Cardiac diseases during pregnancy

Heart disease during pregnancy

Introduction:

Pregnancy induces haemodynamic changes, which include a

40%increase in plasma volume and cardiac output as well as a marked
reduction in systemic vascular resistance. By 8 weeks gestation the
cardiac output has already increased by 20% reaching a maximum
increase of 40% by 28 weeks gestation. Additionally haemostatic changes
lead to hypercoagulability. The physiological changes of pregnancy are
often well tolerated by women with heart disease, but may also induce
complications such as heart failure, arrhythmias and thromboembolic
events
Cardiac disease is the most common cause of indirect maternal
death. Deaths from cardiac disease are more frequent than those from
thromboembolic disease or bleeding. Also, women with heart disease are
at risk of cardiac complications during pregnancy and delivery.

Incidence of heart disease during pregnancy:

 1-4%, of pregnancies. Most of cases are rheumatic (mitral stenosis

is the most common lesion).

I. Causes of heart disease during pregnancy:

 Rheumatic heart (75%):

The most common acquired heart disease worldwide is rheumatic
heart disease, caused by rheumatic fever in childhood. Mitral valve
affection is the commonest followed by aortic valve then both or others.

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 Cardiac diseases during pregnancy

 Congenital heart diseases (10%):

o Acyanotic (left to right shunt): more common, includes septal defects
and patent ductus arteriosus.
o 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.

II. Effect of pregnancy on heart disease:

1- Heart failure:
o During pregnancy, heart failure can occur at any time but the
maximum incidence is between 32 and 34 weeks when the blood
volume and cardiac output are in their peaks. After that they have a
plateau level up to full term.
o During the 2nd stage, heart failure may occur due to stress on the
heart. Pain and uterine contractions result in additional increases in
COP and blood pressure.
o After delivery of the placenta due to passage of placental blood into
the general circulation.

Risk factors for cardiac failure during pregnancy

o Infection
o Anemia
o Obesity
o Hypertension
o Hyperthyroidism
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 Cardiac diseases during pregnancy

o Multiple pregnancy
2- Liability to atrial fibrillation and thromboembolism.
3- Reactivation of the rheumatic condition.
4- Bacterial endocarditis : Subacute bacterial endocarditis: may
develop in the puerperium.
5- Development of cardiomyopathy.

III. Effect of heart disease on pregnancy:

 Spontaneous Abortion
 Intrauterine growth restriction (small-for-dates)
 Intrauterine fetal death.
 Preterm labor.
 Congenital anomalies ( increased 6 times)
 Polyhydraminos
 Cyanotic heart disease (fetal) -------- 5 folds.
These complications are encountered especially in cyanotic heart
diseases.

IV. Grades Of Heart Functional Status

I. Grade (1): no symptoms and no limitation of
activity.
II. Grade (2): Dyspnea, palpitation, or anginal pain on
ordinary physical activity.
III. Grade (3): Symptoms on less than ordinary activity,
but the patient is comfortable at rest.
IV. Grade (4): Dyspnea at rest.

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 Cardiac diseases during pregnancy

Prognosis:
 According to Grades Of Heart Functional Status
- In general, women in NYHA classes I and II lesions usually do well
during pregnancy and have a favorable prognosis with a mortality rate
of <1%.
- Patients in NYHA classes III and IV may have a mortality rate of 5%
to 15%. These patients should be advised against becoming pregnant.

 According to the type of organic lesion (more important) for

prognosis

V. Diagnosis of heart disease during pregnancy:

1. History
2. S/S
3. Investigations
4. Differential diagnosis

 History of:

o Rheumatic fever
o Heart lesion
o Dyspnoea
o Paroxysmal nocturnal dyspnoea
o Orthopnoea
o Haemoptysis
o Prophylaxis with long acting penicillin.

 Examination may reveal:

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 Cardiac diseases during pregnancy

o Murmur
o Arrhythmia
o Central cyanosis
o Displaced apex beat
o Manifestations of left side heart failure e.g. gallop rhythm,
crepitating over lung bases and pleural effusion.
o Manifestations of right side heart failure e.g. congested neck veins,
enlarged tender liver, ascetics and edema lower limbs.

 Investigations:

o Chest X-ray: may show cardiac enlargement, pulmonary congestion or

pleural effusion.
o Electrocardiography (ECG).
o Echo cardiography: shows cardiac structure and function.
o ABG
o Non StressTest
o Biophysical profile

 Differential diagnosis of heart disease during pregnancy:

o Normal physiological changes of pregnancy
o Anemia

Misleading in diagnosis of the heart disease during pregnancy:

 Dyspnoea and tachycardia: are common physiological changes
during normal pregnancy.
 Increased neck (jugular) venous pressure: during normal pregnancy
up to +5 cm is not uncommon due to high cardiac output. This level
is indicative of right side heart failure in non-pregnant state.
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 Cardiac diseases during pregnancy

 Displacement of apex beat: 2-3 cm lateral to its normal position due

to rotation of the cardiac axis caused by elevation of the diaphragm.
 Normal pregnancy associated with specific changes that may place
an extra burden on women with heart disease Such As : - Increase
Plasma volume , increased cardiac output& drop in systemic
vascular resistance
 Changes specific to labor
Pain (increase heart rate and blood pressure) & postpartum increase
in blood volume and cardiac output.

There is misleading in diagnosis of cardiac diseases during

pregnancy due to Symptoms of normal pregnancy that can be
confused with symptoms of heart disease (Functional systolic
murmurs, fatigue, dyspnea, palpitations & lower limb edema).

VI. Management of heart disease during pregnancy:

According to New York Heart Association (1964); these classification
systems are useful to clinicians to evaluate the functional capacity and to
aid in counseling the woman regarding advisability of conception or
continuation of pregnancy. Also, it will guide the primary care provider
in the management of cardiovascular disease during the antepartum,
intrapartum, and postpartum periods and assist with predicting client
outcomes.

