Obstetrics 3.

8a

CARDIOVASCULAR DISEASES IN PREGNANCY

OUTLINE
I.
Cardiovascular Disease In Pregnancy
A. Cardiac Diseases
B. Physiological Consideration With Heart Disease In Pregnancy
II.
Diagnosis Of Heart Disease
III.
Preconceptual Counseling
IV.
Risk For Maternal Mortality Caused By Various Heart Disease
V.
Management
VI.
Prognosis
VII.
References

CARDIOVASCULAR DISEASE IN PREGNANCY

It is a relatively common in women of child bearing age, complicating
about 1% of pregnancies
Maternal mortality related to heart disease has decreased remarkably
over the past 50 years (from 5.6 to 0.3/100000 live birth)
Heart disease is still the second most common non-obstetrical cause of
maternal mortality
CARDIAC DISEASES
Rheumatic heart disease
o Used to be the most common cardiac disease but there has been a
shift in etiology due to effectivity of antibiotics in treating
Rheumatic Heart Disease (RHD).
o
Incidence of rheumatic fever is decreasing in developed countries.
It still remains the chief cause of serious mitral valve disease in
women. (3/4 of cases of mitral stenosis)
o Most common is mitral valve prolapse, but the one to watch out
for is mitral stenosis[1]
Congenital heart disease
o Now, more common due to the decrease in RHD cases
o Many congenital heart lesions appear to be inherited as polygenic
characteristic, 10% of women with congenital heart disease would
give birth to similarly affected infants, 50% were concordant for
the same anomaly
o Most common congenital heart defect is the ventricular septal
defect. The deadliest is aortic coarctation with the possibility of
pulmonary HPN developing.[1]
Hypertensive heart disease
o Hypertensive heart disease is also becoming more common
despite protective factor of hormones during reproductive age.
o This is due to current lifestyle and increase in cases of obesity and
DM.
Peripartum Cardiomyopathy
o Diagnosis of exclusion
o Women with peripartum heart failure with no apparent etiology
o Cardiac decompensation appear during the last weeks of
pregnancy or 1 to 6 months postpartum
o Obstetrical complications such as preeclampsia, anemia from
blood loss, and infection either contribute or precipitate heart
failure
o Why it is important to monitor the patient for 10 days after
delivery. In this disorder, the cardiac muscles are diseased, and the
cardiac function is diminished. This is why patients are not able to
go back to their daily routine.[1]
o Advised to no longer have another pregnancy after being
diagnosed with Peripartum Cardiomyopathy[1]
Others
o Coronary
o Thyroid
o Syphilitic
o Kyphoscoliotic cardiac disease

Group 23 | TAN, G., TAN, D., TAPALLA, TAPIA, TEE

o
o
o
o
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DRA. PADOLINA
02 October 2014

Idiopathic cardiomyopathy
Cor Pulmonale
Constrictive pericarditis
Geart block
Isolated myocarditis

