Pregnancy With

Cardiac Diseases
By: DR.RABIA IRAM

How significant is heart disease in pregnancy?

Accounts for 12% of maternal death in 1996.

Commonest cause of indirect maternal death in
Malaysia.
In Sarawak there were a total of 9 maternal
deaths from heart diseases in the 3 years period
between 2010-2012

How common?
Coronary artery disease is uncommon in premenopausal women of child-bearing age.
Majority of cardiac conditions encountered during
pregnancy will be either congenital heart disease
or rheumatic valvular heart disease.
Cardiac complications result from hemodynamic
changes that occur during pregnancy.

CVS adaptation to
pregnancy

Cardiac output
Stroke volume
Heart rate
Blood pressure

CVP
SVR & PVR
sr,.colloid oncotic
pressure

Increased by 45%
increased
Increase by10-20
bpm
Reduced in the 1st &
2nd trimester.
static
Reduced 25-30%
Reduced 10-15%

 Plasmavolumeandredbloodcell(RBC)increaseduringthetrimestersof
pregnancy.Theplasmavolumeincreasestoapproximately50%aboveb
aselinebythesecond
trimesterandthenvirtuallyplateausuntildelivery.

 Hemodynamicchangesduringpregnancyrelatetoincreasedcardiacoutput
anda
fallinperipheralresistance.Bloodpressureinmostpatientsremainsthesam
eorfalls slightly.Venouspressureinthelegsincreases,causingpedal
edemainmanypatients.

Misleading features during pregnancy:

Dyspnoea and tachycardia.

Displacement of apex beat.
Bounding/collapsing pulse
Third heart sound, ejection systolic murrmur,
ectopics,

Misleading features during

pregnancy
ECG:
Ectopics
Q-wave and inverted T ,
ST-depression,
QRS axis left shift.
CXR:
Increased pulmonary vascular marking
Slight cardiomegaly

Preconception
counselling:
Counseling plays an important role.
Should be referred by cardiologist or physician to
the PPC Clinic, if the patient is keen to embark on
a pregnancy.
Estimate the risk during pregnancy.
Any optimization needed?
Contraception necessary if advised not to
conceive

Contraception
Surgical: vasectomy
BTL
Barrier method:
condom spermicides
COCP
POP: /Implanon NXT
IUCD/LNG-IUS
(Mirena)

Best, low failure rate

(LFR)
Laparoscopic/minilap
Compliance issues , High
failure rate (HFR).
Avoid in IHD, valvular
heart disease and
Pulmonary hypertension
Very useful
LFR, contraindicated in
prosthatic valve,
endocarditis.

High Risk Heart Diseases

Women with the following conditions are usually
advised to avoid pregnancy.
Pulmonary hypertension (>60% systemic pressure)
Dilated cardiomyopathy, ejection fraction <40%.
Symptomatic obstructive lesions (delay pregnancy
until the obstruction has been corrected)
- Aortic stenosis
-Mitral stenosis
-Pulmonary stenosis
-Coarctation of the aorta.
Marfan syndrome with aortic root >40 mm diameter.
Cyanotic lesions

Indicators of heart
disease:
Symptoms
Signs
Dypsnoea
Orthopnea
PND
Haemoptysis
Syncope
Chest pain

Cyanosis
Clubbing
Persistent neck vein
distension
Loud diastolic
murmur
Cardiomegaly
Arrythmia

Consider termination if:

Pulmonary hypertension.
Eisenmenger syndrome.
Cyanotic heart disease.
LVEF <40% .
Marfan Syndrome with aortic root more than 4cm.

Risk categorisation:
Low-Risk

ASD
VSD
PDA
MS

Mod High Risk

MS with AF
Artificial valve
COA
Previous MI

Antenatal care:

Combined clinic.
Precipitating factor of heart failure.
Watch out for dangerous periods.
Dental care.
Rest/ diet/ smoke.
Contraception.
Planning of delivery (mode) always get anesthetic
review/opinion.
Multidisciplinary Team approach maybe necessary
in high risk patients.
COMPLIANCE to follow up is important

CVS drugs safety profile in pregnancy:

Beta-blockers
Digoxin
Diuretics
Ace-i
Calcium antagonist
Adenosine
Lidocaine
Procainamide
Quinidine
Amiodarone

safe
Safe
Use judiciously
Unsafe
Use judiciously
Safe
Safe
Safe
Safe
unsafe

Mode of Delivery
For most patients,vaginal delivery feasible and
preferable.
Caesarean section indicated only for
obstetricreasons,except the following.
Patient anticoagulated with warfar in
Patient with dilated unstable aorta
(e.g.,Marfansyndrome).
Severepulmonaryhypertension.
Severeobstructivelesionsuchasaorticstenosis.
High-risk patients should be delivered in center with
expertise to monitor hemodynamic changes and
intervene when necessary.
No consensus regarding antibiotic prophyl axis at time
of delivery,but many institutions routine lygive.

Hemodynamic changes
during labour and delivery
Hemodynamic changes often abrupt.
With uterine contraction, up to 500 mL of blood may be
released into circulation, causing rapid increase in cardiac
output and blood pressure.
Cardiac output often 50% above baseline during 2nd stage of
labour and may be even higher at time of delivery.
During normal vaginal delivery, about 400 ml of blood is lost.
With caesarean section, about 800 ml of blood is lost.
After delivery of baby, abrupt increase in venous return
(autotransfusion from uterus & baby no longer compresses
inferior vena cava).
Autotransfusion of blood continues for up to 24 to 72 hours
after delivery, and this is when pulmonary oedema may
occur.

