HEART DISEASE IN

PREGNANCY
Presented by:-
Neha Barari
Assistant professor
SNSR
 Introduction
 In most pregnancies, heart disease is
diagnosed before pregnancy. Although heart
disease is an uncommon problem in
pregnancy, complicating less than 1% of
maternities, it continues to contribute
significantly to maternal morbidity &
mortality.
 Seen either as RHD or congenital heart

diseases (ASD,VSD,PDA,Pulmonary stenosis,

TOF, endocarditis,IHD)
 EFFECT OF CARDIOVASCULAR
PHYSIOLOGY:

 In normal pregnancy the hemodynamic

profile alters in order to meet the increasing
demands of the feto-placental unit.
 Normal healthy women are able to adjust to

these changes easily.

 In women with coexisting heart disease,

added workload can precipitate

complications.
 The cardiac failure occurs during pregnancy
around 30 weeks, during labour & mostly
soon following delivery.
 Additional factors responsible for
deterioration are : advancing age, cardiac
arrythmias, infection, anaemia, multiple
pregnancy, pre- eclampsia.
 PROGNOSIS
 Maternal : depends upon
1. Nature of lesion
2. Functional capacity of the heart.
3. Quality of medical supervision.
4. Socio economic ,psychologic & family strain
5. Appearance of other risk factors.( pulmonary
edema, pulmonary embolism, active
rheumatic carditis, endocarditis)
 Prognosis ( coun….)
Fetal :
 In RHD fetal outcome is usually good .
 In cynotic group of heart lesion, there is

increased risk of abortion, IUGR &

prematurity.
 Fetal congenital malformation is increased by

3 – 10 % if either of the parents have

congenital lesions.
 SIGN & SYMPTOMS
 Recognition is difficult as many of the
symptoms are similar to normal pregnancy.
 Fatigue, dyspnoea, orthopnea, palpitations,
collapsing pulse, chest pain, development of
peripheral odema, distended jugular vein,
progressive limitation of physical activity.
 GRADING
Symptoms are classified by degree of compromise.
New York Heart Association Grading:
 Grade – I : uncompromised. Patient with cardiac

disease but no limitation of physical activity.

 Grade –II : slightly compromised. Patients with

cardiac disease with slight limitation of physical

activity. Comfortable at rest.
 Grade – III : markedly compromised. Marked

limitation of activity. Discomfort occurs with less

than ordinary activity.
 Grade – IV : severely compromised. Discomfort

even at rest.
 DIAGNOSIS
 Full Blood Count
 Electrocardiography.
 Chest X- Ray.
 Clotting studies.
 Echocardiography.
 Presence of diastolic murmur.
 Cardiac enlargement.
 Presence of arrhythmia.
PRECONCEPTION COUNSELLING
 Treatment can be made optimal.
 A specific plan outlay can be prepared for
pregnancy.
 General health advices with regard to diet,
weight, exercise, rest , prevention of
anaemia, avoidance of alcohol, drugs &
tobacco.
 MANAGEMENT
 Principles:

 Early diagnosis & evaluation of the functional

grading of the cases.
 To prevent, to detect & to institute effective
therapy for cardiac failure.
 To prevent & to control the additional
complications.
 Mandatory hospital delivery.
 THERAPEUTIC TERMINATION
 Primary pulmonary hypertension.
 Pulmonary veno-occlusive disease.
 Grade III & IV cardiac lesions.
 Grade I & II with previous history of cardiac
failure in early months or in between pregnancy.
Done with in 12 weeks with D&E or suction &
evacuation.
 ANTENATAL CARE
 Initial assessment should be made in consultation
with a cardiologist.
 More closer monitoring on frequent visits regarding :
dyspnoea & cough, lung sounds for crepitations,
pulse rate more than 100/min requires
hospitalization, anaemia, weight, blood pressure,
reevaluation of the functional grading, exclude fetal
congenital abnormality by USG at 20 weeks in
congenital heart lesions.
 Advices given:
 Advice patient to have adequate rest. 10 hrs in bed
at night & 2 hrs rest at noon.
 Limit the activities that cause the shortness of
breath. Avoid undue excitement & strain.
 Avoid caffeine, alcohol, high calorie or spicy diet.
Diet should contain low salt, less caffeine,
carbohydrate & fat but more protein.
 Avoid cold & infections. I/M injection of benzathine
penicillin ( penidure LA 12) may be given at
intervals of 4 weeks through out the pregnancy to
prevent recurrence of rheumatic fever.
 Advices given:
 Adequate dental care & avoid dental caries
& other such source of infection.
 On case of congenital heart disease patient
having warfarin should discontinue as soon
as pregnancy is diagnosed & should be
replaced with heparin 5000 units.
 ADMISSION:
 Grade I : At least two weeks prior to the
E.D.D
 Grade II : at 28th week specially in case of

unfavorable social surroundings.

 Grade III & IV : as soon as the pregnancy is

diagnosed. The patient should be kept in

hospital through out the pregnancy.
 In case of emergency like deterioration of

functional grading, appearance of dyspnoea

or crepitations, anaemia, pre eclampsia or
abnormal weight gain.
 MANAGEMENT DURING LABOUR:
 There is no place of induction for the heart lesion.

FIRST STAGE :
 The patient should be confined to bed & be placed
in lateral recombant position.
 Oxygen should be kept by the side & to be
administered ( 5 – 6 L/min) as & when required.
 Quantity of infused fluid should not be more than
75ml/hour to prevent pulmonary edema.
 Careful watch on pulse & respiration rate. If
pulse exceeds 110/min between the
contractions, rapid digitalisation is done by
I/V Digoxin 0.5 mg.
 Cardic monitoring & pulse oxymetry can

detect arrhythmias & hypoxaemia early.

 Prophylactic antibiotics during labour & 48

hrs. after delivery can be given to prevent

puerperal endocarditis. ( ampicillin &
gentamicin)
 SECOND STAGE :

 Delay in second stage should not be there.

 Forceps or ventouse delivery is preferred.
 Ventouse is preferable as it can be applied

without putting the mother in lithotomy

position.
 I/V ergometrine with the delivery of anterior

shoulder should be withheld to prevent

sudden overloading of the heart by the
additional blood.
 THIRD STAGE :
 Conventional management to be followed.
 If blood loss is more oxytocin can be given by

infusion rather than ergometrine in all cases

of heart diseases.

CAESAREAN SECTION :
 Only to be done in case of any obstetric
indication.
 In coarctation of aorta, elective caesarean

section is indicated to prevent rupture of the

aorta or any aneurysm.
 PUERPERIUM:
 The patient is to be observed closely
for the first 24 hrs.
 She should be in absolute bed rest.
 Oxygen to be administered.
 Hourly pulse & respiration are to be

recorded.
 She should be kept in hospital for at least
two weeks. In the first week confined to bed
& is allowed to move her limbs & to have
breathing exercise.
 Puerperal fever of any origin should be dealt

seriously by proper antibiotic therapy.

 Breast feeding is only contraindicated in

case of cardiac failure. Anticoagulant

therapy is not contraindication of breast
feeding.
 CONTRACEPTION

 Steroidal contraception is contraindicated as it

may precipitate thromboembolic phenomenon.
 Barrier method of contraceptives is the best.
 Permanent sterilisation should be considered
after completion of family at the end of first
week in the puerperium provided heart is well
compensated.
THANK YOU