ANATOMICAL AND PHYSIOLOGICAL CONSIDERATION IN PREGNANCY

The most important changes in cardiac function occurs in the first 8
weeks of pregnancy with maximum changes at 28 weeks
In order to supply blood and nutrition both to her body and the fetus,
there is a need for the pregnant body to INCREASE IN CARDIAC OUTPUT
(about 30-50%) and INCREASE IN STROKE VOLUME through
hemodilution. This is brought about by the following:
o Decreased vascular resistance
o Decreased blood pressure
o Increased heart rate
Compensatory
o Increased blood volume
In hemodilution, there is increase in blood volume but RBC number
remains to be normal. This becomes burdensome for the heart of a
pregnant patient with cardiac disease.
Other effects in cardiac output (COP):
o Maternal weight and basal metabolic rate also affect COP
o Later in pregnancy COP is higher when women is in the lateral
recumbent position than when she is in the supine
o During labor COP increase moderately in the first stage of labor
and apprecibly greater in the second stage
o COP also increase in the immediate post partum period
The heart is displaced upward and to the left with lateral rotation on its
long axis due to gravid uterus
Resting pulse increase by about 10 bpm
There are some changes in the cardiac sounds include:
o An exaggerated splitting of the first heart sound with increase
loudness of both components. No definite changes in the aortic
and pulmonary elements of the second sound, and aloud easily
heard third sound
o Systolic murmur is heard in 90% of cases
o Soft diastolic murmur transiently in 20%
o Continuous murmur arising from the breast vasculature in 10% of
case
o Therefore it is important to investigate since not all pregnant
patients will tell you they have a cardiac problem
o Diagnose if changes in cardiac sounds are physiologic or pathologic
There are 4 periods during pregnancy which would make the patient
with cardiac disease at risk for decompensation due to congestive heart
failure: [1]
1. 8th week due to start of physiologic hemodilution
2. 28th week peak of hemodilution
3. Labor and delivery
o Due to supine position wherein gravid uterus impinges on IVC
controlling the amount of blood going back to the heart, once
the fetus is evacuated from the uterus, there is sudden
increase in cardiac load. Use sandbags placed on the
abdomen so there will be no immediate recall of blood from
extremities to the heart
o Due to bearing down causing extra cardiac load. Shorten by
vacuum or forceps delivery so as not to unnecessarily strain
the heart
4. Peripartum
o There is third spacing initially and recall of this fluid would
increase cardiac load. Treat with diuretics.

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OBSTETRICS 3.8

DIAGNOSIS OF HEART DISEASE

SYMPTOMS
Progressive dyspnea or orthopnea
Nocturnal cough
Hemoptysis
Syncope
Chest pain

CLINICAL FINDINGS
Cyanosis
Clubbing of fingers
Persistent neck vein distention
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrhythmia
Persistent split-second sound
Criteria for pulmonary hypertension

CLINICAL CLASSIFICATION
The New York Heart Associations Functional Classification [NYHA]

First published in 1928

This is important. It doesnt change whether you have an internal

medicine patient or a pregnant cardiac patient. You need to do and
classify your patient according to their functional classification because
you treat them differently and individually. This would also carry the
burden of what kind of anatomical defect they have.[1]

*According to the lecturer, know this by heart, this is memorable

Table 1. NYHA (New York Heart Association) Classification
NYHA CLASS
Symptom
Class 1
Class 2

Class 3

DIAGNOSTIC STUDIES
ELECTROCARDIOGRAPHY
As the diaphragm is elevated in advancing pregnancy, an average 15degree left-axis deviation in the ECG, and mild ST changes may be seen
in the inferior leads 3
Atrial and ventricular premature contractions are relatively frequent
A reflection of the biochemical changes of what is happening in the
heart [1]

Class 4

CHEST X-RAY
Slight heart enlargement cannot be detected accurately because the
heart silhouette normally is larger in pregnancy, however gross
cardiomegaly can be excluded
Used to determine cardio-thoracic ratio
An abdominal shield is used to protect the baby and mothers ovary.
Important to balance risk vs benefit. [1]
Lead apron shield lessens the effects of radiation to the fetus 3
A single exposure to radiation from the x-ray does not cause congenital
anomalies to the fetus
ECHOCARDIOGRAPHY
Normal changes include: tricuspid regurgitation, significantly increase
left atrial size and left ventricular outflow cross sectional area
Most diagnostic which is an ultrasound of the heart
It is important because it allows you to zero-in on the type of cardiac
defect that she has. If these are congenital anomalies, then youll be
able to access the valves. [1]
The other more important feature is once you have an early diagnosis of
the functional capacity of the heart, take note that 30-40% of the time
there is collaborative findings of whatever the mother has especially if
this is a congenital heart disease on what her unborn baby has. So you
also have what is referred to as fetal echocardiography, wherein you
dont need to deliver the baby but you can do it while the mother is still
pregnant. [1]
Congenital anomaly scanning is usually done between 18-24 weeks
AOG. The sonologist do a physical exam from head to toe using the
ultrasound exam. If there is a question of any fetal congenital anomaly
in the heart, the baby is subjected to fetal echocardiography that
should be done before 29-30 weeks. You want to do it even before the
ribs of the baby ossifies because this would give you the window period
wherein you could use the ultrasound and look into the functional
capacity and anatomical structure of the fetal heart. [1]

