3) 5% due to other causes like disorder of rhythm, cardiomyopathy, thyrotoxicosis, aneamia.
Cardiac disease is a major cause of maternal mortality due to heart failure & increase incidence of venous thrombosis & pulmonary embolism.
Unless heart failure develop cardiac disease does not alter the perinatal mortality but there is high incidence of IUGR & preterm labour.
Assessment of cardiac function in pregnancy
The physiological change associated with pregnancy give rise to symptoms & sign which may cause confusion in the assessment of cardiac disorder such as dyspnoea, tachycardia ,ankle oedema ,soft ejection murmur.
The heart of every pregnant women should be auscultated at the first antenatal visit .
Any suspicious sign like grade 3 systolic murmur any diastolic murmur marked disturbance of rate & rhythm require further investigation preferably by cardiologist ,ECG, echocardiography .
The functional capacity or the functional reserve of the heart should be assessed because it is usually more important than the anatomical nature of the lesion.
New york heart disease association proposed four grades.
7)cardic surgery:- with close surgery (mitral valvotomy) there is little increase risk for the fetus but open surgery involving cardio pulmonary by pass result in increase incidence of fetal loss.
Indication of surgery is recurrent pulmonary oedema in association with predominant mitral stenosis occuring early in pregnancy and with failure to respond to medical treatment .
-mitral stenosis ---mitral valvotomy.
-ligation of patent ductus arteriosus.
-closure of atrial & ventricular septal defects are difficult during pregnancy. Best result of surgery is obtained between 16 & 20 th week of pregnancy.
8) therapeutic abortion:-
With increase sophistication of cardiac surgery the need for therapeutic abortion has been reduced . It should be reserved for those women in the first 20 th week of pregnancy who remain in grade 3&4 despite medical treatment & who are assessed as unsuitable for surgery.
Termination is also may be indicated for patient with cynotic heart disease ,primary or secondary pulmonary hypertension , or eisemmengers syndrome
Management of labour
-vaginal delivery is preferable to caesarian section except in cases of coarctation of the aorta . However if there is obstetric indication for caesarian section it is not contraindicated .
-there is no place for trial of labour.
-labour is managed like in healthy women.
-oxygen should be available .
-adequate sedation and analgesia are important by pethidine but epidural is the best method of pain relief .
-assisted delivery by forceps or ventouse is indicated unless the second stage of labour is very rapid.
-third stage it is usual to give only syntocinon as ergometrine is contraindicated as it may precipitate heart failure.
-antibiotic prophylaxis is commonly given to guard against the risk of bacterial endocarditis
Management of the puerperium
- the high risk of acute cardiac failure persist for 24 hours after delivery & careful observation during this period is essential .
-breast feeding is not contraindicated.
-although adequate rest essential early ambulation is desirable to minimize the risk of thrombo embolic disorders.
The use of anticoagulant is contraversial.
-if the patient wants more children she can safely become pregnant provided that she is grade 1or2 & her heart is well compensated . Grade 3&4 should be discouraged from being pregnant until cardiac surgery has been performed.
If the patient desire no further children contraception can be used oral pills & condom are preferable to IUCD.
Tubal ligation is best deferred until the patient has overcome the burden of pregnancy & puerperium
Cardiomyopathy of pregnancy
1) hypertrophic obstructive cardiomyopathy characterized by hypertrophy & disorganization of cardiac muscle particularly the left ventricle and septum.
-cause is unknown .
-the patient present with chest pain ,syncope ,arrhythmia ,or the symptoms of heart failure. treatment is by B-blockers
-occurs in the last quarter of pregnancy & puerperium .
-the heart is growthly dilated .
Usually in multiparous – black-relatively elderly women of low social class.
-pulmonary ,peripheral ,and cerebral embolism is a major cause of morbidity & mortality.
-the condition recur.
-cause unknown. It is considered to be a form of congestive cardiomyopathy .
-treatment is with anti failure drugs & anticoagulant until the heart size return to normal.
-assuming that the patient recover from the initial episode the long term prognosis is good.