Outcome of pregnancy in patient with heart disease: a case series

*Fitra Rizia

*Obstetrics and Gynecology Department of Syiah Kuala University

Abstract
The frequency of pregnancy complicated by maternal heart disease does not appear to have
changed over the years. Heart disease complicates approximately 1% of all pregnancies. In
women with heart disease, maternal mortality is reported to be much higher than average and
the risk appears to be increasing such that in western countries heart disease is the major
cause of maternal death. However, we do not fully understand what the impact of pregnancy
is on the progression of heart disease or how heart disease affects the outcome of pregnancy.
The full spectrum of structural heart disease including congenital heart disease (CHD),
valvular heart disease (VHD), and cardiomyopathy (CMP), and also ischaemic heart disease
(IHD) may be encountered in pregnant women. We reported two cases, first a woman 26
years old, nullipara, with term pregnancy (38 weeks) single live head presentation with post
mitral valve prostheses and second women 33 years old, nullipara with term 36-37 weeks,
twin pregnancy, head-transverse lie presentation both alive, monochorionic diamniotic,
mother with CHF NYHA fc III-IV, Rheumatoid Heart Disease, baby with IUGR, non
reassuring fetal status. From patient 1 born female baby 3100 gram, 46 cm, HC: 36 AC: 31
AS 9/10 BS : 38 40 weeks, clear amniotic fluid, placenta born completely. From patient 2
born male baby I, BW: 2000 g BL 37 cm, AS 8/9, BS ~ 36 weeks and born male baby II,
BW: 1500 g BL 37 cm, AS 7/8, BS ~ 36 weeks, Diminished amniotic fluid Placenta
monochorionic diamniotic was born completely.

Keywords: mitral valve reconstruction, pregnancy

I. Introduction The prevalence of pregnancy

The frequency of pregnancy
complicated by maternal heart disease
does not appear to have changed over the
years. Heart disease complicates
approximately 1% of all pregnancies. In
women with heart disease, maternal
mortality is reported to be much higher
than average and the risk appears to be
increasing such that in western countries
heart disease is the major cause of
maternal death.4
In the presence of maternal heart
disease, the circulatory changes of
pregnancy may result in decompensation
or death of the mother or fetus
complicated by rheumatic heart disease
(RHD) has decreased in developed
countries and the former ratio of 3:1 for
RHD to congenital heart disease (CHD) in
patients with cardiac disease complicating
pregnancy is now essentially reversed.
Although rheumatic diseases are reported
to be almost eradicated in developed
countries, they still continue to contribute
significantly to maternal morbidity and
mortality in the developing world.4,5
On the other hand, the first
successful replacement of heart valve in
human was reported in 1960 (1). Since
then, prosthetic heart valves (PHV) have
been developed into remarkably useful
devices. A large number of PHVs are
being implanted every year around the
world, and many of them in women of
childbearing age who desire to have
children.1,2,3
For patients with mechanical heart
valve, lifelong anticoagulation is
mandatory.1 However in pregnant women,
anticoagulation management is a complex
issue. Pregnancy is a hypercoagulable
state, due to increase in fibrinogen, factors
VII, VIII and X, von Willebrand factor and
relative decrease in protein S activity,
stasis and venous hypertension.5 This
further increases the already existing risk
of thrombo-embolic complications (TEC)
in these patients. This state of
hypercoagulability extends into the
postpartum period too and requires a
persistently higher maintenance dose of
warfarin.6 Similarly, increase in total
blood volume affects the distribution of
heparin and low molecular weight heparin
(LMWH ). The presence of placental
heparinase further contributes to
unpredictable changes in the quantum of
medication required. Thus, optimal
anticoagulation therapy is considered
essential, but the appropriate choice of
agent among the options available
(warfarin, heparin or LMWH) is highly
debatable.3,4
There is controversy about the
safest anticoagulant regimen during
pregnancy. Anticoagulation is essential for
women with a mechanical valve and for
those with a bioprosthesis who are in atrial
fibrillation or have a history of
thromboembolism. Antiplatelet agents do
not offer protection. Heparin carries a high
risk of fetal loss from retroplacental
haemorrhage as well as maternal bleeding
events, the various regimens are non
standardised, hard to control, and heparin's
efficacy in preventing arterial
thromboembolism is not established.5
Coumarin derivatives are alleged to
increase fetal wastage by bringing a risk of
warfarin embryopathy during the first
trimester as well as a continuing risk of
central nervous system damage throughout
pregnancy.1,4
II. Case Report
We reported two cases, first a
woman 26 years old, nullipara, with term
pregnancy (38 weeks) single live head
presentation with post mitral valve
prostheses and second women 33 years
old, nullipara with term 36-37 weeks, twin
pregnancy, head-transverse lie presentation
both alive, monochorionic diamniotic,
mother with CHF NYHA fc III-IV,
Rheumatoid Heart Disease, baby with
IUGR, non reassuring fetal status. From
patient 1 born female baby 3100 gram, 46
cm, HC: 36 AC: 31 AS 9/10 BS : 38 40
weeks, clear amniotic fluid, placenta born
completely. From patient 2 born male baby
I, BW: 2000 g BL 37 cm, AS 8/9, BS ~ 36
weeks and born male baby II, BW: 1500 g
BL 37 cm, AS 7/8, BS ~ 36 weeks,
Diminished amniotic fluid Placenta
monochorionic diamniotic was born
completely.
Both patients conducted medical
history, physical examination, laboratory
and ultrasound examination. Additional
examination as well as echocardiography
and ECG was conducted in both patients to
analyzes cardiac function. After complete
evaluation, patient 1 was plan to elective c-
section and patient 2 was plan to
emergency c-sections due to fetal distress.
Fig 1. Echocardiography shows mild pulmonary hypertension and prosthetic valve

