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Heart disease with

pregnancy
Prof Uma Singh
Incidence of heart
disease
Varies between 0.1 4.0 %, average 1%
Mortality due to heart disease has
decreased
Devpd countries maternal mortality due
to heart disease has increased
Pregnancy with heart disease has
increased
Devpd countries rheumatic is decreasing
Congenital heart disease with pregnancy
is also increasing
Hemodynamic changes in
normal pregnancy
PARAMETER CHANGE (PERCENT)
Plasma volume +40
Cardiac output +43
Heart rate +17
Mean arterial +4
pressure
Stroke volume +27
Systemic vascular -21
resistance
Pulmonary vascular -34
Critical periods
Changes start from as 6weeks
Max changes around 30 weeks
Intra partum period
Just after delivery
Second week of puerperium
Pregnancy changes mimic
cardiac disease
Symptoms breathlessness,
weakness, oedema, syncope
Tachycardia
Splitting of 1st hear sound
Murmur systolic , breast bruit
Displacement of apex beat
upwards to left
Symptoms of heart
disease
Progressive dyspnea or
orthopnea
Nocturnal cough
Syncope
Chest pain
Hemoptysis
Clinical findings of heart
disease
Cyanosis
Clubbing of fingers
Persistent neck vein distention
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrythmia
Persistent split second sound
Pulmonary hypertension
Investigations
ECG cardiac arrhythmias,
hypertrophy
Echocardiography cardiac status
and structural anomalies
X-ray chest cardiomegaly,
vascular prominence
Cardiac catheterization - rarely
NYHA (New York Heart
Association) Functional
grading of heart disease
Grade I: No limitation of physical activity-
asymptomatic with normal activity
Grade II: Mild limitation of physical activity
-Symptoms with normal physical activity
Grade III: Marked limitation of physical
activity -Symptoms with less than normal
activity, comfortable at rest
Grade IV: Severe limitation of physical
activity- symptoms at rest
Classification of Heart
Disease according to
etiology
Congenital non cynotic ( ASD, VSD,
Pulm stenosis, coarctation of aorta),

cyanotic (Fallots tetralogy, Eisenmengers


syndrome)
Rheumatic heart disease MS, MR, AS,
AR
Cardiomyopathy
Ischaemic heart disease
Others conduction defects, syphilitic,
thyrotoxic, hypertensive,
Classification of Heart
Disease during pregnancy
according to risk
Low risk ( 0 1%) ASD, VSD, PDA,
MS-1,2, corrected FT
Medium risk ( 5 15 %) MS-3,4,
MS with atrial fibrillation, AS,
uncorrected FT
High risk ( 25 50%) PH,
Eisenmengers Syndrome, aortic
coarctation with valvular
involvement, Marfans with aortic
involvement
Poor prognostic
indicators
h/o heart failure, ischaemic attack,
stroke
Arrhythmias,
Base line NYHA class 3 and 4
MV area below 2cm sq, AV area
below 1.5
Ejection fraction less than 40%
Additional risk factors
Anaemia
Infections
Hypertension
Physical labour
Weight gain
Multiple pregnancy
Caffein , alcohol intake
Pain
Drugs tocolytic
Effect of pregnancy on
heart disease
Worsening of cardiac status
CCF, bacterial endocarditis,
pulmonary edema, pulmonary
embolism, rupture of aneurism
No long term effect on basic
defect
Effect of heart disease on
pregnancy
Abortion
Preterm labour
IUGR
Congenital heart disease in baby
5%
Intrauterine fetal demise
Management
Requires-
High index of suspicion
Timely diagnosis
Effective management
Team Approach-
Obstetrician
Cardiologist
Anesthetist
Neonatologist
CTV surgeon
Nursing Staff
Preconceptional

Counseling
No pregnancy unless must esp in high risk
types
Maternal mortality varies directly with
functional classification at pregnancy onset
Optimal Medical/Surgical treatment pre-
pregnancy
Counselling-
Maternal & Fetal risks
Prognosis
Social and cost considerations
Hospital delivery- Preferable at tertiary care
centre
Medical termination of
pregnancy
Termination advised in early pregnancy in
high risk group only ( Primary
pulmonary Ht, Eisenmenger syndrome,
Coarctation of aorta, Marfan syndrome
with dilated aortic root)
Only in 1st trim, better before 8 weeks
Suction evacuation preferred
MTP also carries risk for life
Antenatal care
Clear counseling of risk and prognosis
ANC every 2 weeks upto 30 weeks then weekly
On each visit-note-pulse rate, BP, cough
dyspnea, weight, anaemia, auscultate lung
bases, re-evaluate functional grade
Ensure treatment compliance
Exclude fetal congenital anomaly by level-III
USG and fetal ECHO at 20 weeks in maternal
congenital heart disease
Fetal monitoring
Special Advice
Rest, Avoid undue excitement/strain
Diet/ Iron and vitamins
Hygiene, dental care to prevent any infection
Dietary salt restriction (4-6g/d)
Avoid smoking, drugs betamimetics
Early diag and tmt of PIH, infections
Therapeutic/prophylactic cardiac interventions as
applicable-
Benzathine Penicillin 12 lacs at 3 weeks - to prevent
recurrence of rheumatic fever
Diuretics, Beta Blockers, Digitalis, Anticoagulants
Surgical treatment as applicable - balloon mitral valvotomy
Indications for admission
Elective admission-
NYHA 1 2 weeks before EDD
NYHA 2 28 to 30 weeks
NYHA-III/IV- Irrespective of POG as soon as patient
comes
To Change from oral anticoagulants to heparin-early
pregnancy, 36 weeks in patients on anticoagulant
Emergency admission-
Deterioration of functional grade
Symptoms and signs of complications- Fever/
persistent cough/ basal crepts/ tachyarrhythias (P/R
>100 min)/ JVP>2cm/Anaemia/ Infections/
PET/Abnormal weight gain /other medical disorders
Labor and Management
Institutional delivery
Induction of Labor
Only for obstetric indications
Oxytocin preferred- Higher concentration
with restricted fluid
Intracervical foley instillation esp in
congenital heart
disease
PGE2 Gel may be employed- Vasodilatation
- use with caution
Management in first stage
of labor
Confined to bed- propped up or semi
recumbent
Intermittent oxygen inhalation 5-6 l/min
Sedation and analgesia- (Epidural,
pethidine, tramadol)
Cautious use of I.V. fluids (not >75ml/hr
except in aortic stenosis and VSD)
Stop anticoagulants
Digitalise if in CHF,P.R.>110/ min,
R/R >24/min
Management in first stage
of labor
Diuretics in pulmonary congestion
Deriphyllin if bronchospasm
Prevention of infective endocarditis
Cardiac monitoring and pulse
oximetry pulmonary artery
catheterisation- continuous
haemodynamic monitoring
Evaluation by Anaesthetist and
cardiologist
SABE Prophylaxis

