HEART DISEASE IN PREGNANCY

MOHANA PREESHA
 INTRODUCTION
The incidence of heart diseases ranges from
1%-4% of all pregnancies

 Heart disease in pregnancy is common cause

of maternal mortality & morbidity in Malaysia
Maternal mortality from cardiac disease is very
much reduced over the past few decades due
to improved medical care of the pregnant
patient
PHYSIOLOGICAL ADAPTATIONS OF CVS TO
PREGNANCY

 Blood volume increased by 30-50%

 Stroke volume increase
 Heart rate increased by 10-20 bpm
 Colloid oncotic pressure decreased by 30%
contributes to susceptibility to acute
pulmonary edema
PHYSIOLOGICAL ADAPTATIONS OF CVS TO
PREGNANCY

 Blood pressure decreases in 1st & 2nd

trimesters

 Systemic vascular resistance decreased by

25-30% due to large arteriovenous shunts at
placental bed & physiologic vasodilatation
secondary to endothelial prostacyclin &
circulating progesterone
PHYSIOLOGICAL ADAPTATIONS OF CVS TO
PREGNANCY

 Cardiac output increased by 40%

It begins to rise in first trimester & rises to peak
at 32 weeks

 Supine hypotensive syndrome need to be

considered when women lie in supine
position as cardiac output can decrease
 Pregnant women should avoid lying on their
back
 CLINICAL FEATURES IN A NORMAL
PREGNANCY WHICH CAN MIMIC A
CARDIAC DISEASE

Tiredness, dyspnea, orthopnea, syncope, light

headedness mainly due to hyperventilation,
elevated diaphragm

Peripheral edema

Raised JVP, jugular veins may be distended

 CLINICAL FEATURES IN A NORMAL
PREGNANCY WHICH CAN MIMIC A
CARDIAC DISEASE

Cardiac impulse- Diffused and shifted laterally

from elevated diaphragm

Palpable right ventricular impulse

Increased S1 intensity, persisting splitting of S2

 CLINICAL FEATURES IN A NORMAL
PREGNANCY WHICH CAN MIMIC A
CARDIAC DISEASE

Systolic ejection murmurs along left sternal

border occur in 96% of pregnant women &
are believed to be caused by increased flow
across the aortic & pulmonary valves
 COMMON HEART DISEASE

Congenital:
Patent ductus arteriosus
Atrial/ ventricular septal defect
Congenital aortic stenosis
Coarctation of aorta
Tetralogy of Fallot
Pulmonary atresia
Marfan’s syndrome.
 COMMON HEART DISEASE

• Acquired: Following rheumatic fever (mitral

stenosis and mitral regurgitation)
• Cardiomyopathy
• Cardiac arrhythmias
• Acute coronary syndrome and myocardial
infarction
 New York Heart Association (NYHA)
Functional Classification
Class I Uncompromised
No breathlessness

Class II Slightly compromised

Breathlessness on severe exertion
Class III Moderately compromised
Breathlessness on mild exertion
Class IV Severely compromised.
Breathlessness on rest
 DIAGNOSIS
Criteria to diagnose cardiac disease during
pregnancy:

• Presence of diastolic murmur

• Systolic murmur of severe intensity (grade 3)

• Unequivocal enlargement of heart (x-ray)

• Presence of severe arrhythmias, atrial

fibrillation, atrial flutter
Mortality associated with specific cardiac lesion

• In general, women in NYHA classes 1 & 2

lesions do well during pregnancy & have good
prognosis with mortality rate < 1%

• Women in NYHA classes 3 & 4 may have

mortality rate of 5% to 15%. They should be
advised against becoming pregnant
 SPECIFIC HEART DISEASE
MITRAL STENOSIS

• Chronic rheumatic heart disease may present

for the first time in pregnancy
• Mitral stenosis with or without regurgitation
is the most common valvular disease(90%)
• If detected early patients may have had valve
replacement or balloon mitral valvotomy
 SPECIFIC HEART DISEASE
MITRAL STENOSIS
Symptoms:
In well compensated states they remain
asymptomatic
Exertional dyspnoea, orthopnoea, paroxysmal
nocturnal dyspnoea indicates deterioration and
require review and treatment
Cough with haemoptysis
Greater risk with MS is acute pulmonary
oedema
 SPECIFIC HEART DISEASE
MITRAL STENOSIS

 Right atrial enlargement & pulmonary

hypertension are seen in MS

 Beta blockers & heparin may be initiated to

avert development of atrial fibrillation
 DEVELOPMENT OF ACUTE PULMONARY
OEDEMA IN MITRAL STENOSIS

