The Maternal and Fetal Outcome of Women With Cardiac Diseases : A

Restrospective Study in a Tertiary Hospital During 2009 - 2013

Karina Niken Pratiwi, Sulaeman Andrianto Susilo, Oktavia Lilyasari, Rima
Irwinda, Noroyono Wibowo
Department of Cardiology & Vascular Medicine University of Indonesia, National
Cardiovascular Center Jakarta, Indonesia
Department of Obstetrics & Gynecology, Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo Hospital, Jakarta Indonesia
Abstract
Background : Cardiac disease in pregnancy is a challenging health care problem and is
now leading cause of maternal mortality and neonatal morbidity in developed countries.
There is generally a paucity of data describing cardiac disease related to pregnancy from
developing countries. This study was to describe the maternal and fetal outcome of
pregnancy with history of cardiac disease in Indonesia.
Method : Data were collected through 4 years period from 2009 2013 with all women
who delivered their babies in Cipto Mangunkusumo General Hospital with history of
cardiac disease. Participants were the recorded patients in Cipto Mangunkusumo General
Hospital and data was subject to descriptive statistical analysis.
Result : Out of 112 women with cardiac disease, valvular disease was found to be the
predominant cardiac disease (n = 42, 37.5 %) followed by heart failure (n = 27, 24.1%),
Congenital Heart Disease ( n = 14, 12.5%), PPCM (n = 13, 11.6%),HHD (n = 12, 10.7%),
and arrhythmia (n = 4, 3.6%) . Low apgar score at 1 minute were seen in 90 (80.4%)
neonates and normal apgar score at 5 minutes were seen in 88 (78.6%) neonates. IUFD
were found in 7 (6.3%) neonates and maternal death occured in 4(3.6%) women, preterm
birth were seen in 67 (59.8%) deliveries. Median duration of pregnancies was 36 weeks
(range 8 40) and median birth weight 2400g (range 360 3800)
Conclusion : This study presents that valvular heart disease was found to be the most
prevalent case among all cardiac diseases in pregnant mother.
Keywords : cardiovascular disease, pregnancy, neonates
Introduction

Heart disease is the leading cause of non obstetrical cause for perinatal and maternal
mortality and morbidity and still a challenging health care problem.

1-3

The prevalence of

heart disease in pregnancy is 0,3 3,5 %.4,5 Pregnancy for women with heart disease is of
moderate to high risk. A normal heart is able to tolerate the physiological hemodynamic
changes during pregnancy (decrease of systemic vessel resistance, increase of blood
volume, increase of heart rate and cardiac output).1,6-8 For a pregnant woman with an
impaired cardiac function these changes increase the cardiac burden and may lead to
maternal and perinatal complications during pregnancy and delivery.1,9,10 Woman with
cardiovascular disease tends to have a preterm baby.11 While many women with a history
of heart disease may go through a pregnancy without difficulty, assessing overall
maternal and neonatal risks and monitoring the pregnancy consistently is mandatory.5
Heart disease in pregnancy is also hard to diagnose. Many signs and symptoms of normal
pregnancy can imitate heart disease. The most common symptom is dyspnoe (75 %). It
should be considered abnormal if there was activity impairment.6 Electrocardiogram and
echocardiography still remains an invaluable tool in evaluation of pregnant woman with
suspected heart disease, as it carries no risk to the woman or her fetus. 6,7 In this study, we
report maternal and fetal outcomes of 112 singleton deliveries with heart disease who
delivered their babies in Cipto Mangunkusumo General Hospital throughout 2009
2013.
Methods
This study was a restrospective evaluation of pregnancy outcome with heart disease. All
cases were followed during pregnancy, labour and delivery at the Cipto Mangunkusumo
General Hospital from January 2009 to December 2013. Data were collected through the
database including: History of cardiac disease, maternal age (divided into three groups :
<19 years old, 20 35 years old, and >35 years old), parity, history of ANC, MAP,
Ejection Fraction of heart by echo, mode of delivery, age of gestation. Neonatal outcomes
included APGAR Score at 1 and 5 minutes, IUFD, Preterm birth, birth weight. Maternal
outcomes included maternal death and mode of delivery. Data analysis was performed
using SPSS for Mac 20.0. Means and standard deviations (SD) or median were calculated
as appropriate.

Result
Data of 112 women with cardiac disease were obtained. They were all singleton
deliveries. The average age of the patients was 31 years old, with an age range of 17 - 47
years. The majority of patients were multiparous (n = 75, 67%) with normal ejection
fraction (n = 41, 61.2%) and all of them were had routine antenatal care (n = 112, 100%).
Variables
Maternal Age
< 19 years
19 35 years

No. (N = 112)

> 35 years old

Parity
Nullipara
Multipara
Ejection Fraction
< 70%
> 70%
Routine Antenatal Care
Yes ( > 3x)
No (1 3x)
MAP
< 105
> 105

30 (26.8%)

3 (2.7%)
79 (70.5%)

37 (33%)
75 (67%)
26 (38.8%)
41 (61.2%)
112 (100%)
0
(0%)
58 (53.7%)
50 (46.3%)

Table 1. Clinical Characteristics of Women with Cardiac disease in Pregnancy

The distribution of these patients by the type of heart disease is presented in table 2. The
most common heart disease was Vavular heart disease which was reported in 37.5% of
patients (n = 42, 37.5%), followed by heart failure (n = 27, 24.1%), Congenital Heart
Disease ( n = 14, 12.5%), PPCM (n = 13, 11.6%),HHD (n = 12, 10.7%), and arrhythmia
(n = 4, 3.6%). Congenital heart disease in these patients including : TOF, Eisenmenger,
VSD, and ASD. In these patients, 2 out of 4 arrythmia were caused by AV block.
Cardiac Disease
Congestive Heart Failure
Valvular Heart Disease
PPCM

