Heart Disease in Pregnancy

Prof. Nilanjana Chaudhury

 Hemodynamic changes in normal
pregnancy
PARAMETER CHANGE (PERCENT)
Plasma volume +40
Cardiac output +43
Heart rate +17
Mean arterial pressure +4
Stroke volume +27
Systemic vascular -21
resistance
Pulmonary vascular -34
resistance
 Critical periods
• Changes start from as – 6weeks
• Max changes around –30 weeks
• Intra partum period
• Just after delivery
• Second week of puerperium
Pregnancy changes mimic cardiac disease

• Symptoms – breathlessness, weakness,

oedema, syncope
• Tachycardia
• Splitting of 1st hear sound
• Murmur – systolic , breast bruit
• Displacement of apex beat – upwards to left
 Incidence of heart disease
• Varies between 0.1 – 4.0 %, average 1%
• Mortality due to heart disease has decreased
• Pregnancy with heart disease has increased
• Devpd countries – rheumatic is decreasing
• Congenital heart disease with pregnancy is
also increasing
 Classification of Heart Disease
according to etiology
• Congenital – non cynotic ( ASD, VSD, Pulm
stenosis, coarctation of aorta),
cyanotic (Fallots tetralogy, Eisenmenger’s
syndrome)
• Rheumatic heart disease – MS, MR, AS, AR
• Cardiomyopathy
• Ischaemic heart disease
• Others – conduction defects, syphilitic,
thyrotoxic, hypertensive,
Classification of Heart Disease during
pregnancy according to risk
• Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-
1,2, corrected FT
• Medium risk ( 5 – 15 %) – MS-3,4, MS
with atrial fibrillation, AS, uncorrected FT
• High risk ( 25 – 50%) – PH, Eisenmengers
Syndrome, aortic coarctation with
valvular involvement, Marfans with aortic
involvement
Symptoms of heart disease

• Progressive dyspnea or orthopnea

• Nocturnal cough
• Syncope
• Chest pain
• Hemoptysis
Clinical findings of heart disease
• Cyanosis
• Clubbing of fingers
• Persistent neck vein distention
• Systolic murmur grade 3/6 or greater
• Diastolic murmur
• Cardiomegaly
• Persistent arrythmia
• Persistent split second sound
• Pulmonary hypertension
 Investigations
• ECG – cardiac arrhythmias, hypertrophy
• Echocardiography – cardiac status and
structural anomalies
• X-ray chest – cardiomegaly, vascular
prominence
• Cardiac catheterization - rarely
NYHA (New York Heart Association)
Functional grading of heart disease

• Grade I: No limitation of physical activity-

asymptomatic with normal activity
• Grade II: Mild limitation of physical activity -
Symptoms with normal physical activity
• Grade III: Marked limitation of physical activity -
Symptoms with less than normal activity,
comfortable at rest
• Grade IV: Severe limitation of physical activity-
symptoms at rest
 Poor prognostic indicators
• h/o heart failure, ischaemic attack, stroke
• Arrhythmias,
• Base line NYHA class 3 and 4
• MV area below 2cm sq, AV area below 1.5
• Ejection fraction less than 40%
Additional risk factors
• Anaemia
• Infections
• Hypertension
• Physical labour
• Weight gain
• Multiple pregnancy
• Caffein , alcohol intake
• Pain
• Drugs – tocolytic
Effect of pregnancy on heart disease

• Worsening of cardiac status

• CCF, bacterial endocarditis, pulmonary
edema, pulmonary embolism, rupture of
aneurism
• No long term effect on basic defect
Effect of heart disease on pregnancy