Prophylaxis
Not recommended for Ampicillin-2G IV/IM +
all Gentamicin 1.5mg/kg
At risk for infection (max120) 6 hours later-
Severe lesions
Ampicillin-1G I.V./IM or 1G
P.O.

If Allergic to
Penicillin
-Vancomycin-1G I.V.
or Clindamycin
600mg IV
+ Gentamicin-1.5mg/kg
Management of second
stage of labor
Delivery in propped up position
Avoid forceful bearing down
Adequate pain relief-
epidural/pudendal block avoid
spinal/Saddle block
Cut short second stage of labor-
episiotomy, vacuum, forceps not
always must
Strict Cardiovascular monitoring
Third stage of labor-
AMTSL-10 U oxytocin IMI
Avoid bolus syntocinon/Ergometrine
Propped Up, oxygen inhalation
Furosemide I.V. 40 mg
Pethidine/morphine (15mg)
Watch for signs of CHF & Pul. Edema
Treat PPH energetically
First Hour After Delivery
Propped up/sitting position,
oxygen
Watch for signs of pulm
edema
Sedation
Antibiotics
Indications for LSCS-
Mainly obstetrical
Coarctation of aorta
Marfan syndrome with dilated root of
aorta
Prefer epidural anaesthesia
Narcotic conduction analgesia/GA in
Pulmonary hypertension and pts having
intracardiac shunts
Advice at time of discharge:
Continue medical treatment
Avoid infection
Reassesment after 6 weeks or earlier if
some complication occurs
Iron supplementation
Cardiological consultation for definitive
management of heart disease
Contraceptive advice at time
of discharge:
Contraception- Barrier,
Progesterone good option- DMPA,
Norplant
IUCD-Less preferred
COC - contraindicated
Sterilization- vasectomy-best
Tubal ligation-Interval, puerperial can be
done
MCQs

Text book of Obstetrics, Dr J B


Sharma, 1st edition
Page 529 to 536
1. Pregnancy is contra indicated w
Mitral stenosis
Aortic stenosis
Fallots tetralogy
Eisenmengers syndrome
2. Pregnancy is contra indicated
Mitral stenosis
Aortic stenosis
Fallots tetralogy
Eisenmengers syndrome
2. Third stage of labour in a
case of heart disease should
be managed by
Ergometrine
Oxytocin
Misoprostol
Carboprost
Third stage of labour in a
case of heart disease should
be managed by
Ergometrine
Oxytocin
Misoprostol
Carboprost
3. In pregnancy with heart
disease risk of cardiac failure
increases at
10-12 weeks
20-22 weeks
30-32 weeks
40-42 weeks
3. In pregnancy with heart
disease risk of cardiac failure
increases at
10-12 weeks
20-22 weeks
30-32 weeks
40-42 weeks
4. A pregnant women suffering
from heart disease gets
breathless on doing minimal
activity but is comfortable at
rest. Her cardiac function
status is
NYHA Class 1
NYHA Class 2
NYHA Class3
NYHA Class 4
4. A pregnant women suffering
from heart disease gets
breathless on doing minimal
activity but is comfortable at
rest. Her cardiac function
status is
NYHA Class 1
NYHA Class 2
NYHA Class3
NYHA Class 4
5. Which of the following
contraceptive is contraindicated in a
woman with heart disease?
OCP
POP
Lng IUS
Diaphragm
5. Which of the following
contraceptive is contraindicated in a
woman with heart disease?
OCP
POP
Lng IUS
Diaphragm
6. A 24 year old pregnant Gr2 P1
woman, having prosthetic valve was
being given warfarin. She should be
switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
6. A 24 year old pregnant Gr2 P1
woman, having prosthetic valve was
being given warfarin. She should be
switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
7. A pregnant woman suffering from
mitral stenosis is breathless even
when lying down. Her NYHA cardiac
function status is
a) class 1
b) class 2
c) class 3
d ) class 4
7. A pregnant woman suffering from
mitral stenosis is breathless even
when lying down. Her NYHA cardiac
function status is
a) class 1
b) class 2
c) class 3
d ) class 4