CARDIAC

DISEASES DURING
PREGNANCY

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Introduction

Pregnancy may be complicated by a variety of disorders and conditions that

can profoundly affect the woman and her family. Care for the women with pre-

existing medical disorders should ideally take place before conception. The process

should begin during adolescence with discussions about family planning,

contraception and pregnancy.

A complete medical history and assessment of health at this time, including

obtaining up to date investigations enables a risk assessment for pregnancy to be

made. These risks should be discussed with the woman and her family. So, that

appropriate choices can be made.

Cardiac Disease:

In most pregnancies heart disease is diagnosed before pregnancy . cardio

vascular changes in pregnancy results in marked increase in cardiac output &

stroke volume resulting in additional burden on the heart. A normal heart can cope

with these changes but in a woman with heart disease, these may lead to cardiac

failure.

Incidence:

The incidence of heart disease among pregnant women is 0.3% - 3.5%

Classification;

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 Heart diseases can be broadly classified in to 2 types

1. Congenital 2. Acquired

I. Congenital Heart disease:

The most common congenital heart diseases are

1. Ventricular Septal Defect (VSD)

2. Patent Ductus Arteriousus (PDA)

3. Aortic Stenosis

4. Tetralogy of Fallot

Particularly high risk cardiac conditions for pregnancy include

1. Essenmenger’s syndrome

 happens when a large left right shunt of blood, usually through a VSD, ASD

or PDA, is not corrected.

 This results in an increase in the pulmonary blood flow, which over leads to

fibrosis and the development of hypertension and cyanosis.

 The great risk of the fetus is prematurity which contributes to the high

perinatal mortality rate.

2. Marfan’s syndrome

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  It is caused by an autosomal dominent defect on chromosome -15. This is a

connective tissue disease that affects the musculo skeletal system. The

cardiovascular system and the eyes.

Congenital heart disease are

1. Ventricular Septal Defect (VSD):

 It is an abnormal opening in the septum between right and left ventricles.

 There flow of oxygenated blood from high pressure left ventricle to low

pressure right ventricle through the VSD.

 Increased right ventricular and pulmonary arterial pressure leads to

pulmonary over circulation.

 Increased venous return to the left heart results in left heart dilation. It leads

to pulmonary vascular resistance which can reverse the shunt from right to

left.

2. Patent Ductus Arteriosus (PDA):

It is the persistent vascular connection between the pulmonary artery and

the aorta.

Functionally the closure of ductus arteriosus ( which normally present in

fetal life) occurs soon after birth. When ductus arteriesus remains patent and

open after birth, the blood flows in the ductus from the aorta to the pulmonary

artery due to higher pressure in the aorta.

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 In PDA, there is left to right shunt as blood flows from aorta (higher

pressure) to pulmonary artery (lower pressure) leading to pulmonary over load.

Thus, oxygenated blood of systemic circulation flows back to the pulmonary

circulation, resulting in increased vascular pressure in the pulmonary tree.

In severe degree PDA, pulmonary vascular disease and pulmonary

hypertension may occur.

3. Aortic Stenosis:

In is the most common form of left ventricular out flow tract obstruction.

i.e ; co- arctation of aorta & mitral valve stenosis.

Co – arctation of aorta: it is a distinct narrowing or a long segment hypoplesia of

the aortic arch, usually distal to the sub clavian artery.

4. Tetralogy Of Fallot (TOF):

It is combination of 4 defects

1. Pulmonary Stenosis

2. Ventricular Septal Defect

3. Over riding or Dextro position of aorta

4. Right ventricular hypertrophy

Due to structural defects, there is right to left heart shunt causing cyanosis.

The most abnormalities are pulmonary stenosis and VSD. Obstruction of

blood flow from the right ventricle due to pulmonary valve, stenosis results in

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shunting of de oxygenated blood through the VSD in to the left Ventricle then to

the aorta causes cyanosis.

II. acquired Heart disease:

These diseases include

1. Rheumatic heart disease:

It is a serious complication of Rheumatic fever, a disease in which infection

of the upper reapiratory tract by streptococcal bacteria leads to heart disease.

The infection typically affects the heart valves but it can also affect other

heart structures.

2. Myocardial Infarction:

It is commonly known as heart attack. It happens when blood stops flowing

properly to part of the heart and the heart muscle is injured due to not receiving

enough oxygen due to blockage of coronary arteries.

3. Aortic Dissection:

It is a serious condition in which a tear develops in the inner layer of the

aorta, the large blood vessel branching off the heart. Blood surges through this tear

in to the middle layer of the aorta.

4. Endo Carditis:

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 It is an inflammation or infection of the endo cardium which is the inner

lining of the heart muscle and most commonly heart valves. It is caused by

bacterial infection or by fungus.

5. Peripartum cardiomyopathy:

Peripartum cardiomyopathy is a rare disorder in which a weakened heart is

diagnosed with in the final month of pregnancy or with in 5 months after delivery.

Classification of the Heart Disease (New York heart Association)

(Depending upon the Cardiac response to the Physical activity)
Grade –I : Uncompromised patients with Cardiac disease, but no
limitation of physical activity
Grade–II : Slightly compromised. Patients with cardiac disease
slight limitation of physical activity. The patients are
comfortable at rest but ordinary physical activity causes
discomfort.
Grade–III : Markedly compromised. Patients with cardiac disease
with marked limitation of activity. The patients are
comfortable at rest but discomfort occurs with less than
ordinary activity.
Grade–II : Slightly compromised. Patients with cardiac disease
slight limitation of physical activity. The patients are

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 comfortable at rest but ordinary physical activity causes
discomfort.
Grade–IV : Severely compromised, Patients with cardiac disease
with discomfort even at rest.

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 Physiological changes during pregnancy in Cardiac disease
Clinical manifestations
 Hyper dynamic circulation
 Systolic ejection murmur at left sterna border (due to increased
blood flow across the aortic and pulmonary valves)
 Dyspnoea, Decrease exercise tolerance, Fatigue
 Trachycardia, Shift of ventricular apex
 Loud first sound with splitting.
 Chest murmurs – Pansystolic, Late systolic, Louder ejection
systolic or Diastolic associated with a thrill
 Cardiac enlargement
 Arrhythmia
 Breathlessness, Syncope, Chest pain
Diagnosis:
Chest Radiography:
Cardiomegaly, increased pulmonary vascular markings,
enlargement of pulmonary vascular markings, enlargement of
Pulmonary veins.
Electrocardiography:
Cardiomegaly, increased pulmonary vascular markings,
enlargement of pulmonary vascular markings, enlargement of
Pulmonary veins.

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