Group 23 | TAN, G., TAN, D., TAPALLA, TAPIA, TEE

Uncompromised. Cardiac disease, but no symptoms and

no limitation of physical activity
Slightly compromised. Comfortable at rest. Mild
symptoms (mild shortness of breath and/or angina) and
slight limitation of physical activity
Markedly compromised. Marked limitation of physical
activity, even during less-than-ordinary activity, e.g.
walking short distances (20-100m); comfortable only at
rest
Severely compromised. Inability to perform any physical
activity without discomfort. Experience symptoms even
while at rest. Mostly bedbound patients

PRECONCEPTIONAL COUNSELING
Maternal mortality generally varies directly with functional
classification at pregnancy onset; however this relationship may change
as pregnancy progresses
Patient with pulmonary hypertension, primary or secondary are in
danger of undergoing decompensation during pregnancy
Life threatening cardiac abnormalities can be reversed by corrective
surgery and subsequent pregnancy is less dangerous
In other cases fetal consideration predominate, for example the
teratogenic effect of warfarin
It is not much done in the Philippines, but this is part of the process of
antepartal care in a pregnant patient with cardiac disease. Ideally even
before they get pregnant, counsel patient with the risk of losing her life
if she gets pregnant with cardiac disease.[1]
The number 1 congenital heart disease that has high mortality is
aortic stenosis. 50-60% of the time, the woman might die due to this
condition. You should counsel the patient and her family in terms of
prognosis and natural course of the illness.[1]
Prognosis and management are influenced by: [2]
o Functional classification Class II usually dont have
complications during labor and delivery
o Nature and severity of the specific lesion
Cardiac disease in pregnancy is a life-threatening condition and
depending on what kind it is, treat them medically or surgically as
needed.1

RISKS FOR MATERNAL MORTALITY CAUSED BY VARIOUS HEART DISEASE

Life threatening cardiac abnormalities can be reversed by corrective
surgery and subsequent pregnancy is less dangerous

In other cases fetal consideration predominate, for example the

teratogenic effect of warfarin

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OBSTETRICS 3.8

Table 2. Risks For Maternal Mortality Caused By Various Heart Diseases

CARDIAC DISORDER
MORTALITY %
Group 1 Minimal Risk
0-1%
Atrial septal defect
Ventricular septal defect (most
common)
Patent ductus ateriosus
Pulmonic or tricuspid disease
Fallot tetralogy, corrected
Bioprosthetic valve
Mitral stenosis, NYHA Classes 1&2
Group 2 Moderate Risk
2A
Mitral stenosis, NYHA Classes 3&4
Aortic stenosis
Aortic coarctation without valve
involvement
Fallot tetralogy, uncorrected
Previous myocardial infarction
Marfan syndrome, normal aorta
2B
Mitral
stenosis
with
atrial
fibrillation
Artificial valve
Group 3 Major Risk
Pulmonary hypertension
Aortic coarctation with valvae
involvement
Marfan syndrome with aortic
involvement

5-15%

25-50%

MANAGEMENT
In assuring the optimal outcome, management should be a team
approach involving: obstetrician, cardiologist and anaesthesiologist.
Risk of patient of: Heart failure, subacute bacterial endocarditis,
thromboembolic disease wll be identified and minimized.
Four concepts that affect management are emphasized by the ACOG:
o The 50% increase in blood volume and COP by the early 3 rd
trimester. So as much as possible dont give additional load.
o Further fluctuation in volume and COP in the peripartum period
Time at danger of developing cardiac myopathy.
o A decline in systemic vascular resistance, reaching a nadir in the
2nd trimester, and then rising to 20% below normal by late
pregnancy
o Hypercoaguability of special importance in women requiring
anticoagulation in the non pregnant state. So if you need blood
thinners, choose whats appropriate. Caution them also to wear
anti thromboembolic stockings.
MANAGEMENT OF CLASS 1 & 2
General measures:
o Avoid contact with persons who have respiratory infection, the
usual URTI.
o Pneumococcal and influenza vaccines are recommended, also
Tdap for pertussis (patient with valvar heart disease)
o Cigarette smoking is prohibited
o Diet, avoidance of strenuous activity and avoidance of anemia.