• Abortion
• Preterm labour
• IUGR
• Intrauterine fetal demise
• Congenital heart disease in baby – 5%
 Causes of Maternal Death
• Cardiac failure most common
• Pul edema
• Pul embolism
• Active rheumatic carditis
• SBE
• Rupture of cerebral aneurysm in coa
 Management
Requires-
• High index of suspicion
• Timely diagnosis
• Effective management
• Team Approach-
• Obstetrician
• Cardiologist
• Anesthetist
• Neonatologist
• CTV surgeon
• Nursing Staff
 Preconceptional Counseling
• No pregnancy unless must esp in high risk types
• Maternal mortality varies directly with functional
classification at pregnancy onset
• Optimal Medical/Surgical treatment pre-pregnancy
• Counselling-
– Maternal & Fetal risks
– Prognosis
– Social and cost considerations
– Hospital delivery- Preferable at tertiary care centre
Medical termination of pregnancy
• Termination advised in early pregnancy in high risk
group only – ( Primary pulmonary Ht, Eisenmenger
syndrome, Coarctation of aorta, Marfan syndrome
with dilated aortic root)
• Only in 1st trim, better before 8 weeks
• Suction evacuation preferred
• MTP also carries risk for life
 Antenatal care
• Clear counseling of risk and prognosis
• ANC every 2 weeks upto 30 weeks then weekly
• On each visit-note-pulse rate, BP, cough dyspnea,
weight, anaemia, auscultate lung bases, re-
evaluate functional grade
• Ensure treatment compliance
• Exclude fetal congenital anomaly by level-III USG
and fetal ECHO at 20 weeks in maternal
congenital heart disease
• Fetal monitoring
 Special Advice
• Rest, Avoid undue excitement/strain
• Diet/ Iron and vitamins
• Hygiene, dental care to prevent any infection
• Dietary salt restriction (4-6g/d)
• Avoid smoking, drugs – betamimetics
• Early diag and tmt of PIH, infections
• Therapeutic/prophylactic cardiac interventions as
applicable-
– Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence
of rheumatic fever
– Diuretics, Beta Blockers, Digitalis, Anticoagulants
– Surgical treatment as applicable - balloon mitral valvotomy
 Indications for admission
Elective admission-
• NYHA 1 – 2 weeks before EDD
• NYHA 2 – 28 to 30 weeks
• NYHA-III/IV- Irrespective of POG as soon as patient
comes
• To Change from oral anticoagulants to heparin-early
pregnancy, 36 weeks in patients on anticoagulant
Emergency admission-
• Deterioration of functional grade
• Symptoms and signs of complications- Fever/ persistent
cough/ basal crepts/ tachyarrhythias (P/R >100 min)/
JVP>2cm/Anaemia/ Infections/ PET/Abnormal weight
gain /other medical disorders
 Labor and Management
• Institutional delivery
• Induction of Labor
– Only for obstetric indications
– Oxytocin preferred- Higher concentration with
restricted fluid
– Intracervical foley instillation esp in congenital heart
disease
– PGE2 Gel may be employed- Vasodilatation - use with
caution
Management in first stage of labor
• Confined to bed- propped up or semi
recumbent
• Intermittent oxygen inhalation 5-6 l/min
• Sedation and analgesia- (Epidural,
pethidine, tramadol)
• Cautious use of I.V. fluids (not >75ml/hr
except in aortic stenosis and VSD)
• Stop anticoagulants
• Digitalise if in CHF,P.R.>110/ min,
R/R >24/min
Management in first stage of labor
• Diuretics in pulmonary congestion
• Nebulisation in bronchospasm
• Prevention of infective endocarditis
• Cardiac monitoring and pulse oximetry
±pulmonary artery catheterisation-
continuous haemodynamic monitoring
• Evaluation by Anaesthetist and
cardiologist
 SABE Prophylaxis

Prophylaxis
Not recommended for all Ampicillin-2G IV/IM +
• At risk for infection Gentamicin 1.5mg/kg (max120)
•Severe lesions
6 hours later- Ampicillin-1G I.V./IM
or 1G P.O.

If Allergic to Penicillin -
Vancomycin-1G I.V.
or Clindamycin – 600mg IV
+ Gentamicin-1.5mg/kg
Management of second stage of labor
• Delivery in propped up position
• Avoid forceful bearing down
• Adequate pain relief-epidural/pudendal block
avoid spinal/Saddle block
• Cut short second stage of labor- episiotomy,
vacuum, forceps – not always must
• Strict Cardiovascular monitoring
 Third stage of labor-
• AMTSL-10 U oxytocin IMI
• Avoid bolus syntocinon/Ergometrine
• Propped Up, oxygen inhalation
• Furosemide I.V. 40 mg
• Pethidine/morphine (15mg)
• Watch for signs of CHF & Pul. Edema
• Treat PPH energetically
First Hour After Delivery
• Propped up/sitting position, oxygen
• Watch for signs of pulm edema
• Sedation
• Antibiotics
 Indications for LSCS-
• Mainly obstetrical
• Coarctation of aorta
• Marfan syndrome with dilated root of aorta
– Prefer epidural anaesthesia
– Narcotic conduction analgesia/GA in Pulmonary
hypertension and pts having intracardiac shunts
• Advice at time of discharge:
• Continue medical treatment
• Avoid infection
• Reassesment after 6 weeks or earlier if some
complication occurs
• Iron supplementation
• Cardiological consultation for definitive
management of heart disease
• Breast feeding
• Contraceptive advice at time of
discharge:
• Contraception- Barrier,
• Progesterone – good option- DMPA, Norplant
• IUCD-Less preferred
• COC - contraindicated
• Sterilization- vasectomy-best
• Tubal ligation-Interval, puerperial can be done
 Management of Cardiac Failure
• Propped up
• O2
• Cont cardiac monitoring
• Diuretic Furosemide 40-80 mgIV
• Inj Morphine 15 mg IM
• Digoxin 0.5mg IM then Tab Digoxin mg