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Heart Disease’s in Pregnancy
Incidence
• Heart disease complicates about 1 percent of pregnancies.
Component
• congenital heart disease
• rheumatic heart disease
• Ischaemic heart disease
• idiopathic cardiomyopathy (perinatal cardiomyopathy)
• various forms of heart block
Sharp decline in the incidence of chronic rheumatic heart disorders.
Advances in the medical and surgical treatment of patients with congenital
heart defects has resulted in an increased survival to reproductive age.
Maternal mortality
• 0.3 per 10,000 live births
Heart disease still significantly contributes to maternal mortality.
Fetal risks of maternal HD
IUGR
Iatrogenic prematurity
Risk of congenital H.D
Effects of maternal drugs
Cardiovascular Physiology of Pregnancy
Increase in cardiac output is most significant change during pregnancy.
Normal pregnancy is associated with an increase of 30 to 50 percent in
blood volume
Decrease peripheral resistance
These physiologic hemodynamic changes account for many of the normal
symptoms reported during pregnancy including shortness of breath, orthopnea ,
decreased exercise tolerance, fatigue and palpitations .
Normal physical findings may include distended neck veins, exaggerated heart
sounds, and a "new" systolic ejection murmur best heard over the mid or lower
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left sternal border. A physiologic gallop may be appreciated. Peripheral edema
will be present in the last trimester.
One of the challenges for the clinician is how to distinguish between these
normal symptoms and signs of pregnancy and similar symptoms that may
indicate underlying heart disease in the mother.
Diagnosis of heart disease
Disease history, Symptoms and Clinical Findings
Investigation:
Echocardiography is non-invasive& useful for Dx & to assess function & valves,
an Echo at booking visit & around 28w is done.
Clinical Classification
(By the New York Heart Association)
Class I Uncompromised:
Patients with cardiac disease and no limitation of physical activity. They do
not have symptoms of cardiac insufficiency, nor do they experience angina pain.
Class II Slightly compromised:
Patients with cardiac disease and slight limitation of physical activity.
These women are comfortable at rest, but if ordinary physical activity is
undertaken, discomfort results in the form of excessive fatigue, palpitation,
dyspnea, or anginal pain.
Class III Markedly compromised:
Patients with cardiac disease and marked limitation of physical activity.
They are comfortable at rest, but less than ordinary physical activity causes
discomfort by excessive fatigue, palpitation, dyspnea, or anginal pain.
Class IV Severely compromised:
Patients with cardiac disease and inability to perform any physical activity
without discomfort. Symptoms of cardiac insufficiency or angina may develop at
rest, and if any physical activity is undertaken, discomfort is increased.
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Pre-conceptional counselling
Ideally, the obstetrician and cardiologist should work together to help the
patient make an informed decision
Any concurrent medical problems should be treated ,dental problems
solved& medical therapy optimized. Surgical correction should be
undertaken before pregnancy
High risk cardiac conditios:
Systemic vt. dysfunction(NYHA III-IV)
IHD
Pulmonary HT
Cyanotic CHD ,Prosthetic HV, Marfan syndrom
Previous peripartum cardiomyopathy
Antenatal care
Obstetric and cardiac clinic
1-Frequent visits
2-Rest,admission to hospital
3-Avoid factors which may lead to HF
Anaemia
Overwork
Infection
Overweight
Preeclampsia
Cardiac arrhythmias
Hyperthyroidism
Pain related stress
Corticosteroids &Tocolytic
4-Anticoagulant ,warfarin, heparin. indications:
artificial valve replacement
atrial fibrillation
congenital heart disease with
pulmonary hypertension
5-Sustained tachyarrhythmias, such as atrial flutter or atrial fibrillation, should
be treated promptly. preferred drugs include digoxin, beta-blockers and
adenosine.
6-Heart failure Rx is diuretics ,vasodilators& digoxin.
O2 ,morphine &anti-arrhythmics may be required.
Assessment of fetal well-being with ULS&CTG,
Premature delivery may be considered in case of fetal compromise or
intractable HF.
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MANAGEMENT OF LABOR AND DELIVERY:-
All gravidas with cardiac disease can expect to attempt vaginal delivery because
it poses less cardiac risk than cesarean section. Pregnant women with acquired
cardiac disease who are considered functionally normal are allowed to go into
labor spontaneously.
Antibiotics,O2,Sedation &analgesia
Fluid balance
If there are any concerns about the functional adequacy of the heart and
circulation, labor should be induced under controlled conditions. It is useful to
plan the induction so that delivery occurs during the working day when all
hospital services are readily available.
Forceps or vacuum extraction should be considered at the end of the second
stage of labor to shorten and ease delivery.
Postpartum care:-
After expulsion of the placenta, bleeding is reduced by uterine massage and
intravenous oxytocin administration. Methylergometrin should be avoided
because of the high rate of vasoconstriction and elevation of systemic pressure.
After delivery of the fetus and placenta, during 1-2 days, great amont of blood
return into the systemic circulation, and great amont of fluid from interstissual
space return to the systemic circulation, so increase cardiac burden occurs &
they are the most danger time for pregnant women with heart disease.
In patients requiring prolonged bed rest, meticulous leg care, elastic support
stockings, and early ambulation are important preventive measures that reduce
the risk of thromboembolism postpartum.
Lactation should be encouraged unless patient is in failure.
Contraception
Contraceptive pills: COC contraindicated.
Progesterone only pill have less side effect & long acting slow releasing
intrauterine system as Mirena have improved efficacy
IUCD, Barrier method, Tubal ligation
Valvular Heart Disease;
Mitral &Aortic Stenosis:
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Obstructive lesions of the Lt HT are risk factors for maternal mortality
&morbidity ,as they result in inability to increase output to meet the demands
of pregnancy.AS is usually congenital &MS is usually rheumatic in origin.
The aim of treatment is to reduce heart rate, by bed rest,O2,beta-blockade&
diuretic therapy. Ballon mitral &Aortic valvotomy is done after delivery ,but it
can be considered in pregnancy depending on the clinical condition &gestation
Ischaemic heart disease
The risk of MI in pregnancy is 1 in 10 000,and the peak incidence is in the 3
rd
trimester ,in parous women older than 35.The underlying pathology is
frequently not atherosclerotic, and coronary artery dissection is the primary
cause in the postpartum period. Percutaneous transluminal coronary
angioplasty (PTCA)is now considered acceptable but only when absolutely
necessary ,avoiding the time when the fetus is most susceptible to radiation (8-
15w). Thrombolytic therapy carry risks of fetal &maternal haemorrhage
&experience is little with them.
Edited by : TWANA NAWZAD