Group 23 | TAN, G., TAN, D., TAPALLA, TAPIA, TEE

Pregnant patient should engage in 30 min moderate

physical activities at least 3x a week preferably 5-6x a
week. With cardiac disease, tailor to appropriate. For the
diet, what we want is to avoid straining. So give vegetables
and fibers.

Progesterone retards bowel movement.

Signs of Heart Failure:
o Heart functions are not able to cope up with pregnancy because
of defects.
o Persistent basilar rales
o Nocturnal cough
o A sudden diminution in ability to carry out usual duties
o Increasing dyspnea on exertion
o Attacks of smothering with cough
o Hemoptysis, progressive edema, and tachycardia
Labor & Delivery
o Vaginal delivery is preferred unless there is an obstetrical
indication
o Operative Vaginal delivery best way to deliver a pregnant cardiac
patient since
1. More physiologic
2. Vacuum and forceps will shorten 2nd stage of labor
3. You do not need to give her extra fluid like in CS so theres no
risk of overloading the heart and
4. No problem with anesthesia unlike in CS you have to give
spinal, so you may overload also.[1]
o Relief of pain with intravenous analgesics
o Continuous epidural analgesia (ALWAYS BEST) is recommended
for most situation, but it is contraindicated in patient with
intracardiac shunt, pulmonary hypertension, aortic stenosis, to
avoid the risk of maternal hypotension.
o Epidural anesthesia is the best because
1. Painless and
2. No need to increase fluids which would again increase
cardiac load[1]
o Fluid balance and antibiotic prophylactic. Patients with valvular
defects are at risk of subendocardial infection. Their prophylaxis
depends on their cardiac defect. Ampicillin 1-2 g every 6h or
Gentamycin 80 mg slow IV 3x/ day.
o Semi recumbent position with lateral tilt. If she can deliver
standing up or sitting down, then thats the best way. If not, only
put her on supine position only on the brink of actual delivery,
and dont forget the sand bags on the maternal abdomen.
o Intensive medical management for any signs of impending
venricular failure [pulse > 100, RR > 24, dyspnea]
o Expedite vaginal delivery using forceps or vacuum.
o Close monitoring for the 3rd stage of labor. Recall of fluids. She is
always in danger of embolic phenomenon, cardiac overload and
hemorrhage. Recognize this because any amount of anemia or
hypovolemic shock would be very detrimental for her. So balance
your blood transfusions properly.
Puerperium
o Avoid complication of postpartum hemorrhage, anemia,
infection, and thromboembolism
o Delay the procedure of tubal sterilization until it is obvious that
the mother is a febrile, not anemic, and can ambulate without
evidence of distress
o This is advised to prevent succeeding pregnancies
o Option of contraceptive device.
o Best contraceptives for a cardiac patient is progestin ONLY. Not
the combination type

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OBSTETRICS 3.8

MANAGEMENT OF CLASS 3 & 4

Whether pregnancy should be undertaken
o It is discussed whether or not the patient should be pregnant, and
if so, the birth plan is discussed[[1]
Consider pregnancy interruption
o Not available here in the Philippines[1]
Prolonged hospitalization or bed rest
o Usual hospital stay for a cardiac patient is at least 10 days
compared to the usual of 2 days after delivery in order to monitor
the patient if she would develop heart failure due to cardiac
problems[1]
Vaginal delivery is preferred
o Best is operative vaginal delivery with use of forceps or suction,
under epidural anesthesia.[1]
Caesarean section delivery should be with the availability of
experienced anesthetic support in a facility with experience with
complicated cardiac disease
PROGNOSIS
Favourable outcome for the mother with heart disease depends on:
o Functional cardiac capacity
o Other complications that further increase cardiac load
o Quality of medical care provided
o Psychological and socioeconomical factors

IN A NUT SHELL
First, you define the lesion via history, PE, etc. Then you determine the risks
involved. Based on these, you consider two things: Management options for
the obstetrical condition, and the management options for the medical
problem.[1]

1.
2.

REFERENCES
Dra. Padolinas lecture
Williams Obstetrics 24th edition

Group 23 | TAN, G., TAN, D., TAPALLA, TAPIA, TEE

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