1. Heart Disease &Heart Disease &
PregnancyPregnancy
Pregnancy places an additional strain on thePregnancy places an additional strain on the
heart due to the cardiovascular changes thatheart due to the cardiovascular changes that
occur due to the physiological adaptation tooccur due to the physiological adaptation to
pregnancypregnancy..
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2. There is steady increase in blood volume reaching 40% increaseThere is steady increase in blood volume reaching 40% increase
by 36 weeksby 36 weeks..
Parallel with the increase in volume there is an increase in cardiacParallel with the increase in volume there is an increase in cardiac
out put due to increase of both stroke volume & heart rateout put due to increase of both stroke volume & heart rate
(c.o.p. increases from 3-5L to 6-7.5 L(c.o.p. increases from 3-5L to 6-7.5 L(.(.
Also immediately after delivery there is a transient increase afterAlso immediately after delivery there is a transient increase after
delivery of the placenta & retraction of the uterusdelivery of the placenta & retraction of the uterus..
There is marked reduction in peripheral resistanceThere is marked reduction in peripheral resistance..
Blood pressure fall rather than increase & reaches its lowest levelBlood pressure fall rather than increase & reaches its lowest level
at the end of the second trimesterat the end of the second trimester..
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3. IncidenceIncidence
about 0.5-1%about 0.5-1%
AetiologyAetiology:-:-
11((70%70%of cases are of rheumatic origin usuallyof cases are of rheumatic origin usually
causing mitral stenosis with mitral or aorticcausing mitral stenosis with mitral or aortic
regurgitation being less commonregurgitation being less common..
22((25%25%are due to congenital defects. in someare due to congenital defects. in some
developed countries it reaches 50% of casesdeveloped countries it reaches 50% of cases
(decline in rheumatic fever & increase survival(decline in rheumatic fever & increase survival
due to surgerydue to surgery(.(.
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4. The commonest malformation areThe commonest malformation are:-:-
Patent ductus arteriosus, atrial septal defect,Patent ductus arteriosus, atrial septal defect,
ventricular septal defect, coarctation of theventricular septal defect, coarctation of the
aorta, pulmonary stenosis, fallots tetralogy,aorta, pulmonary stenosis, fallots tetralogy,
aortic stenosis & eisenmengers syndromeaortic stenosis & eisenmengers syndrome..
33((5%5%due to other causes like disorder ofdue to other causes like disorder of
rhythm, cardiomyopathy, thyrotoxicosis,rhythm, cardiomyopathy, thyrotoxicosis,
aneamiaaneamia..
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5. ComplicationsComplications
Cardiac disease is a major cause of maternalCardiac disease is a major cause of maternal
mortality due to heart failure & increasemortality due to heart failure & increase
incidence of venous thrombosis & pulmonaryincidence of venous thrombosis & pulmonary
embolismembolism..
Unless heart failure develop cardiac disease doesUnless heart failure develop cardiac disease does
not alter the perinatal mortality but there is highnot alter the perinatal mortality but there is high
incidence of IUGR & preterm labourincidence of IUGR & preterm labour..
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6. Assessment of cardiac function inAssessment of cardiac function in
pregnancypregnancy
The physiological change associated with pregnancyThe physiological change associated with pregnancy
give rise to symptoms & sign which may causegive rise to symptoms & sign which may cause
confusion in the assessment of cardiac disorder such asconfusion in the assessment of cardiac disorder such as
dyspnoea, tachycardia ,ankle oedema ,soft ejectiondyspnoea, tachycardia ,ankle oedema ,soft ejection
murmurmurmur..
The heart of every pregnant women should beThe heart of every pregnant women should be
auscultated at the first antenatal visitauscultated at the first antenatal visit..
Any suspicious sign like grade 3 systolic murmur anyAny suspicious sign like grade 3 systolic murmur any
diastolic murmur marked disturbance of rate & rhythmdiastolic murmur marked disturbance of rate & rhythm
require further investigation preferably byrequire further investigation preferably by
cardiologist ,ECG, echocardiographycardiologist ,ECG, echocardiography..
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7. The functional capacity or the functional reserve of the heartThe functional capacity or the functional reserve of the heart
should be assessed because it is usually more important than theshould be assessed because it is usually more important than the
anatomical nature of the lesionanatomical nature of the lesion..
New york heart disease association proposed four gradesNew york heart disease association proposed four grades..
Class1:- no limitation of physical activityClass1:- no limitation of physical activity..
Class2:- slight limitation of activity ordinary activity causesClass2:- slight limitation of activity ordinary activity causes
fatigue ,palpitation ,dyspnoea ,& anginal painfatigue ,palpitation ,dyspnoea ,& anginal pain..
Class3:- marked limitation of physical activity symptoms occurClass3:- marked limitation of physical activity symptoms occur
with less than ordinary activitywith less than ordinary activity..
Class4:- inability to carry any physical activity without discomfortClass4:- inability to carry any physical activity without discomfort
( dyspnoea at rest( dyspnoea at rest((
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8. Management.Management.