Intra-partum

Delivery in specialist hospitals.

Fluid management important.
Lateral position if symptmatic.
Ensure good analgesia.
Oxygen maybe necessary.
CCU maybe required post delivery.
Use syntocinon and avoid syntometrine.
Shortened second stage in some cases

Intra-partum
IOL and Mode of delivery generally follow
obstetric indication.
SBE prophylaxis: IV Ampicillin 1 g & gentamicin
1.5 mg/Kg (max 120mg) followed by ampicillin
500mg 6 hourly till delivery.
If allergic to penicillin: IV vancomycin1g over 2
hours.
SBE prophylaxis only necessary in some cases

Postpartum:

HIGH RISK period.

CCU care.
Counseling for contraception needs.
Encourage to limit number of pregnancy and BTL.
Breast feeding not contraindicated.
PPC clinic appointment if still keen on future
pregnancy.
Family planning clinic appointment (encourage
BTL)

Specific conditions:

Atrial fibrillation (AF) .

Valvular heart disease.
Mitral stenosis.
Mitral regurgitation.
Aortic stenosis.
Aortic regurgitation

Atrial Fibrillation
Usually associated with another underlying cause,
such as mitral stenosis, congenital heart disease,
or hyperthyroidism.
Antithrombotic therapy recommended.
Use heparin in 1st trimester and last month of
pregnancy. Subcutaneous unfractionated heparin
10,000 to 20,000 units every 12 hours, adjusted
to achieve APTT 1.5-2.0 times control.
Use oral anticoagulant during 2nd trimester.
Target INR 2.0-3.0.
Control ventricular rate with digoxin, calcium
channel antagonist, or beta blocker.

Valvular heart Disease

Most can be managed with conservative medical
measures.
Symptomatic or severe valvular lesions should be
rectified before conception and pregnancy
whenever possible.
Drugs should be avoided when possible.

Mitral Stenosis
Mild to moderate mitral stenosis can be managed
with diuretics and cardio selective beta blockers.
Severe mitral stenosis should undergo PTMC
before conception, if possible.
PTMC recommended if develop severe symptoms
during pregnancy.

Mitral Regurgitation
Can usually be managed medically with diuretics.
If surgery is required, repair is preferred.

Aortic Stenosis
Mild stenosis and normal left ventricular systolic
function can be managed conservatively.
Moderate to severe stenosis or symptomatic,
delay conception until aortic stenosis is corrected.
Pregnant women with severe aortic stenosis who
develop symptoms may require either early
delivery or percutaneous balloon valvotomy or
surgery before delivery.

Aortic Regurgitation
Isolated aortic regurgitation can be managed with
diuretics and vasodilator therapy.
Surgery during pregnancy only for control of
refractory symptoms.

Anticoagulation therapy
Low molecular weight heparin (LMWH) and Factor
Xa inhibitors should not be used in pregnancy
unless Factor Xa activity can be measured.
The anticoagulation therapy for patients with
mechanical valves is of critically important and
should be managed by Cardiologists

Anticoagulation: 1st trimester

If warfarin maintenance dose is 5 mg/day, risk of
teratogenicity is 8-10%. Convert warfarin to
subcutaneous unfractionated heparin (UFH) b.d.
Maintain APTT 1.5-2X control.
If warfarin dose is <5 mg/day, risk of
teratogenicity is 2%. Discuss risks with patient
and the options of changing to UFH or continuing
warfarin.

Anticoagulation 2nd & 3rd trimester

Use warfarin. Maintain INR 2.0-3.0.

At 36 weeks, admit patient and convert to i.v.
UFH. Plan for delivery once INR <1.5.
Stop i.v. UFH 6 hours before delivery and restart 6
hours after delivery if no bleeding.
First dose of warfarin can be given Day 1 postpartum. Stop i.v. heparin once INR >1.8.

Shared care:
Its important to maintain good communication
between the Cardiologists/Physicians and the
Obstetrician.
These patients should be f/up in a combine clinic
setting but shared care with health clinics is
possible depending on the severity of cases

General Advice for MOs

1. If a pregnant woman is suspected or known to have heart
disease, she should be referred to a physician or cardiologist as
soon as she is found to be pregnant. In the referral letter,
request the specialist to state clearly in his/her reply letter:
a. The cardiac diagnosis
b. Whether the pregnancy is allowed to continue or
whether termination is recommended
c. The type of antenatal follow up required polyclinic,
district hospital, hospital with specialist or cardiac centre
2. If unsure, always check the drug formulary (MIMS, MOH blue
book, internet resources, etc) to confirm that whatever
medication prescribed is safe to use during pregnancy.
3. The best guide to how well a patient with heart disease is
tolerating pregnancy is her functional status. If the patient is
asymptomatic and able to do moderate or heavy work without
any difficulty, then most likely she will also tolerate the
pregnancy.
4. Physical examination should be geared towards looking for
signs of heart failure basal lung crackles, raised JVP, peripheral

Now What You think to

do!!!!

Questions .!!!!
Welcome most to the constructive questions and
discussion!!