Fig 2. ECG shows atrial fibrillation with rapid ventricular respons.

Fig 3. Ultrasound examination

III. Pregnancy related heart failure and
rheumatic heart disease
Pregnancy produces significant
cardiovascular and hemodynamic changes,
which in patients with structural heart
disease, may lead to decompensation.
Congestive heart failure is a serious
problem of cardiac decompensation and is
often associated with maternal death. In
our series maternal mortality due to
rheumatic heart disease was 2% and the
majority of deaths were due to pulmonary
edema. All the women were in NYHA
class III IV. There was no death due to
infective endocarditis as routine
endocarditis prophylaxis was given to all
women during labor.4,5
Pregnancy outcome is strongly
influenced by the maternal functional
status and the potential for successful
outcome is determined by the maternal
functional status in which patient enters
pregnancy. Both maternal morbidity and
mortality are high in pregnant women with
poor function (functional classes III and
IV. Hsieh et al. in their series reported that
out of the total maternal deaths 75% were
in patients with NYHA classes III and IV.
In our series also, eight of 10 maternal
deaths (80%) occurred in patients with
NYHA class III and IV. Higher perinatal
morbidity and mortality was seen in
patients with poor functional status.4,5,6
The maternal and perinatal
outcome in patients with rheumatic heart
disease depends mainly on the functional
cardiac status of the mother at the time of
pregnancy. The risk of maternal morbidity
and mortality is greater in those patients
with functional classes III and IV.
Perinatal outcome is also poorer in these
patients.4,5,6
IV. Pregnancy related valvular
prostheses
The problem of prosthetic heart
valves in preg nancy is many faceted. The
physician is concerned with the welfare of
two individuals, either of whom may be
adversely affected by the heart disease or
its specific therapy. He must be on the
alert for the occurrence of congestive
heart-failure, embolie phenomena, carditis,
upper-respiratory tract infection, anemia,
and emotional upset, all of which may alter
the course of events in less than 24 hours
in any stage of gestation. Finally, one of
the most perplexing aspects of the
management of these patients concerns the
use of anticoagulants. Although in this
patient an embolism did occur during the
immediate postoperative period, her
gestational period was not complicated by
any medical problems. Because it is
recognized that systemic embolization is a
constant danger after insertion of
prosthetic valves, it is advisable to
maintain these patients on continuous
anticoagulant therapy.' The administration
of anticoagulants to pregnant patients has
been the subject of numerous reviews,
most of which have concluded that
coumarin derivatives may have a
deleterious effect on the fetus. Heparin,
with a molecular weight of 20,000,
apparently does not cross the placental
barrier and does not affect the fetus. In an
extensive review of 92 cases, Villasanta
found an 18.4% perinatal mortality rate in
those patients receiving coumarin
derivatives alone or in conjunction with
heparin. However, no congenital physical
anomalies could be related to the drugs,
and the most frequent fetal lesion found
was hemorrhage or maceration or both.
Eight of these patients received
anticoagulants in the first trimester of
pregnancy, none prior to the eighth week
of gestation.2,3,5
The risk of complications during
pregnancy in patients with mechanical
heart valve depends on the patients
symptoms, cardiac function, and her
functional capacity as well as on the type
of valve prosthesis, its position and
function.3,4,6
1. Patient factors
There is an increased haemodynamic load
during pregnancy, labour and delivery.
The published experience indicates that
most patients that were asymptomatic or
only mildly symptomatic before
conception, tolerate this haemodynamic
burden well. However, cardiac
decompensation may occur, especially in
patients with impaired LV function and/or
possible patientprosthesis mismatch. In
addition, an increased incidence of
arrhythmia is reported during pregnancy
and may add to patient discomfort. Thus it
is not surprising that decreased functional
capacity, pulmonary oedema and death are
not uncommon in pregnant women with
mechanical valves. Patients with prosthetic