• Tachycardia is the common cause of acute

pulmonary edema
• Tachycardia is induced by infection, anemia,
anxiety, coitus, exercise and pain of labor
• Commonly seen in 2nd & 3rd trimester
 DEVELOPMENT OF ACUTE PULMONARY
OEDEMA IN MITRAL STENOSIS

• Diastolic filling of left ventricle is further

reduced with tachycardia causing rise in left
atrial pressure due to mitral stenosis resulting in
acute pulmonary oedema
• Mitral valve are <1 cm²
 MANAGEMENT FOR MITRAL STENOSIS

Confirm diagnosis and categorize NYHA status

Admit for hospital stay until delivery if patient is
NYHA 3 & 4
Correct anemia and avoid common cause of
tachycardia
Evaluate fetal gestation and fetal well being
 MANAGEMENT FOR MITRAL STENOSIS

Plan obstetric care, time and mode of delivery

according to general guidelines
Avoid supine or lithotomy position especially
during labour
Beta blockers are indicated for maternal
tachycardia
Acute pulmonary oedema is treated with
morphine, diuretics(furosemide) and oxygen
therapy
 MANAGEMENT FOR MITRAL STENOSIS

 Pre pregnancy care would optimize cardiac

status of MS
 Pre pregnancy surgical valvotomy decreased
fetal mortality
 Balloon valvotomy & closed mitral valvotomy
in pregnancy is safe but best done for non
calcified valves with minimal regurgitation
 MITRAL REGURGITATION

• This may be concomitantly present with MS in

rheumatic heart disease

• Most patients tolerate MI well as afterload is

reduced as a result of a reduction in peripheral
vascular resistance and systemic vasodilation
in pregnancy
 MITRAL REGURGITATION

• Severity of its effects is related to how good

the left ventricular function is

• In the presence of left ventricular dysfunction

drug therapy can alleviate symptoms of heart
failure
-> Digoxin
-> Furosemide
-> Vasodilators
 MANAGEMENT

Pre-pregnancy care:

Planned pregnancy after corrective surgery if

warranted and optimization of cardiac status is
desired
Discuss potential risks and treatment options
 For those on anticoagulants, discuss the risks
of warfarin embryopathy
 MANAGEMENT
Document the following prior to pregnancy:

 Nature of heart disease

 Functional status and hemodynamic status
 Presence of anemia and co-morbid disease
 Details of care given by cardiologist if applicable
 Presence of cyanosis and pulmonary
hypertension
 MANAGEMENT

Document the following prior to pregnancy:

 Past history of acute pulmonary edema, heart

failure and ejection fraction of left ventricle
 Anticoagulant therapy
 Past obstetric and surgical history
 Investigation- ECG, MRI, echocardiogram,
troponin 1 level
 MANAGEMENT

Pre delivery care:

 Book in hospital in combined clinic &

manage with physician/ cardiologist
 Assess nature of heart disease & categorize
functional state
 Draw clear management plan
 Aim to optimize cardiac status prior to
pregnancy if possible
 MANAGEMENT
Pre delivery care:

 Ensure diagnosis is confirmed with

echocardiogram & ECG
 Decide if there is need for anticoagulant,
beta blocker, pulmonary artery vasodilator,
diuretic
 Warfarin protects against thrombosis but
has risks to fetus (embryopathy &
miscarriage)
 MANAGEMENT
Pre delivery care:

 Antibiotic prophylaxis may be indicated in

those with cyanotic heart disease & previous
infective endocarditis
 Amoxicillin 2mg IV &gentamycin 1.5gm/kg IV
at onset of labour or when membrane
rupture or before incision is made at
caesarean section
 Give 3 doses at 8 hourly interval
 MANAGEMENT
Pre delivery care:

 Follow up with amoxicillin 500mg orally

after delivery
 Vancomycin 500mg IV 2 doses is given for
those who allergic to amoxicillin
 Monitor & minimize additional load to
heart as pregnancy advances with diuretic,
beta blocker & vasodilator
 MANAGEMENT

Pre delivery care:

 Heart failure & pulmonary hypertension

needs to managed with diuretic, morphine &
digoxin
 Monitor pregnancy & effect of oxygen
saturation & drug therapy on fetus
 Plan intrapartum care
 MANAGEMENT

Pre delivery care:

 Genetic counselling -

• Risk of fetus having heart lesion is higher if

mother/father has heart disease
• Left sided outflow tract lesion in mother
tends to repeat in fetus & risk of ASD in fetus
is 5-10%
 MANAGEMENT OF LABOUR

