WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital
CLINICAL GUIDELINES
AND
NEWBORN
HEALTH
SECTIONWOMEN
B: GUIDELINES
RELEVANT
TO OBSTETRICS
ANDSERVICE
MIDWIFERY
King Edward Memorial Hospital

3 MEDICAL DISORDERS ASSOCIATED WITH PREGNANCY

3.2 CARDIAC DISEASE AND PREGNANCY

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Quick Reference Guide

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CARDIAC DISEASE AND PREGNANCY QRG
ANTEPARTUM
Preconception counselling, education &assessment & refer early pregnancy care to tertiary
centre
Baseline evaluation early pregnancy (risks, physical examination, electrocardiogram (ECG) &
other tests as per Obstetric Physician), with careful check-up of women from developing countries.
st
nd
Ultrasound (1 trimester screen; tertiary fetal anatomy scanning at 18-22 weeks & 2 trimester
fetal echocardiography if maternal structural cardiac disease).
Regular antenatal care
 Visits every 2-3 weeks >20wks, fortnightly >28wks, weekly >36wks
 Check blood pressure (BP) manually; check for signs/ symptoms of cardiac failure (auscultate
lungs, pulse rate/rhythm, jugular venous pressure) & monitor for atypical signs of ischaemia.
 Screen for asymptomatic bacteriuria at first appointment (if not already done) &prevent anaemia
Birth planning (Multidisciplinary team approach)
 Document planned intrapartum care (analgesia, labour supervision, birth mode, second stage
management, oxytocic, PPH prevention, thromboprophylaxis & antibiotic prophylaxis (where
indicated) and length of postpartum stay) in medical record on MR 004.
 Vaginal birth (where appropriate) usually carries the lowest risk of complications.
Encourage rest & admit if chest infection or cardiac failure occurs.
Ask Obstetric Physician about endocarditis prophylaxis &antibiotics for dental/surgical procedures.
INTRAPARTUM
Notify Obstetric Registrar (And in major risk cases: Senior Obstetric Registrar, Obstetric
Consultant, Obstetric Physician, Anaesthetic Registrar, Labour Suite Consultant Anaesthetist).
Additional observations/care (Cardiac exam 4 hourly, strict fluid balance chart, oxygen if required,
haemodynamic monitoring & pulse oximetry if indicated; respirations, pulse & BP half hourly)
 If major cardiac risk: Position in sitting or semi-Fowlers.
Continuous fetal heart rate monitoring.
Consider: Analgesia (e.g. epidural) & monitoring intravenous fluids; Antibiotic prophylaxis &
Shortened second stage when major cardiac risk present.
Prevent PPH: Use oxytocin infusion 60units in 500mL Hartmann’s solution- rate to be documented
by Obstetric Physician. Do not use ergometrine routinely.
POSTPARTUM
Manage high risk cases in Adult Special Care Unit (ASCU) until maximum risk period passed.
Thromboprophylaxis: Anti-embolic stockings & early ambulation; delay warfarin (where applies).
Breastfeeding: Encourage, where not medically contraindicated. Encourage rest & educate on
signs/ symptoms of mastitis/ infection & action to take if develops.
Discuss contraception, future pregnancy guidance & regular cardiac reviews.
Follow up at 6 weeks (& 6 months if continued concerns), then return to usual cardiac care.

Note: This flowchart represents minimum care & should be read in conjunction with the following full guideline & disclaimer.
Additional care should be individualised as needed.

