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
