Cardiac Disease and

Pregnancy
Prof. Nelson Fomulu

09/09/16

Pr. Nelson Fomulu MD, Ob/Gyn

Introduction
Pregnancy is a temporary complication in the disease
process of the patients lesion.
Aim of obstetrician is to prevent the additional burden of
pregnancy from accelerating the rate of the patients
decline by
+ Good ANC supervision by satisfactorily meeting up
with the extra demand of pregnancy.

+ Avoiding harmful complications (anaemia,

infection)
Prevent degradation of cardiac disease process thus
+Reducing the 11% associated MMR
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Pr. Nelson Fomulu MD, O

Incidence
0. 4 -5% of all antenatal clinic attendees
have cardiac lesion.

09/09/16

Pr. Nelson Fomulu MD, O

Cause

> 90% of cardiac diseases are due to

rheumatic fever > Rheumatic heart
lesion:
MS accounts for of all rheumatic
valvular lesions.
MS + MI most common
Aortic incompetence < 10% of cases

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Pr. Nelson Fomulu MD, O

Cause contd

Congenital Heart Diseases

Patient + ductus arteriosus
Artrial (ventricular defects)
Tetralogy of Fallop

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Pr. Nelson Fomulu MD, O

Cause contd
Hypertensive Heart disease
Syphilitic Heart Disease

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Pr. Nelson Fomulu MD, O

Cause contd
Cardiomyopathy

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Pr. Nelson Fomulu MD, O

Physiologic Cardiovascular
Alterations in Pregnancy
Objective :
Ensure that a patients heart is not worse after
pregnancy than it was before as pregnancy confers no
beneficial affect on a damaged heart.
Nature of additional temporary burden of pregnancy:
Cardiac output by 40% above non- pregnant level up to
last 8/52 when it declines slightly.
Heart rate to peak of 15 beats / minute above normal at
term.
Stroke volume in early pregnancy but decreases to
pregnancy level towards term.
09/09/16

Pr. Nelson Fomulu MD, O

Objective
Plasma volume and red cell mass: by 32 - 36 /52
Plasma volume increases to 50% above non- pregnant
level.
Red cell mass by 20 25 % above non pregnant level
Cardiac output, stroke volume, blood volume and
peripheral resistance adequate blood supply to
growing foetus.
-Evaluation of diaphragm elevation and rotation of the
heart vital respiratory capacity not decreased because of
increase in thoracic cage diameter
Pregnancy therefore involves the heart in increased
effort
09/09/16

Pr. Nelson Fomulu MD, O

Complications
Atrial fibrillation Incidence of heart failure in
pregnancy uses from 25% - 70% in cases of
fibrillation.
Pulmonary oedema especially in MS and heart
failure
Superimposed acute rheumatic fever carditis
and endocarditis
Death rate: 1-7%, 2/3 of deaths after delivery due
mainly to acute pulmonary oedema and cardiac
failure in cases and to superimposed
endocarditis in 15% and infection following C/S in
4% cases.
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Pr. Nelson Fomulu MD, O

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Classification of Heart Diseases

in Pregnancy
Based on the heart functional capacity
than type of structural damage. Grading is
done according to patients tolerance to
effort, presence or history of atrial
fibrillation, pulmonary oedema and
previous heart surgery.

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Pr. Nelson Fomulu MD, O

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New York Heart Association

Classification
Grade 1 No Limitation of physical activity
signs but no symptoms present.
Grade 2 Slight limitation of physical
activity comfortable at risk but ordinary
activity
Previous symptoms: fatigue dyspnoea.
Palpitation or angina pain.

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Pr. Nelson Fomulu MD, O

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New York Heart Association

Classification
Grade 3. Marked limitation of physical
activity less than ordinary activity cause
fatigue, dyspnoea, palpitation or angina
pain.
Grade 4. Symptoms at rest cannot
perform any physical activity without

discomfort.

Includes pervious heart failure,

surgery, atrial fibrillation and current
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Management
Collaboration between obstetrician and cardiologist.
Cardiac grade of patient to be decided early in
pregnancy as management depends on patients
grading.

+ AMPLE REST

+ ANC visits monthly for grade 1 and weekly for the

others.

+ Avoid infection and febrile illnesses.

+ Routine lung base auscultation to detect failure.

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Management

+ Grade 1 and 2: 12 hrs in bed at night and 2hrs rest

during the midday +
Home help service
+ Reassenment of grade at 28 32 weeks of
gestation.
+ Grade 3. Admission throughout pregnancy on
bed rest+ 4.
Avoid tooth infection sub acute bacterial endocaditis
HDP
+ Surgical P+ of MS by valvotomy at any stage of
pregnancy of heart failure in spite of medical P
+ Risk of termination of pregnancy > continued
pregnancy and delivery.
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Labour management
Trial of labour is absolutely contraindicated.
Labour in most cases is fairly easy as CX dilates
easily because it is softer and more vascular
than usual due to venous congestion.
Parenteral ATB, sedation
Grade 3/4propped up, give digitalis, O2
Shortens 2nd stage of labour via instrumental
delivery
No ergometrine in third stage of labour
C/S not indicated on cardiac grounds
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Pr. Nelson Fomulu MD, O

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Puerperium
12 hrs postpartum most critical because of
circulatory overload pulmonary oedema.
Sedentary for 1st few days to allay anxiety
Breastfeeding contraindicated in grade 4
cases
Avoid domestic strain by home help
service and ensure medical home visit.

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Contraception

Condoms
NFP methods
Surgical
Sterilisation after puerperium or
vasectomy.

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Conclusion
Grade 1 / 2 cases can undertake pregnancy
under strict supervision to live within their
cardiac reserve.
Limitation of physical activities, adequate rest
More pregnancy ANC visits.
Admission between 28 32 weeks.
Grade 3 / 4 should preferably not become
pregnant. If they do, hospital admission
throughout pregnancy for complete bed rest,
sodium restriction, digitalis and diuretics and
close supervision for complications.
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Thank you for

your kind
attention
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Pr. Nelson Fomulu MD, O

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