Pre conceptional care:

o Suitability of the cardiac condition for pregnancy

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 Cardiac diseases during pregnancy

o Generally class I & II are allowed safely, but class III & IV, cases
with severe pulmonary hypertension and Eisenmeger syndrome, are
advised to avoid pregnancy.
o Adequate spacing between pregnancies

 Contraindication of pregnancy in cardiac patients :

o Primary pulmonary hypertension.
o Uncorrected tetralogy of Fallot
o Eisenmenger syndrome
o Marfan syndrome with significant aortic root dilation.
o Coarctation of aorta with valvular involvement.

Management with pregnancy:

1. Grade 1 and 2 (compensated heart) or ( general measures)
o Outpatients & admission to hospital at 38 weeks. Hospitalization: if
signs of decompensation occur, the earliest evidence is tachycardia
exceeding 100 beats/minute and crepitations at the lung bases. Rest in
hospital is desirable in the last 2 weeks of pregnancy.
o More frequent ANC every two weeks until 28th week and then
weekly by both the obstetrician and the cardiologist.
o Increase rest & sleep: Bed rest, 2 hours in the afternoon and 10
hours by night.
o Diet: Avoid abnormal gain in weight and foods rich in salt.
o Guard against heart failure by treatment of anemia and avoid
emotional upsets and smoking.
o Guard against infection
o Atrial fibrillation should be controlled by digoxin &anticoagulants

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 Cardiac diseases during pregnancy

2. Grade 3 and 4 ( heart failure) or (Specific management)

A-Before 12 weeks : Termination (is more
risky than allowing pregnancy to continue)

 Indications of Termination of pregnancy:

o Grade 3 and 4 seen in early pregnancy.
o History of heart failure before
pregnancy.
o History of heart failure in previous
pregnancy.
o Eisenmeger syndrome.
o Severe pulmonary hypertension.

B- After 12 weeks : Hospital Admission throughout

pregnancy

In hospital she is given the treatment of heart failure:

o Rest in bed in the semi-sitting

position.
o Diet: salt free and diminish fluids.
o Medical treatment:

1. Diuretics: are used in acute and chronic heart failure

2. Digitalis (Digoxin): is indicated in acute heart failure to increase
myocardial contractility.
3. Beta - adrenergic blockers: as propranolol may be indicated for
arrhythmia associated with ischaemic heart disease.
4. Aminophylline: relieves bronchospasm.
5. Heparin: is indicated in patients with artificial valves or atrial
fibrillation.

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 Cardiac diseases during pregnancy

 N.B: Acute pulmonary oedema is urgently treated by:

o Morphine 15 mg IV, to allay anxiety and reduce venous return.
o Oxygen.
o Digoxin 1 mg IV, except in severe mitral stenosis as the increase
in right heart output cannot be handled by the mitral valve.
o Aminophylline 250 mg IV.
o Venesection, removing 500 ml blood rapidly may be indicated in
severe cases.

Management of labor:
o Senior cardiologist, Anesthesiologist and obstetrician
o There is no indication to induce labor because of cardiac disease.
o If induction of labor is indicated for an obstetric because e.g.
antepartum haemorrhage a low amniotomy + oxytocin in a
concentrated glucose solution is the best method. This minimises
the incidence of infection and pulmonary oedema.
o Induction of labor never to be undertaken in patient with acute heart
failure.
o There is no place for "trial of labor" in cardiac patients. Mode of
delivery:

I. During 1st stage of labor:

o Rest in bed (semi-setting position)

o Oxygen should be always available
o Avoid excessive fluids
o Avoid PROM.
o Good Analgesia
o Antibiotic for prophylaxis against infective endocarditis.
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 Cardiac diseases during pregnancy

o Observation of the mother and fetus.

 NB: Heart failure is expected to occur when

Pulse rate > 100 per min.Respiratory rate > 24 (between
contractions). In this case active management is given of (rapid
digitalization, diuretic, oxygen inhalation and sedation).

II. During 2nd stage of labor:

o Semi-recumbent position.
o Oxygen
o An analgesic as nitrous oxide.
o Straining is avoided, because the rise of blood pressure may lead to
heart failure.
o Shorten the second stage by the use of forceps or vacuum extractor

III. During 3rd stage of labor:

o Ergometrine is better avoided as it causes sudden load of the

circulation with blood from the uterus leading to acute heart failure.
Oxytocin can be used instead.
o Furosemide should be always available during 3rd stage to avoid
heart failure which may be precipitated after placental separation
o Close observation of the patient
for at least 24hrs after delivery

IV. During puerperium:

o Rest for at least three weeks after delivery an
more if there is heart failure.
o Sedatives to reduce tachycardia.

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 Cardiac diseases during pregnancy

o Breast feeding is allowed, unless there is heart failure. Estrogens

should not be used to suppress lactation and bromocriptine can be
used.
o Antibiotics are given to guard against bacterial
endocarditis.
o 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.
o If a patient had developed heart failure she is not
allowed to become pregnant again. Sterilization may be advised if
decompansation occurred in this pregnancy
o Contraception: progesterone only pills and barrier methods are the
best.
1. IUCD can cause infection- endocarditis.
2. OC pills are not ideal as they can cause thrombo embolism.
3. Barrier contraceptives – Have high failure rates.
4. Progestin only pills or Long acting injectable progesterone are better

 PILL-Desogestrel
 INJECTABLES
a- Medroxy progesterone 150mg IM every 3 months.
b- Norethisterone.200 mg every 2 months
5. Sterilization is best: may be advised if decompensation occurred in
this pregnancy.

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