DPMS
Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 1 of 7

arrhythmias and stroke. Pregnant women with cardiac disease are at risk of serious morbidity such as heart failure. ischaemic heart disease in pregnancy is becoming more prominent with a higher number of older 2 women giving birth. cholesterol and coagulation homeostasis. glucose.2% to 4% of pregnant women. groups living in poor socio economic conditions. Maternal mortality in pregnant women with CVD is about 1%. which is 100 times higher than women without 2 2. intrapartum and postnatal periods. obesity. where pregnancy may be contraindicated . Except in an emergency. as 6 decided by the Obstetric Medical team. Postpartum: Angiotensin Converting Enzyme (ACE) Inhibitors including enalapril and ramipril may be 8 used. and are safe to use in breastfeeding mothers. 3. ACUTE CARDIAC FAILURE If acute cardiac failure develops:  Sit the woman up and lower her legs  Administer oxygen  Intravenous frusemide 40mg (diuretics ) and/or intravenous morphine 5mg to 10mg administered slowly 5 5 5  Consult the physician. pulmonary hypertension. a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the chest (if dissection is suspected) and serum troponin levels may be ordered. Class I asymptomatic with normal activity. whilst rheumatic cardiac disease is still an important cause of morbidity and mortality in developing 3 countries. 3 CVD. digoxin is to be commenced by the obstetric physician and is rarely utilised.AIM  To provide information on the management of cardiac disease in pregnancy for the antenatal. smoking. Careful monitoring through pregnancy is required as there are altered physiological demands on the woman’s body. and Marfan’s syndrome 3 with pathology of the aorta. hypertension. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 7 . KEY POINTS 1. Class II symptoms with normal activity. and Indigenous Australians. Furthermore. An electrocardiogram (ECG) is required by all women who have chest pain in pregnancy. 3. hypercholesterolaemia and the incidence of 3 diabetes increasing. if the pain is severe. Class III symptoms with less than normal activity. including 1 cardiovascular system. CLASSIFICATION OF CARDIAC DISEASE 5 Cardiac disease is classified according to functional status: 1. BACKGROUND 1 Cardiovascular disease (CVD) affects approximately 0. Additionally. Mortality of women with cardiac disease is low except in certain conditions such as Eisenmenger’s syndrome. severe systemic ventricular dysfunction. 2. 2. 4. If the woman has congenital heart disease the risk of fetal congenital heart disease varies 7 between 6 to 50%. Class IV symptoms with any physical activity or at rest. In western countries CVD is increasing and is a major cause of maternal mortality in 1 4 pregnancy. Congenital heart disease (CHD) is the predominant type of CVD in first world countries.

specialist medical staff presence. 4.g. Preconception counselling should be undertaken with multidisciplinary specialists as to the risks posed by the pregnancy.  A woman with significant cardiac disease will require more frequent antenatal assessments. Pre-conception counselling.  The obstetric management plan is to be discussed with the woman and documented in the 8 medical record on the MR 004: Obstetric Special Instruction Sheet. and length of postpartum stay. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 7 . check jugular venous pressure. thus providing earlier 1 detection. thromboprophylaxis. early consultation is essential for 3 assessment of maternal risk if the pregnancy continues and discussion of all options. Planning for birth should be undertaken by the Obstetric Medical team in consultation with the woman and other members of the multidisciplinary team which may include cardiologists. ECG. Antenatal care:  Prevent anaemia. This should occur early in 9 6 1 pregnancy and again at 32-34 weeks.g. second stage management. dizziness or vomiting. increased nuchal thickness of the fetus at the 12 week gestation scan is associated with fetal congenital cardiac disease (some studies suggest it may have a sensitivity of up to 90% for cardiac lesions). Referral sent to Obstetric Physician for women with:  A past history of cardiac disease  Symptoms or signs of cardiac disease 3. pulse rate and rhythm). 3. 5. maternal 4 fetal medicine specialists. 8 disease will have been assessed in the preconception period. Significant pulmonary 3 hypertension in pregnancy is a high risk situation. postpartum haemorrhage (PPH) 6 prevention. who should supervise the labour. due to the risk of pyelonephritis. oxytocic. Ideally women with known cardiac 1.  Monitor for any atypical signs of ischaemia such as shortness of breath.  An ECG shall be done on referral. fortnightly after 28 weeks gestation and weekly after 36 weeks gestation. 9 and services available) and early pregnancy management. Induction may increase the chance of caesarean birth. risks 3. Baseline evaluation early pregnancy with physical examination. Ultrasound:  First trimester ultrasounds.  At each assessment check blood pressure manually and check for signs and symptoms of 6 cardiac failure (e. 9 1. or deteriorating maternal cardiac function as decided by the Obstetric Medical 8 8 team. planned birth mode. In the event of an unplanned pregnancy. although ideally long and difficult labours should be avoided. troponin levels. Referral of high risk women to a tertiary maternity service (dependent on CVD complexity. anaesthetists and midwives. stress testing).  Screen women with CHD for asymptomatic bacteriuria at the first antenatal appointment if not 11 done previously in the pregnancy. 9 The suggested frequency is every 2-3 weeks after 20weeks . 8.  Induction of labour may be appropriate for optimising anticoagulation. 6. have been shown to detect major congenital heart disease with 85% sensitivity and 99% specificity. auscultate lungs. Plans include analgesia . 3 with a low threshold for cardiac investigations (e.  Careful tertiary fetal anatomy scanning at 18-22 weeks should be performed looking for 1 cardiac abnormality. 10 developing countries as the incidence of rheumatic heart disease is high in these areas. consideration of options and management.  Fetal echocardiography by a fully trained fetal cardiologist should be offered in the second 6 trimester to women with structural cardiac disease. other investigations should be left to the obstetric physician. 8  Careful screening with a physical examination should be performed on women who come from 6 3. including risk of maternal death.  Risk stratification assists in determining appropriate level and timing of antenatal care. 2. In the case of congenital heart disease of the mother.  Vaginal birth usually carries the lowest risk of complications. education and assessment. particularly around 13 weeks.ANTENATAL 1.