heart valves and markedly impaired LV
function that are moderately or severely
symptomatic (New York Heart
Association, class III and IV) are best
advised against pregnancy.4,6,7
Residual tricuspid incompetence
often co-exists in patients with prosthetic
heart valves. The reported incidence of
foetal loss in mothers suffering from
tricuspid incompetence severe enough to
require diuretics is around 73%.21 This
risk is significantly higher when compared
with foetal loss in pregnancies in which
the mother did not exhibit tricuspid
incompetence.7
2. Prosthesis related factors
The commonest cause of maternal
death in patients with mechanical heart
valves is the device thrombosis. In
addition, there is also a high incidence of
thromboembolic events in these patients,
ranging from 7% to 23%.10,11,14,18,22
Mechanical prostheses in aortic position
have a lower thromboembolic risk than in
mitral position. Also, the relatively older
prostheses (StarrEdwards, Bjrk-Shiley
standard, and Omniscience) have a higher
thromboembolic risk than the subsequent
generation valves (St Jude Medical or
Medtronic Hall). However, thromboses of
these newer valves, including those in
aortic position, are not unknown.5,7
3. Drug therapy
Foetal complications related to
maternal anticoagulant therapy are
teratogenicity and foetal loss. The
incidence of abortion or foetal wastage
(resulting from retroplacental
haemorrhage, congenital malformations,
etc) in these patients is high, with reported
rates ranging between 23% and 50%.
Maternal risk of haemorrhage while on
anticoagulation is estimated at around
2.5%, with majority of such episodes
(almost 80%) occurring in association with
delivery. Moreover, in addition to
anticoagulants, the use of other
cardiovascular drugs during pregnancy
may also adversely affect the foetal
outcome. Cardiac drugs that are relatively
safe during pregnancy include heparin,
propranolol (and other beta blockers),
verapamil, digoxin and few
antihypertensives such as labetolol,
methyldopa, hydralazine, nifedipine and
prazosin. Amiodarone is associated with
foetal hypothyroidism and intrauterine
growth retardation. It should be reserved
only for cases with refractory
4,5,7,8
arrhythmias.
 Heparin (both UFH and LMWH)
does not cross the placenta, and does not
cause teratogenicity. On the contrary,
warfarin readily crosses the placenta.
Vitamin K acts as a co-factor for
carboxylation of glutamic acid residues of
osteocalcin and matrix Gla protein, which
modulate calcium deposition.45 Oral
anticoagulants when used during the first
trimester, may thus cause a failure in the
synthesis of osteocalcin and Gla matrix
protein resulting in nasal hypoplasia and
stippling seen on X-ray of proximal
epiphyseal growth areas (Chondroplasia
punctata). Exposure during the second and
third trimesters may lead to central
nervous system and eye abnormalities
(optic atrophy, cataract, blindness,
microphthalmia, intraventricular
haemorrhage, microcephaly,
hydrocephalus, seizures, and
6,8
growth/mental retardation).
5. Jolien W, Ruys T, Stein J. Outcome of
pregnancy in patients with structural or
ischaemic heart disease. European Heart
Journal: 2013; 34;657-665.
6. Siu SC, Sermer M, Colman JM.
Prospective multicenter study of
pregnancy outcomes in women with heart
disease. Circulation:2001;104;515-521.
7. Kreber Ij, Warr OS, Richard C.
Pregnancy in a patient with a prosthetic
mitral valve. Clinical notes: 2015.
8. Saia PJ. Pregnancy and Delivery of a
Patient with a Satrr-Edward Mitral Valve
Prostheses. Obstetrics and Gynecology:
1966.
9. Sliwa K, Johnsonn MR, Zilla P.
Management of valvular disease in
pregnancy : a global perspective. Eur Soc
Cardiology: 2015.
10. Sbauroni E. Outcome of pregnancy in
womwn with valve prostheses. Audit;
1994

Referensi 11. Elkayam U, Bitar F. Valvular Heart

Disease and Pregnancy. American College
of Cardiology; 2005.
1. Sutton SW, Duncan MA, Chase VA.
Cardipulmonary bypass and mitral valve
replacement during pregnancy. Perfusion:
2005;20: 359-368.
2. Niranjan N, Ruclidge MWM.
Management of Pregnant Women With
Mechanical Valve. ATOTW; 201.1
3. Sritavasta A, Modi P, Sahi S.
Anticoagulation for Pregnant Patients with
Mechanical Heart Valve. Annals of
Cardiac Anesthesia; 2007.
4. Sawhney H, Aggarwal N, Suri V.
Maternal and Perinatal outcome in
rheumatic heart disease. IJGO: 2001;80;9-
14.