Antenatal managementAntenatal management
Aim is to prevent heart failure & to detect obstetric complications & to minimize themAim is to prevent heart failure & to detect obstetric complications & to minimize them
where possiblewhere possible..
General managementGeneral management:--:--
11((ideally should be seen at a joint clinic by cardiologist and an obstetricanideally should be seen at a joint clinic by cardiologist and an obstetrican..
22((visit need to be more frequent at least fortnightly in the first half of pregnancy andvisit need to be more frequent at least fortnightly in the first half of pregnancy and
weekly in the second halfweekly in the second half..
33((in each visit she should be asked aboutin each visit she should be asked about..
----any increase in her shortness of breathany increase in her shortness of breath..
----any increase in exercise toleranceany increase in exercise tolerance..
----tachycardiatachycardia..
----any marked increase in tirednessany marked increase in tiredness..
----fetal movementfetal movement..
Examination should always include pulse rate, rhythm, blood pressure jvp lung baseExamination should always include pulse rate, rhythm, blood pressure jvp lung base
,increased sacral or ankle oedema liver ,fundal hieght and fetal growth,increased sacral or ankle oedema liver ,fundal hieght and fetal growth..
A careful watch of pregnancy complications like PIH ,UTI, chest infection, bacterialA careful watch of pregnancy complications like PIH ,UTI, chest infection, bacterial
endocarditis atrial fibrillation and anaemiaendocarditis atrial fibrillation and anaemia
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9. 44((out patient management is used but if there are any signs ofout patient management is used but if there are any signs of
heart failure ,infection ,grade3 &4 disease ,obstetricheart failure ,infection ,grade3 &4 disease ,obstetric
complications indicate admission to hospitalcomplications indicate admission to hospital..
55((adequate rest is essential with at least 9 hours at night & restadequate rest is essential with at least 9 hours at night & rest
in bed in the afternoonin bed in the afternoon..
66((dietary supervision ensuring reasonable protein ,vitamin ,&dietary supervision ensuring reasonable protein ,vitamin ,&
iron intake & because of the additional cardiac strain imposed byiron intake & because of the additional cardiac strain imposed by
anaemia prophylactic iron & folic acid is indicatedanaemia prophylactic iron & folic acid is indicated..
77((infection must be avoided . The onset of any intercurrentinfection must be avoided . The onset of any intercurrent
infection even corysa is an indication of hospital treatment .infection even corysa is an indication of hospital treatment .
Complete dental care & tooth extraction should be underComplete dental care & tooth extraction should be under
antibiotic coverantibiotic cover
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10. Specific managementSpecific management
Similar to that for the non pregnantSimilar to that for the non pregnant..
11((digoxin:- indicated primarily in patient with atrial fibrillationdigoxin:- indicated primarily in patient with atrial fibrillation
& acute heart failure. Prophylactic therapy is sometime& acute heart failure. Prophylactic therapy is sometime
advocated but evidence infavour of this is not strongadvocated but evidence infavour of this is not strong..
22((diuretics:- thiazide diuretics can be used in chronic congestivediuretics:- thiazide diuretics can be used in chronic congestive
failure with k supplement .frusemide is required for acute heartfailure with k supplement .frusemide is required for acute heart
failurefailure..
33((beta adrenargic blocker may be required for dysrhythmiabeta adrenargic blocker may be required for dysrhythmia..
44((aminophylline is of considerable value in alleviation ofaminophylline is of considerable value in alleviation of
broncho spasm & pulmonary oedemabroncho spasm & pulmonary oedema
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11. 55((heparin is indicated in patient with prosthetic valve, atrialheparin is indicated in patient with prosthetic valve, atrial
fibrillation & pulmonary hypertensionfibrillation & pulmonary hypertension..
66((in acute pulmonary oedema morphine, oxygen, digoxin, lasix,in acute pulmonary oedema morphine, oxygen, digoxin, lasix,
& aminophylline& aminophylline..
77((cardic surgery:- with close surgery (mitral valvotomy) there iscardic surgery:- with close surgery (mitral valvotomy) there is
little increase risk for the fetus but open surgery involving cardiolittle increase risk for the fetus but open surgery involving cardio
pulmonary by pass result in increase incidence of fetal losspulmonary by pass result in increase incidence of fetal loss..
Indication of surgery is recurrent pulmonary oedema inIndication of surgery is recurrent pulmonary oedema in
association with predominant mitral stenosis occuring early inassociation with predominant mitral stenosis occuring early in
pregnancy and with failure to respond to medical treatmentpregnancy and with failure to respond to medical treatment..
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12. --mitral stenosis ---mitral valvotomymitral stenosis ---mitral valvotomy..
--ligation of patent ductus arteriosusligation of patent ductus arteriosus..
--closure of atrial & ventricular septal defects are difficult during pregnancy.closure of atrial & ventricular septal defects are difficult during pregnancy.
Best result of surgery is obtained between 16 & 20Best result of surgery is obtained between 16 & 20thth
week of pregnancyweek of pregnancy..