Labour and Birth Suite Consultant Anaesthetist (the Obstetric Physician will indicate if he/she is to be notified).  Minor Risk .such as women with Grade III and IV cardiac disease.  prosthetic valve(s) of any type.  In all major risk cases .4 Women with cardiac conditions.those women with increased risk of cardiac failure . Obstetric Consultant.  Clinical Guideline Section B 2. Consider two groups:  Major Risk .Obstetric Registrar. Admit if chest infection or cardiac failure occurs. respirations and blood pressure) and be nursed in a sitting or semi Fowler's position.those women with relatively minimal disease . and may require it in the postpartum period. continuation of antibiotic prophylaxis for 24 to 48 hours postnatally is not currently recommended although this may be indicated in certain clinical circumstances (e.  previous infective endocarditis. Use in all women with: 4. MANAGEMENT IN LABOUR 1. 9 women with prosthetic valves or history of infective endocarditis ). Note: Routine labour antibiotic prophylaxis is not indicated for women with cardiac disease of low 14 risk.  Strict fluid balance chart. For venous thromboembolism (VTE) information and prophylaxis see also: 8  Clinical Guideline Section B 2.  presence of surgically constructed systemic-pulmonary shunts or conduits. Obstetric Physician. INTRAPARTUM Labour is potentially the most dangerous period for many women as this is the period with the greatest 4. mitral stenosis and atrial fibrillation. 13  congenital heart disease (cyanotic and non-cyanotic). Ask the Obstetric Physician's opinion on:  Endocarditis prophylaxis in women with a history of rheumatic carditis or any valve abnormality  Appropriate antibiotic cover for dental (penicillin) and surgical (amoxycillin and gentamicin) procedures. 8. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 7 .Senior Obstetric Registrar. Anaesthetic Registrar. invasive haemodynamic monitoring and pulse oximetry if indicated.  hypertrophic cardiomyopathy.1 Venous thrombosis occurring in the present pregnancy.12.  Relevant cardiac examination at least 4 hourly. Women with a major cardiac risk must have half-hourly observations (pulse. Additionally. 2. In addition to routine labour observations:  Respirations half-hourly.  Oxygen.12. Notify:  In all cases . Encourage rest in the third trimester (symptomatic women may need to finish work earlier ) and admit to hospital if there is a major risk of cardiac failure. Document specific instructions for intrapartum antibiotic prophylaxis (where applicable). 9 7. Women with significant cardiac disease require thromboprophylaxis when admitted to hospital for bed rest in pregnancy.such as women with Barlow's Syndrome or a small atrial septal defect.g. 12. 13 increase in cardiac output. Antibiotic cover: (see next page for dosage) Start when labour commences or at induction (including cervical ripening). 3.

15 PLUS Gentamicin Initial: 5mg/kg IV once a day Thereafter: If the birth is 24 hours or more after commencing antibiotics.Prophylactic antibiotics For women NOT allergic to penicillins. Dilution: 500mg vancomycin/100mL 0.5 grams IV over 2 hours twice a day. No additional dose of vancomycin post Caesarean section should be required Therapeutic antibiotics:  Treat any suspected infection aggressively with parenteral antibiotics after blood and other appropriate cultures are taken. Thereafter: If the birth is 24 hours or more after commencing antibiotics. a repeat dose of gentamicin 5mg/kg should be given. Section P 3. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 7 . Postnatal: If the birth is within 24 hours of commencing gentamicin no additional postnatal dose is required. betalactams or cephalosporin antibiotics: Amoxycillin Initial: 2 grams intravenously (IV). Thereafter: 1 gram IV 8 hourly. betalactams or cephalosporin antibiotics replace cefazolin with vancomycin as per above recommendations. Postnatal: If the birth is within 24 hours of commencing gentamicin no additional postnatal dose is required. Betalactams or Cephalosporin antibiotics: Vancomycin Initial & thereafter: 25mg/kg up to 1. For women allergic to penicillins. Postnatal: An additional IV dose 6 hours after birth.9% sodium chloride. NOTE Amoxycillin based regimens may need alteration if a woman has required a course of antibiotic therapy in the preceding month or is on long term prophylactic penicillin therapy for rheumatic fever. Women having an Elective/Non-elective Caesarean Birth Initial: Antibiotic prophylaxis at the time of caesarean in accordance with Clinical Guidelines. PLUS Gentamicin Initial: 5mg/kg IV once a day.2 Antibiotic prophylaxis for Caesarean Section (see link). Postnatal: An additional dose of cefazolin intravenously 6 hours post Caesarean section. a repeat dose of gentamicin 5mg/kg should be given.  Contact the on-call Clinical Microbiologist for specific advice. PLUS Gentamicin NOTE Initial: 5mg/kg IV Thereafter: No additional dose of gentamicin is usually required. For women allergic to Penicillins.

