OBSTETRICS 

Class IV: Severely compromised

CARDIOVASCULAR DISEASES IN PREGNANACY
Predictors of Cardiac Complications
Physiologic Considerations 
Prior heart failure, transient ischemic attack (TIA),

Maternal adaptations arrhythmia, stroke

Cardiac output 
NYHA Class III or greater or cyanosis

 by 50% occur by 8 week 
Left sided heart obstruction

Maximized by mid-pregnancy: Physiologic anemia 
Mitral valve area:  2 cm2

Due to  stroke volume with  vascular 
Aortic valve area:  1.5 cm2
resistance 
Echocardiography: Left ventricular outflow tract

Later in pregnancy, resting pulse rate ,  diastolic gradient  30 mmHg
filling,  blood volume 
Ejection fraction 40%

Increased risk if one, more risk if 2 or more
Heart Failure Events

28 weeks Maternal Fetal Risks

Pregnancy-induced hypervolemia 
Maternal risk

Peripartum: Rapid changes in cardiac output 
Cardiac failure

Puerperium: Rapid return (Diminution of blood 
Hypotension
vessels in the pelvic region with damping of the blood 
Pulmonary hypertension
into the right heart 
Peripheral edema

Even without heart problems, patients are often 
Must give aggressive treatment, patient must not
tachycardic & tachypneic which predisposes them to be allowed to ambulate
heart failure 
Fetal risk

Intrauterine growth restriction (IUGR): (±2 standard
Clinical Indicators of Heart Disease deviation)

Presence of these does not automatically mean that 
Prematurity
the patient has heart disease, but its presence 
Congenital heart disease: 5-10%
necessitates evaluation & investigation 
Decreased maternal peripheral perfusion 

Symptoms Increase hypoxic episodes in the uterus  Increase

Progressive dyspnea/ orthopnea contraction  Premature labor

Nocturnal cough: Secretion is formed in upper
respiratory tree because of damping into the Mortality Rates (Maternal)
pulmonary circulation 
Group I: Mortality of < 1%

Hemoptysis 
Atrial septal defect

Syncope 
Ventricular septal defect

Chest pain 
Patent ductus arteriosus

Clinical findings: Objective evidence of heart disease 
Pulmonic/ tricuspid stenosis
indicating a cardiac problem 
Corrected tetralogy of Fallot

Cyanosis 
Bioprosthetic valve

Clubbing of fingers 
MItral stenosis, NYHA class I & II

Persistent neck vein distention 
Group II: Mortality of 5-15%

Systolic murmur grade 3/6 (But grade of < 3/6 in 
Mitral stenosis with atrial fibrillation
the presence of anemia maybe normal indicating a 
Artificial valve
hemic murmur) 
MItral stenosis, NYHA Class III & IV

Diastolic murmur (Presence is always pathologic) 
Aortic stenosis

Cardiomegaly 
Coarctation of Aorta, uncomplicated

Persistent arrhythmia 
Uncorrected tetralogy of Fallot

Persistent split 2nd sound 
Previous myocardial infarction

Pulmonary hypertension 
Marfan’s syndrome with normal aorta

Group III: Mortality of 25-50%
Diagnostic Test 
Pulmonary hypertension

ECG: Pregnancy does not alter voltage findings 
Coarctation of aorta, complicated

Chest radiography: Use lead apron (Abdominal shield) 
Marfan’s syndrome with aortic involvement
especially during early pregnancy 
Presenting with pregnancy loss (Early): Common

Echocardiography

Evaluation of structural (Shift in apex) & functional Perinatal Mortality
cardiac factors 
After 20 weeks age of gestation up to neonatal period

Best single tool up to 28 days

Class I: 5%
Clinical Classification (New York Heart Association) 
Class II: 10-15%

Class I: Uncompromised, no limitations of physical 
Class III: about 35%
activity (Maybe associated with normal physiologic 
Class IV: > 50%
pregnancy) 
Both maternal, fetal & neonatal mortality is included

Class II: Slight limitation of physical activity

Class III: Marked limitation of physical activity Management

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Prenatal 
Vaginal delivery unless with obstetrical indications

Reduction of cardiac demands 
Pulmonary artery catheterization

Diet 
Relief from pain & adhesion
 Regulate total caloric intake 
Vaginal delivery: Pudendal analgesia
 Restrict dietary sodium 
Forceps delivery: Epidural analgesia
 Iron (Fe) supplementation: 
Cesarean section: Epidural analgesia
Anemia & dilutional aemia

Diuretic Intrapartum Heart Failure
 Don’t give diuretics unless with 
Morphine: Drug of choice if epidural
congestive heart failure 
Maternal transport to a tertiary hospital is important:
 Don’t give diuretics because Best to transport mother when she begins to have
there would be more problems with decreased contraction
fluid volume 
Pregnant patients tend to have a short course of labor
 Drug of choice: Electrolyte- 
Oxygen
sparing diuretics 
IV furosemide

Digitalization: Crosses the placenta, but still 
Fowler position: Head up position
acceptable with monitoring of levels, since it may
still cause fetal arrhythmia & fibrillation Management of Class III

Prophylactic antibiotics (Penicillin: Give 1 gram or 
Hospitalize
more every month or before delivery) to prevent 
Bed rest throughout pregnancy
beta-hemolytic streptococcal infection & bacterial 
Vaginal delivery
endocarditis 
Cesarean section unless indicated; cardiac patients

Anticoagulation since pregnancy is a tolerate surgery poorly
hypercoagulable state

Fetal surveillance: Growth & umbilical artery Management of Class IV
Doppler (Left to right shunt) 
Correct decompensation

Detailed fetal cardiac sonography if maternal 
Medical treatment
congenital heart disease

In labor CHRABI

Labor & delivery in lateral position: To prevent
damping

Pulse oximetry

Adequate pain relief (Epidural, narcotics)

Restrict IV fluids to 75 mL/ hour

Oxygen by breathing mask (Not cannula) to give
oxygen at higher saturation

Avoid bolus oxytocin & ergot compounds

Antibiotic prophylaxis (Penicillin derivatives): 1
gram or more every month & more importantly
prior to delivery

Thrombosis prophylaxis (Heparin)

Prevention of postpartum pulmonary edema

Continuous fetal heart rate monitoring

Vaginal delivery unless there is obstetrical
contraindications

Cesarean section for medical reasons
 Repeated, persistent
congestive heart failure
 Very tight mitral stenosis > 2
diminution
 Persistent pulmonary
hypertension

Assist 2nd stage in certain conditions: Forceps or
vacuum delivery

All class I & II patients may nurse

Cautious, brief early ambulation (7-10 days
hospitalization)

Management of Class I & II


Bed rest 10 hours

No heavy work

Sodium restriction

Weight gain not more than 24 pounds

Avoid cigarette smoking

Warning against onset of congestive heart failure
(Persistent basilar rales, cough, dyspnea)
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