosus.
 Cyanotic (right to left shunt): e.g. Fallot’s tetralogy and
Eisenmenger’s syndrome which is more dangerous carries a
maternal mortality rate exceeding 25%.
• Others (5%): e.g. ischaemic heart disease, arrhythmias and
cardiomyopathy.
 Diagnosis
a) History of:
i. Rheumatic fever,
ii. Heart lesion,
iii.Dyspnoea,
iv.Paroxysmal Nocturnal Dyspnoea (PND)
v. Orthopnoea
vi.Haemoptysis
vii.Prophylaxis with long acting penicillin.
b) Examination may reveal:
i. Murmur,
ii. Accentuated heart sound,
iii.Arrhythmia,
iv.Central cyanosis,
v. Displaced apex beat,
vi.Manifestations of left side heart failure e.G.
Gallop rhythm, crepitations over lung bases.
vii.Manifestations of right side heart failure e.G.
Congested neck veins, enlarged
viii.Tender liver, ascitis and edema lower limbs.
c) Investigations:
i. Chest X-ray: may show cardiac enlargement,
pulmonary congestion or pleural
effusion.
ii. Electrocardiography (ECG).
iii.Echo cardiography: shows cardiac structure
and function.
 Functional Classification
• According to New York Heart Association
(1973);
 Class 1: No symptoms (i.e. dyspnoea,
palpitation or anginal pain) on ordinary
activity.
 Class II: Symptoms on ordinary activity.
 Class III: Symptoms on less than ordinary
activity.
 Class IV: Symptoms at rest. Patient is
decompensated.
 Risk of Maternal Mortality
High Risk (25 – 50%) • Mechanical heart
• Pulmonary hypertension valve
• Complicated aortic Minimal Risk (<1%)
coarctation • ASD, VSD, PDA
• Marfan’s syndrome with • Corrected Tetralogy of
aortic root involvement Fallot
• Myocardial infarction • Tissue valve
Moderate Risk (5 – 15%) prosthesis
• Mitral stenosis NYHA • Pulmonary and
class 3 or 4 tricuspid valve disease
• Aortic stenonis • Mitral stenosis NYHA
1 or 2
• Arrythmias
 GENERAL CONSIDERATIONS
• The obstetric population is generally fit and healthy
with a small proportion of women in this age group
having pre-existing disease.
• When there is pre-existing disease the ideal approach
would be for the patient to be assessed before
pregnancy as described for pre-pregnancy care.
• Either at this stage, or when pregnancy has occurred,
the approach of the obstetrician must be to involve a
multidisciplinary team of colleagues.
• In considering systemic diseases in pregnancy
consideration must be given to TWO BASIC ISSUES:
 The effect of the pregnancy on the disease.
 The effect of the disease (and its treatment) on the
pregnancy.
 The Effect of Pregnancy on HD
• There is an early and sharp rise in cardiac output in the
first trimester and a further slower rise to a maximum
of 40% above normal in mid-pregnancy.
• During labour, cardiac output rises even higher during
contractions but falls again between contractions.
• There is a significant rise after delivery when dramatic
changes take place in the uterine blood flow due to
reduction in flow to the placental bed.
• This acts almost like a sudden autologous blood
transfusion and, in cases of heart disease, may result in
considerable myocardial compromise.
• The effect of pregnancy on heart disease in
general then, is to increase the risk of
cardiovascular compromise, most noticeably in
labour and the third stage in particular.
• However, cardiac failure may occur gradually
throughout pregnancy as the heart fails to meet
the demands on the circulation.
• Left heart failure, presenting as pulmonary
oedema, may present early in pregnancy in those
with moderate or severe disease.
• More commonly acute failure is precipitated
when situations such as marked tachycardia of
110 per minute reduce the interval for
ventricular filling with resulting pulmonary
vascular congestion.
• In mitral valve disease the third stage and puerperium are
particularly dangerous due to the increasing circulatory
volume.
• Infective endocarditis is a significant risk indicating the
need for antibiotic prophylaxis during labour.
• Other infections during pregnancy may cause endocarditis
and women with cardiac disease who are febrile should be
treated with appropriate antibiotics and carefully observed.
 Effect if HD on Pregnancy
• Severe heart disease is associated with
stillbirth, aborton, preterm labour and with
intra-uterine growth restriction.
• Cyanosis and poor functional capacity are
indicators of significant maternal and fetal
risk.
 Management
a) General Management:
• More frequent antenatal visits.
• More rest.
• Diet is directed to restrict weight gain and
prevent anemia as it increases cardiac strain.
• Infection should be avoided and properly treated.
• Hospitalization: if signs of decompensation occur,
the earliest evidence is tachycardia exceeding
100 beats/minute and crepitations at the lung
bases.
• Planned hospitalization is necessary of to 12
weeks, between 32 and 34 weeks and in the last
2 weeks of pregnancy.
b) Specific Management

MEDICAL TREATMENT:
• Digoxin: is indicated in atrial fibrillation to slow the
ventricular response and in acute heart failure to
increase myocardial contractility.
• Diuretics are used in acute and chronic heart failure
with potassium supplements in prolonged therapy.
• Beta-adrenergic blockers: as propranolol may be
indicated for arrhythmia associated with ischemic
heart disease.
• Aminophylline: relieves bronchospasm.
• Heparin: is indicated in patients with artificial valves or
atrial fibrillation.
SURGICAL TREATMENT:
• Therapeutic abortion: should be considered in
class III and IV if the patient is seen early in
pregnancy.
• Cardiac surgery: It may be an alternative to
therapeutic abortion. The principal indication is
recurrent pulmonary edema with mitral stenosis
and heart failure not responding to medical
treatment. There is no increased risk to the
mother or the fetus in closed cardiac surgery e.g.
mitral valvotomy but there is higher incidence of
fetal loss with open surgery.
 Management of Labor
1. There is no indication to induce labor because of
cardiac disease.
2. If induction of labor is indicated for an obstetric cause
e.g. antepartum hemorrhage, a low amniotomy +
oxytocin in a concentrated glucose solution is the
best method. This minimises the incidence of
infection and pulmonary edema.
3. Induction of labor never to be undertaken in patient
with acute heart failure.
4. Vaginal delivery is preferable to cesarean section but
should be an easy and not a prolonged one.
5. Bed rest in semi-sitting position.
6. Oxygen mask or ventilation if heart failure or cyanosis
develop.
7. Adequate analgesia pethidine or morphine can be
used. Epidural anaesthesia is preferable.
8. Shorten the second stage by forceps or ventouse.
9. Oxytocin is preferable.
10. Prophylactic antibiotic is essential to guard against
subacute bacterial endocarditis.
11. Postpartum observation for 48 hours is essential as
the risk of heart failure is high in this period. Although
bed rest is essential, early ambulation is desirable to
avoid thromboembolism.
12. Breast feeding is allowed unless there is heart failure.
Brornocriptine should be used to suppress lactation.
13. Sterilisation may be advised if decompensation
occurred in this pregnancy.