and advanced or teen maternal age.  Avoid routine mid cavity forceps birth. peripheral oedema (pitting). For high-risk women managing their 1. 1 5. Prevent PPH (particularly if surgical intervention) which may lead to cardiovascular instability.  Pushing in the left lateral position. 1 For VTE prevention: Encourage anti-embolic stockings and early ambulation after birth. Continuous electronic fetal heart rate monitoring. Other symptoms 8 include tachypnoea. Educate the woman on breast care. 4. and bottle feeding may be medically 1 indicated in women with high cardiac risks.  In caesarean.e. Epidural analgesia may be used for obstetric indications. future pregnancy guidance and importance of women with significant heart disease having regular cardiac reviews prior to any future 8 pregnancy. Section B: 2. 2. Postnatal multidisciplinary follow up assessment at 6 weeks (and at 6 months if there are 8 continued concerns). 6 6. Discuss safe and effective contraception options. 3 smoking. 16 The woman’s choice to breastfeed should be promoted.  For patients at risk of fluid overload i. 7. 8  Use oxytocin by intravenous infusion in preference to oxytocin 10 units intramuscular or 1. cough. those with mitral stenosis.12. The Anaesthetic Registrar must 4 first discuss major risk cases with the Anaesthetic Consultant. with the woman then returning to her routine cardiac outpatient care.  Intervention carries a risk of infection. and close monitoring is required. PERIPARTUM CARDIOMYOPATHY Peripartum cardiomyopathy is a cardiac condition that develops in the absence of pre-existing heart 17 1 disease or identifiable cause. where not medically contraindicated. the signs/ symptoms of mastitis and what to do if she develops these.4 Women with Cardiac Conditions. 8 8. rather than supine. 8 intravenous bolus (as bolus doses may cause hypotension). 3. and should be considered in women who present with shortness of breath/dyspnoea/orthopnoea (particularly when 6. A chest x3. See also Clinical Guideline. POSTPARTUM 1. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 6 of 7 .  Assisting vaginal birth and limiting active maternal pushing may be necessary dependent on 8 the woman’s clinical situation to reduce additional load on the cardiovascular system. hypertension or pre-eclampsia. chest pain.4. Resumption of warfarin anticoagulation (where applicable) should be delayed by 2 days 8 postpartum due to the increased risk of PPH. and frequent night urination. tachycardia . lessens cardiovascular changes. excessive third trimester 17 weight gain. It can cause serious complications and maternal mortality. adequate rest. outflow tract obstruction or cardiac failure. diabetes. dilute 30iu oxytocins in 25mL Compound Sodium Lactate and administer at 2. palpitations. 8 pain well will decrease their cardiac workload during labour. uterine compression sutures may be beneficial to control PPH from uterine 6 atony.6 Intrapartum fetal heart rate monitoring. This will depend on the nature of the cardiac disease. 6 ray. ethnicity. Monitoring in ASCU should be continued until the maximum 8 4 risk period has passed. There is a small risk of mastitis related bacteraemia. Manage high-risk cases in Adult Special Care Unit (ASCU) postpartum. Shorten the second stage if there is major risk of cardiac failure or hypertension. Vaginal birth is preferred unless obstetric or specific cardiac condition requires caesarean birth.5mL / hour. 5. See also Clinical Guideline Section B: 5. 1  Do not use ergometrine routinely (can cause acute hypertension). Risks include multiparity. Haemodynamics do not return to normal for several days. echocardiogram and ECG should be considered by the obstetric medical team. 17 supine or at night) usually in the third trimester or up to 6 months after birth.