 Vaginal birth is preferred

 Induction of labour is evaluated based on its

merit

 Regional anaesthesia reduce pain & anxiety

thus reducing increases in heart rate, cardiac
output & oxygen demands during labour
 MANAGEMENT OF LABOUR

Cesarean section is indicated only for the

following cardiac conditions:

• Aortic dissection/ Coarctation of aorta

• Marfan’s syndrome with dilated aortic root
• Severe aortic stenosis
Induction of labour

There is no indication to induce labour purely

on basis of cardiac disease

It should be avoided in patient with acute

heart failure

If it is indicated for obstetric cause, a low

amniotomy & oxytocin infusion is the best
method
 MANAGEMENT OF LABOUR

 Adequate analgesia pethidine/morphine can

be used

 Epidural anesthesia is preferable as it

abolishes the bearing down desire so
decreases maternal effort

 Prophylactic antibiotic is essential to prevent

subacute bacterial endocarditis
 MANAGEMENT OF LABOUR

 Auscultate the lungs for any basal crepitation

 Watch for any symptoms & signs of cardiac

failure

 If oxytocin is required after delivery to combat

PPH, infusion of oxytocin with syringe pump is
advised
 MANAGEMENT OF LABOUR

 Avoid bolus oxytocin, carboprost, GTN, &

ergotamine especially in those with fixed
cardiac output as they can precipitate acute
pulmonary edema

 Ergometrine is best avoided as it causes sudden

load of circulation with blood from uterus
leading to acute heart failure
 MANAGEMENT OF LABOUR

 Postpartum observation for 48-72 hours is

essential as the risk of heart failure is high in
this period

 Follow up for upto 6 months because patient

may develop pulmonary complications like
infection & Peripartum cardiomyopathy
 MANAGEMENT OF LABOUR

 Although bed rest is essential, early

ambulation is desirable to avoid
thromboembolism

 Breast feeding is allow unless there is heart

failure
 MANAGEMENT
Indication for medical termination of
pregnancy:
Eissenmenger's syndrome
Marfan’s syndrome with aortic involvement
Severe pulmonary hypertension
Coarctation of aorta with valvular
involvement

• Termination should be done before 12 weeks

of pregnancy
 MANAGEMENT
Medical treatment:

Digoxin is used in:

• Atrial fibrillation to slow ventricular response
• Acute heart failure to increase myocardial
contractility

Diuretic is used in:

• Acute & chronic heart failure with potassium
supplement in prolonged therapy
 MANAGEMENT
Medical treatment:

Beta blocker is used:

• To control heart rate for patients with
functionally significant mitral stenosis &
arrhythmias associated with ischemic heart
disease

Aminophylline : Bronchospasm
Heparin : artificial valves/ atrial fibrillation
 ANTICOAGULATION THERAPY
Oral therapy with warfarin:

• Its use in first trimester can be teratogenic &

can cause fetal embryopathy (15-25%)

• Fetal intracranial bleeding is a risk throughout

pregnancy, particularly during vaginal delivery,
unless warfarin is stopped before labour

• Fetal complication is accentuated if dose is

>5mg daily
 ANTICOAGULATION THERAPY

Heparin:

• Is given subcutaneous doses

• It does not cross placenta hence has no
teratogenic effects
• It may cause maternal thrombocytopenia &
osteoporosis
• It is less effective in preventing thrombosis in
patient with prosthetic valves
 ANTICOAGULATION THERAPY
More recent guidelines recommend either :

Adjusted-dose heparin during entire pregnancy

or
Adjusted-dose heparin until 13th week of
gestation followed by heparin from 14th week
upto 36th weeks & then restart adjusted-dose
heparin. Restart heparin therapy 4 to 6 hours
after delivery if no contraindication. Resume
warfarin therapy slowly & at the same time
gradually reduce & stop the heparin after
delivery
Antibiotic prophylaxis consists of:

IV ampicillin 2gm & IV gentamycin 1.5mg per

kg prior to the procedure followed by one
more dose of ampicillin IV 8 hours later

In patient with penicillin allergy, 1gm

vancomycin IV can be given
Contraception:

• Oral contraceptive pills are not ideal as they

can cause thromboembolism

• IUCD can cause endocarditis

• Barrier contraceptive have high failure rate

Contraception:

• Progestin only pill (desogestrel) / long acting

injectable progesterone (medroxy
progesterone) 150mg IM every 3 months,
norethisterone 200mg every 2 months are
best suited

• Permanent sterilization is ideal option