Obstetrics

2.  About 1% of the pregnancies complicated by
heart diseases
 Leading cause of maternal mortality
 Mortality rate 50% in case of pulmonary
hypertension
 Two main types of heart diseases seen
pregnancy are rheumatic and congenital

3.  Oxygen consumption at rest increase to meet
the needs of the fetus and to support increased
metabolic rate of mother
 Supply of oxygen to tissues is increased by
means of increasing the cardiac output by 40%
 Increase is due to following
increase in pulse rate,partial increase in stroke
volume,fall in peripheral vascular
resistance,increase in contractility

4.  Increase in cardiac output does not increase
blood pressure due to massive fall in
peripheral resistance
 Diastolic blood pressure falls in second
trimester

5.  Increase in cardiac output by 40%
 Increase in stroke volume by 10%
 Increase in heart rate by 10% or 15 bpm
 Increase in blood volume by 40%
 Decrease in peripheral resistance and
diastolic blood pressure
“A diseased heart may not be able to cope
with these haemodynamic changes in
pregnancy”

6. symptoms
 Progressive dyspnoea
 Orthopnea
 Paroxysmal nocturnal
dyspnoea
 Hemoptysis
 Palpitations
 Syncope
 Nocturnal cough
 Chest pain
signs
 Cyanosis
 Clubbing
 Persistent distension of
neckveins
 Thrill,persistent split s2
 Parasternal heave
 A Diastolic murmur
 A grade3 systolic
murmur
 Atrial fibrillation
 Loud p2,cardiomegly

7. Echocardiography :
shows cardiac structure and function.
Does not involve radiation and hence safe
Electrocardiography
Chest Xray :
may show cardiac enlargement,pulmonary
congestion or pleural effusion

8. What are the clinical features
in a normal pregnancy which
can mimic a heart disease???

9.  Collapsing pressure due to wide pulse
pressure
 Increase in HR and ectopic beats
 JVP waves are more prominent
 Heart size increases
 Apex beat is displaced upwards and laterally
due to pressure from the distended abdomen
 S1 may be loud and there can be a third heart
sound

10.  Ejection systolic murmurs may be heard over
the precordium in 90% of women
 Venous hums in the neck and mammary
souffle over the breast
 Peripheral edema is very common
 ECG shows left axis deviation and mild ST
changes

11. Class 1
Uncompromised or no limitation
of physical activity
Slight limitation of physical
activity;dyspnoea on severe exertion
Class
3
Marked limitation of physical
activity;dyspnoea on mild exertion
Class
4
Severity compromised ;dyspnoea
at rest

12.  Myocardial dysfunction(ejection fraction
less than 40% or cardiomyopathy)
 Prior heart failure,arrhythmia or stroke
 Previous arrhythmia needing treatment
 Baseline NYHA class3 or class 4 or cyanosis
 Left sided obstruction
“risk of pulmonary oedema or even death is
substantially increased with even one of
these factors”

13. high risk
 Prosthetic valves
 Prev endocarditis
 Complex cyanotic
heart diseases
 Surgically corrected
shunts
moderate risk
 Most other congenital
cardiac malformations
 Rheumatic valvular
heart diseases
 Hypertrophic
cardiomyopathy
 Mitral valve prolapse
with regurgitation

14.  American heart association recommends
prophylaxis based on risk stratification
 Prophylaxis be given intrapartum to women
at high risk only in presence of suspected
bacteraemia or active infection
 Current recommendations are that
prophylaxis be given 30-60 minutes before
the procedure

15.  Isolated secundum atrial septal defect
 Surgical repair of atrial and ventriular septal
defect and patent ductus arteriosus
 Previous coronary bypass graft surgery
 Mitral valve prolapse without regurgitation
 Previous rheumatic fever without valvular
dysfunction
 Cardiac pacemaker
 Previous kawasaki disease without valvualar
dysfunction

16.  Preconceptional councelling
 Antepartum management
 Intrapartum management
 Puerperium
 contraception

17.  Should be planned pregnancy after complete
evaluation of cardiac status and need for cardiac
surgery before pregnancy
 Most of the congenital lesions and mitral
stenosis should be surgically corrected before
pregnancy
 Women may be adviced to have their family as
early as possible in cases of early diseases like
mild mitral stenosis

18.  Eisenmenger syndrome
 Primary pulmonary hypertension
 Uncorrected severe coarctation
 Murfans with aorta dilated >45mm
 Severe mitral stenosis with complications
 Severe symptomatic aortic stenosis
 Previous peripartum cardiomyopathy with
residual impairment of left ventricular
function

19.  Nature and severity of the disease are
assessed.In the first trimester main two
issues are need for termination of pregnancy
or need for surgery.
 NYHA class 1&2:most women go through
pregnancy uneventfully.adequate rest and
followup.nocturnal cough,persistent basal
crepitations,increasing dyspnoea on exertion
are symptoms of heart failure

20.  Anaemia
 Tachycardia and arrhythmia
 Hyperthyroidism
 Hypertension
 Multiple pregnancy
 Respiratory infections
 stress

21.  NYHA class 3&4 :
these women are at high risk should become
pregnant after surgical correction
If seen in first trimester such patients are
candidates for MTP

22.  Period of maximum risk as pain and
apprehension increases cardiac output
 Vaginal delivery is preferred unless there is an
obstetric indication for caesarean section
1. analgesia:best given epidurallyexcept in
intracardiac shunt
2. Position:semirecumbent position to avoid
supine caval symdrome
3. Fluid management:not more than 75ml/hris to
be given.if iv fluids are given
injudiciously,pulmonary edema can be
precipitated

23. 4) monitoring:
maternal heart rate and bp
continous ECG monitoring to detect arrhythmia
continous fetal heart rate is monitored
5)second stage:shortened with outlet forceps to
avoid strain on heart.
6)third stage:oxytocin should be used to reduce
amt of bleeding.ergometrine and methergin are
contraindicated in women with heart disease

24.  Patient is observed in the labour ward for
atleast 24 hours
 Postpartum haemorrhage,infection and
thromboembolism are serious complications
to be prevented.
 Early ambulation and lactation are
encouraged.fluid balance should be
monitored

25.  Barriers,IUDs,LNG-IUS or Mirena are
preferred
 Combined oestrogen- progesterone pills are
not used in cons=ditions prone for
thrombosis
 If a permanent method of sterilisation is
preferred vasectomy of male partner is better
option.if tubectomy is desired best done as
an interval procedure under general
anaesthesia and not in post partum period