pdf van Mook W.14:137-43. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel). RHD Australia. Therapeutic guidelines: Prevention of endocarditis: Genitourinary and gastrointestinal tract procedures 2008.REFERENCES (STANDARDS) 1.wa. 8. 2013. Available from: http://www.tg.31:429-59. Heart disease and pregnancy: Study group statement: RCOG.gov. Curry R. 2013. Current Opinion in Obstetrics and Gynecology. Thompson D. In: de Sweit M.rcog. Royal College of Obstetricians and Gynaecologists. Cardiac disease in pregnancy.4 Women with Cardiac Conditions. Available from: http://www. Medical Disorders in Obstetric Practice. Walsh W. Cardiac disease in pregnancy. Taubert KA. Levison M.org. Available from: http://online. eTG Complete.15(1):30-2. Cifkova R. Section:  B: 2.gov. Interventions for treating peripartum cardiomyopathy to improve outcomes for women and babies (Review). Clinical practice guidelines: Antenatal care. Department of Health Western Australia. Klein LL. diagnosis and management of acute rheumatic fever and rheumatic heart disease.heartfoundation. Cardiac disease. Heart disease in pregnancy. 2005.1 Venous thrombosis occurring in the present pregnancy  P: 3.12. Gewitz M. 3. The Australian guideline for prevention. 4.12. P: Amoxycillin RESPONSIBILITY Policy Sponsor Medical Director Obstetrics August 2001 Initial Endorsement August 2014 Last Reviewed October 2014 Last Amended August 2017 Review date Do not keep printed versions of guidelines as currency of information cannot be guaranteed. Swan L. National Standards –1. detection and management of chronic heart failure in Australia. 7.health. Blomstrom Lundqvist C. 11. Ferreira R.au 16.13: Cardiac disease and pregnancy: RCOG. 2011. Baddour LM. Circulation. O&G Magazine. Australian Health Ministers' Advisory Council. Carapetis J. Lockhart PB.org. 6. Peeters L. 2010 (9).21:508-13. Maguire G. Lupton M. Cochrane Database of Systematic Reviews. et al.org. ESC Guidelines on the management of cardiovascular diseases during pregnancy: The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). B 2.rcog. European Heart Journal. Foidart J-M. and general management of cardiac disease in pregnancy. p. Ruys TP.Preventing and Controlling Healthcare Associated Infection 4. DPMS Ref: 3383 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 7 of 7 . editor. European Heart Journal. 2002. Johns J. 13. Access the current version from the WNHS website. Severe cardiac disease in pregnancy. part 1: Hemodynamic changes and complaints during pregnancy. Webb GD. Oteng-Ntim E. Department of Health WA. 125-58.Medication Safety Legislation . 2011. Galan HL.Module 1. 10. 2009.uk/files/rcog-corp/GoodPractice13CardiacDiseaseandPregnancy.10 Gentamicin Dosing and Monitoring. Baby friendly hospital initiative: Hospital breastfeeding policy. 14. 17. Steer PJ. 2007. 2009.org. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. de Swiet M. Obstetrics and Gynecology Clinics of North America. Royal College of Obstetricians and Gynaecologists.au/CircularsNew/attachments/411. Available from: http://www.pdf Carlin A. Brown A. Guidelines for the prevention. Prevention of infective endocarditis: Guidelines from the American Heart Association. London: Blackwell. 2. P: Vancomycin.au/antenatal 12. Current Opinion in Critical Care. 2004. P: Gentamicin. Gyte G. Wilson W. Cardiac disease in pregnancy. 15. 2nd ed. 2006. Roos-Hesselink JW. Steer P. Alfirevic Z. Current Opinion in Obstetrics and Gynecology.Poisons Act 1964 Related Guidelines / Policies Other related documents – KEMH Clinical Guidelines. 2002.32(24):3147-97.health. 2011.34:657-65. 2012. Canberra: Australian Government Department of Health and Ageing. Regitz-Zagrosek V. Good practice No.11(5):430-4. Available from: http://www. Borghi C. Perth: Health Networks Branch. Outcome of pregnancy in patients with structural or ischaemic heart disease: Results of a registry of the European Society of Cardiology. Ayida G. Noonan S. 2012.116:1736-54. Niwa K.Clinical Care is Guided by Current Best Practice 3. Thilén U.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancystudy-group-statement 9. et al. Stein JI. Available from: http://www.au 5. et al.