No. (N = 112)
27 (24.1%)
42 (37.5%)
13 (11.6%)

HHD
Congenital Heart Disease
Arrythmia

30 (10.7%)
14 (12.5%)
4 (3.6%)

Table 2. Distribution of cardiac disease in pregnant women

In total of 112 singleton deliveries obtained, caesarian section was found to be the most
predominant for mode of delivery (n = 82, 75.2%), spontaneous vaginal deliveries was
found in 27 (24.8%). Maternal death were occurred in 4 (3.6%) patients. IUFD were
occurred in 7(6.3%) neonates. Preterm deliveries occurred in 67 (59.8%) and median
duration of pregnancies was 36 weeks (range 8 40). There were 51 (51%) neonates with
low birth weight (<2500 g) with median birth weight 2400g (range 360 3800) . Low
APGAR score at 1 minute was found in 20 (22.2%) whereas low APGAR score at 5
minutes was found in 2 (2.2%) neonates.
Variables
Mode of Delivery
Caesarian Section
Vaginal delivery
Maternal Death
Yes

No. (N = 112)

No

104 (92.9%)

82 (75.2%)
27 (24.8%)
4 (3.6%%)

IUFD
Yes

7 (6.3%)

No

93 (93%)

Preterm Birth
< 37 weeks

67 (59.8%)

> 37 weeks

43 (38.4%)

Low Birth Weight

< 2500 g

51 (51%)

> 2500 g

49 (49%)

Apgar score at 1 minute

<7

20 (22.2%)

>7

70 (62.5%)

Apgar Score at 5 minute

<7

2 (2.2%)

>7

88 (97.8%)

Table 3. Fetal and Maternal outcome of women with cardiac disease

Discussion
A number of registries on women with heart disease in pregnancy have been reported in
the past. However, they are predominantly from the developed world with a focus on
women presenting with operated CHD. They, therefore, do not cover the entire burden of
CVD in pregnancy particular to Indonesian population. This study was to evaluate the
clinical of maternal and fetal outcome in a tertiary hospital in Indonesia where
appropriate workup by obstetrician and cardiologist is needed. The study has a shown a
disease pattern markedly different that seen in developed countries, which CHD and
RHD become the two most prevalent cases in High - Income countries as stated by Liu H
et al.12 Our study reported that the highest prevalence of pregnancy complicated with
heart disease was valvular heart disease (n = 42, 37.5%) and the second highest was CHF
(n = 27,24.1%). Mode of delivery ( n = 82, 75.2%) The maternal outcome for this study
was quite good, with maternal death occurred in only 4 (3.6%) women. The perinatal
outcome, we found that there were significant numbers in low APGAR score at 1 minutes
(n = 20, 22.2%), Low birth weight (n = 51, 51%), and preterm birth (n = 67, 59.8%).
These factors may be caused by prenatal stress during pregnancy where there is a change
in hemodynamic of pregnant women with CVD as stated by Plana-Ripoll O et al. In our
study, we found that there was an improvement of APGAR score at 5 minutes, which
means that the rate of survival of neonates increased.
Conclusion
There is still lack of data concerning about pregnancy complicated with heart disease in
developing countries, however our data show a disease pattern in Indonesia, markedly
different to that of the developed countries. This study presents that valvular heart disease
was found to be the most prevalent case among all cardiac diseases in pregnant mother.
References

1.

Hink E, Bolte AC. Pregnancy outcomes in women with heart disease: Experience
of a tertiary center in the Netherlands. Pregnancy Hypertension: An International
Journal of 2015;

2.

Mehta PK, Minissian M, Merz C. Adverse pregnancy outcomes and cardiovascular

risk factor management. Seminars in Perinatology 2015;

3.

Roos-Hesselink JW, Ruys PTE, Johnson MR. Pregnancy in adult congenital heart
disease. Curr Cardiol Rep 2013;15:4011.

4.

Konar H, Chaudhuri S. Pregnancy complicated by maternal heart disease: a review

of 281 women. J Obstet Gynaecol India 2012;62:3016.

5.

Michaelson-Cohen R, Elstein D, Ioscovich A, Armon S, Schimmel MS, Butnaru A,

et al. Severe heart disease complicating pregnancy does not preclude a favourable
pregnancy outcome: 15 years' experience in a single centre. J Obstet Gynaecol
2011;31:597602.

6.

Tan JY-L. Cardiovascular disease in pregnancy. Obstet Gynaecol Reprod Med

2009;20:10715.

7.

Ruys TPE, Cornette J, Roos-Hesselink JW. Pregnancy and delivery in cardiac

disease. J Cardiol 2013;61:10712.

8.

Harris IS. Management of pregnancy in patients with congenital heart disease.

Progress in cardiovascular diseases 2010;53:30511.

9.

Sartain JB, Anderson NL, Barry JJ. Rheumatic heart disease in pregnancy: cardiac
and obstetric outcomes. Intern Med 2012;

10.

Swan L. Congenital heart disease in pregnancy. Best Pract Res Clin Obstet
Gynaecol 2014;28:495506.

11.

Bonamy A, Parikh NI, Cnattingius S, Ludvigsson JF. Birth characteristics and

subsequent risks of maternal cardiovascular disease effects of gestational age and
fetal growth. Circulation 2011;

12.

Liu H, Huang T, Zhao W, Shen Y, Lin J. Pregnancy outcomes and relative risk
factors among Chinese women with congenital heart disease. Int J Gynaecol
Obstet 2013;120:2458.