88((therapeutic abortiontherapeutic abortion:-:-
With increase sophistication of cardiac surgery the need for therapeuticWith increase sophistication of cardiac surgery the need for therapeutic
abortion has been reduced . It should be reserved for those women in theabortion has been reduced . It should be reserved for those women in the
first 20first 20thth
week of pregnancy who remain in grade 3&4 despite medicalweek of pregnancy who remain in grade 3&4 despite medical
treatment & who are assessed as unsuitable for surgerytreatment & who are assessed as unsuitable for surgery..
Termination is also may be indicated for patient with cynotic heart diseaseTermination is also may be indicated for patient with cynotic heart disease
,primary or secondary pulmonary hypertension , or eisemmengers syndrome,primary or secondary pulmonary hypertension , or eisemmengers syndrome
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13. Management of labourManagement of labour
--vaginal delivery is preferable to caesarian section except in cases ofvaginal delivery is preferable to caesarian section except in cases of
coarctation of the aorta . However if there is obstetric indication for caesariancoarctation of the aorta . However if there is obstetric indication for caesarian
section it is not contraindicatedsection it is not contraindicated..
--there is no place for trial of labourthere is no place for trial of labour..
--labour is managed like in healthy womenlabour is managed like in healthy women..
--oxygen should be availableoxygen should be available..
--adequate sedation and analgesia are important by pethidine but epidural isadequate sedation and analgesia are important by pethidine but epidural is
the best method of pain reliefthe best method of pain relief..
--assisted delivery by forceps or ventouse is indicated unless the second stageassisted delivery by forceps or ventouse is indicated unless the second stage
of labour is very rapidof labour is very rapid..
--third stage it is usual to give only syntocinon as ergometrine isthird stage it is usual to give only syntocinon as ergometrine is
contraindicated as it may precipitate heart failurecontraindicated as it may precipitate heart failure..
--antibiotic prophylaxis is commonly given to guard against the risk ofantibiotic prophylaxis is commonly given to guard against the risk of
bacterial endocarditisbacterial endocarditis
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14. Management of the puerperiumManagement of the puerperium
--the high risk of acute cardiac failure persist forthe high risk of acute cardiac failure persist for
24 hours after delivery & careful observation24 hours after delivery & careful observation
during this period is essentialduring this period is essential..
--breast feeding is not contraindicatedbreast feeding is not contraindicated..
--although adequate rest essential earlyalthough adequate rest essential early
ambulation is desirable to minimize the risk ofambulation is desirable to minimize the risk of
thrombo embolic disordersthrombo embolic disorders..
The use of anticoagulant is contraversialThe use of anticoagulant is contraversial..
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15. Future pregnancyFuture pregnancy
--if the patient wants more children she can safelyif the patient wants more children she can safely
become pregnant provided that she is grade 1or2 & herbecome pregnant provided that she is grade 1or2 & her
heart is well compensated . Grade 3&4 should beheart is well compensated . Grade 3&4 should be
discouraged from being pregnant until cardiac surgerydiscouraged from being pregnant until cardiac surgery
has been performedhas been performed..
If the patient desire no further children contraceptionIf the patient desire no further children contraception
can be used oral pills & condom are preferable tocan be used oral pills & condom are preferable to
IUCDIUCD..
Tubal ligation is best deferred until the patient hasTubal ligation is best deferred until the patient has
overcome the burden of pregnancy & puerperiumovercome the burden of pregnancy & puerperium
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16. Cardiomyopathy of pregnancyCardiomyopathy of pregnancy
11((hypertrophic obstructive cardiomyopathyhypertrophic obstructive cardiomyopathy
characterized by hypertrophy & disorganizationcharacterized by hypertrophy & disorganization
of cardiac muscle particularly the left ventricleof cardiac muscle particularly the left ventricle
and septumand septum..
--cause is unknowncause is unknown..
--the patient present with chest pain ,syncopethe patient present with chest pain ,syncope
,arrhythmia ,or the symptoms of heart failure.,arrhythmia ,or the symptoms of heart failure.
treatment is by B-blockerstreatment is by B-blockers
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17. 22((Pregnancy cardiomyopathyPregnancy cardiomyopathy
--occurs in the last quarter of pregnancy & puerperiumoccurs in the last quarter of pregnancy & puerperium..
--the heart is growthly dilatedthe heart is growthly dilated..
Usually in multiparousUsually in multiparous ––black-relatively elderly women of low social classblack-relatively elderly women of low social class..
--pulmonary ,peripheral ,and cerebral embolism is a major cause of morbiditypulmonary ,peripheral ,and cerebral embolism is a major cause of morbidity
& mortality& mortality..
--the condition recurthe condition recur..
--cause unknown. It is considered to be a form of congestivecause unknown. It is considered to be a form of congestive
cardiomyopathycardiomyopathy..
--treatment is with anti failure drugs & anticoagulant until the heart sizetreatment is with anti failure drugs & anticoagulant until the heart size
return to normalreturn to normal..
--assuming that the patient recover from the initial episode the long termassuming that the patient recover from the initial episode the long term
prognosis is goodprognosis is good..
--
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