Dr. Harris N Suharjono
Content of lecture:
Significance of heart disease in
Antenatal care with cardiac problem
Specific heart problems
General advice for Medical Officers
How significant is heart disease
Accounts for 12% of maternal death in
Commonest cause of indirect maternal
death in Malaysia
In Sarawak there were a total of 9
maternal deaths from heart diseases in
the 3 years period between 2010-2012
•Coronary artery disease is uncommon in pre-
menopausal women of child-bearing age.
•Majority of cardiac conditions encountered during
pregnancy will be either congenital heart disease or
rheumatic valvular heart disease.
•Cardiac complications result from hemodynamic
changes that occur during pregnancy.
CVS adaptation to pregnancy
Cardiac output Increased by 45%
Stroke volume increased
Heart rate Increase by10-20 bpm
Blood pressure Reduced in the 1st
SVR & PVR Reduced 25-30%
Misleading features during
Dyspnoea and tachycardia
Displacement of apex beat
Third heart sound, ejection systolic
Misleading features during
Q-wave and inverted T ,
QRS axis left shift.
Increased pulmonary vascular marking
Counseling plays an important role!!!
Should be referred by cardiologist or
physician to the PPC Clinic, if the patient is
keen to embark on a pregnancy
Estimate the risk during pregnancy
Any optimization needed?
Contraception necessary if advised not to
-Best, low failure rate (LFR)
Barrier method: condom,
High failure rate (HFR).
POP: /Implanon NXT
Avoid in IHD, valvular heart
disease and Pulmonary
IUCD/LNG-IUS (Mirena) LFR, contraindicated in
prosthatic valve, endocarditis.
High Risk Heart Diseases
Women with the following conditions are usually
advised to avoid pregnancy.
Pulmonary hypertension (>60% systemic pressure)
Dilated cardiomyopathy, ejection fraction <40%
Symptomatic obstructive lesions (delay pregnancy
until the obstruction has been corrected)
Coarctation of the aorta
Marfan syndrome with aortic root >40 mm diameter
Consider termination if:
Cyanotic heart disease.
Marfan Syndrome with aortic root more
MS with AF
Precipitating factor of heart failure
Watch out for dangerous periods
Rest/ diet/ smoke
Planning of delivery (mode) always get
Multidisciplinary Team approach maybe
necessary in high risk patients
COMPLIANCE to follow up is important
CVS drugs safety profile in pregnancy:
Diuretics Use judiciously
Calcium antagonist Use judiciously
Mode of Delivery
Hemodynamic changes during labour and
• Hemodynamic changes often abrupt.
• With uterine contraction, up to 500 mL of blood may be released into circulation, causing
rapid increase in cardiac output and blood pressure.
• Cardiac output often 50% above baseline during 2nd
stage of labour and may be even
higher at time of delivery.
• During normal vaginal delivery, about 400 ml of blood is lost.
• With caesarean section, about 800 ml of blood is lost.
• After delivery of baby, abrupt increase in venous return (autotransfusion from uterus &
baby no longer compresses inferior vena cava).
• Autotransfusion of blood continues for up to 24 to 72 hours after delivery, and this is
when pulmonary oedema may occur.
Delivery in specialist hospitals
Fluid management important
Lateral position if symptmatic
Ensure good analgesia
Oxygen maybe necessary
CCU maybe required post delivery
Use syntocinon and avoid syntometrine
Shortened second stage in some cases
IOL and Mode of delivery generally follow
SBE prophylaxis: IV Ampicillin 1 g &
gentamicin 1.5 mg/Kg (max 120mg)
followed by ampicillin 500mg 6 hourly till
If allergic to penicillin: IV vancomycin1g
over 2 hours.
SBE prophylaxis only necessary in some
HIGH RISK period!!!!
Counseling for contraception needs
Encourage to limit number of pregnancy and
Breast feeding not contraindicated.
High Risk E-discharge and home visits
PPC clinic appointment if still keen on future
Family planning clinic appointment
Usually associated with another underlying cause,
such as mitral stenosis, congenital heart disease,
Antithrombotic therapy recommended.
Use heparin in 1st
trimester and last month of
pregnancy. Subcutaneous unfractionated
heparin 10,000 to 20,000 units every 12 hours,
adjusted to achieve APTT 1.5-2.0 times control.
Use oral anticoagulant during 2nd
Control ventricular rate with digoxin, calcium
channel antagonist, or beta blocker.
Valvular heart Disease
Most can be managed with conservative
Symptomatic or severe valvular lesions
should be rectified before conception
and pregnancy whenever possible.
Drugs should be avoided when possible.
Mild to moderate mitral stenosis can be
managed with diuretics and cardio
selective beta blockers.
Severe mitral stenosis should undergo
PTMC before conception, if possible.
PTMC recommended if develop severe
symptoms during pregnancy.
Can usually be managed medically with
If surgery is required, repair is preferred.
Mild stenosis and normal left ventricular
systolic function can be managed
Moderate to severe stenosis or symptomatic,
delay conception until aortic stenosis is
Pregnant women with severe aortic stenosis
who develop symptoms may require either
early delivery or percutaneous balloon
valvotomy or surgery before delivery.
Isolated aortic regurgitation can be
managed with diuretics and vasodilator
Surgery during pregnancy only for control
of refractory symptoms.
Low molecular weight heparin (LMWH)
and Factor Xa inhibitors should not be
used in pregnancy unless Factor Xa
activity can be measured
The anticoagulation therapy for patients
with mechanical valves is of critically
important and should be managed by
If warfarin maintenance dose is ≥5
mg/day, risk of teratogenicity is 8-10%.
Convert warfarin to subcutaneous
unfractionated heparin (UFH) b.d.
Maintain APTT 1.5-2X control.
If warfarin dose is <5 mg/day, risk of
teratogenicity is 2%. Discuss risks with
patient and the options of changing to
UFH or continuing warfarin.
Use warfarin. Maintain INR 2.0-3.0.
At 36 weeks, admit patient and convert
to i.v. UFH. Plan for delivery once INR <1.5.
Stop i.v. UFH 6 hours before delivery and
restart 6 hours after delivery if no
First dose of warfarin can be given Day 1
post-partum. Stop i.v. heparin once INR
It’s important to maintain good
communication between the
Cardiologists/Physicians and the
These patients should be f/up in a
combine clinic setting but shared care
with health clinics is possible depending
on the severity of cases
General Advice for MOs
1. If a pregnant woman is suspected or known to have heart disease, she should be referred
to a physician or cardiologist as soon as she is found to be pregnant. In the referral letter,
request the specialist to state clearly in his/her reply letter:
a. The cardiac diagnosis
b. Whether the pregnancy is allowed to continue or whether termination is
c. The type of antenatal follow up required – polyclinic, district hospital, hospital
with specialist or cardiac centre
2. If unsure, always check the drug formulary (MIMS, MOH “blue book”, internet
resources, etc) to confirm that whatever medication prescribed is safe to use during
3. The best guide to how well a patient with heart disease is tolerating pregnancy is her
functional status. If the patient is asymptomatic and able to do moderate or heavy work
without any difficulty, then most likely she will also tolerate the pregnancy.
4. Physical examination should be geared towards looking for signs of heart failure – basal
lung crackles, raised JVP, peripheral edema.
Multiple repeat echocardiograms usually not necessary as the cardiac lesions are “fixed” and
unlikely to change during the course of the pregnancy
Think: What can you do to
reduce the morbidity and
mortality of pregnant
mothers with heart