cardiac disease in pregnancy and management

1. CARDIAC DISEASE
IN PREGNANCY

2. OVERVIEW
• Introduction
• Physiological changes in CVS
• Evaluation of cardiac disease
• Pre-conceptional care
• Management during pregnancy
• Complications
• Specific cardiac lesions and their management

3. INTRODUCTION
• Cardiac diseases complicates 0.5 - 1 % of all pregnancies.
• Incidence 0.5-4%. Rule 9:1 to 3:1 In india
• 85%- 90%: Rheumatic in origin .3-10%: Congenital lesions
• mitral(85%) , aortic (10%) both 5%

4. Cardiac
diseases
Acquired
Rheumatic
others
Congenital
cyanotic
acyanotic
• cardiomyopathies
• Ischemic heart disease
• Hypertensive heart
dieases
• Others: Syphilis,
myocarditis

5. Cardiovascular changes
in pregnancy

6. • Heart is displaced upwards and
outwards with slight rotation to
left due to elevation of
diaphragm.
• Apex beat shifted to 4th
intercostal space , just beyond
midclavicular line.-2.5 cm

7. • 3rd heart sound in upto 90%- rapid diastolic filling
• A systolic murmur may be audible in apical or pulmonary area.
• A continuous hissing murmur may be heard over tricuspid area in left 2nd and 3rd
intercostal spaces called the “Mammary souffle”.
• Exaggerated splitting of 1st heart sound with increased loudness of both
components.

8. • Presence of extrasystoles
• Doppler shows increased left ventricular end diastolic
diameters
• Ecg shows left axis deviation

9. SYMPTOMS:NORMALVS
DEFINITE HEART DISEASE
• DYSPNOEA
• FATIGUE
• EDEMA
• CHEST PAIN
• PALPITATION
• SIGNS
• NECKVEIN PULSATION
• SYSTOLIC GR<3
• DISPLACEDAPEX BEAT
• S3
• SINUSTACHYCARDIA
• SEVERE DYSPNOEA- ORTHOPNEA,
PND
• NOCTURNALCOUGH
• HEMOPTYSIS
• SEVERE CHEST PAIN
• SYNCOPE
• SIGNS
• NECKVEIN DISTENSION
• SYSTOLIC MURMER>GR3
• DIASTOLIC MURMER
• CARDIOMEGALY
• LOUD P2,WIDE SPLIT
• S4
• PERSISTANT, ARRYTHMIA,
CYANOSIS,CLUBBING

10. 10
Cardiovascular Physiology of Pregnancy
A) BLOOD VOLUME
• 40 – 50% increase
(Blood volume increases, starting at the sixth week and rising rapidly until mid
pregnancy; the levels peak by 20 to 24 weeks of pregnancy and then are
either sustained until term or decrease. )
Mechanism: estrogen-mediated stimulation of the
renin-angiotensin system results in sodium and water
retention
10

11. Periods of danger remarks
5-8weeks Hemodynamic changes begin
28-32 weeks Hemodynamic changes peak
During labor Every contraction- 300-500ml
of blood is pushed, increase in
CO by 15-20%
During delivery Maternal bearing down
decreases CO
Immediately after delivery Abrupt increase in blood
volume
4-5 days after delivery Primary pulm Htn, CCHD,
eisenmenger’s, AS- sudden
death

12. 12
B) BLOOD PRESSURE
• Remains almost to pre-pregnant levels except a tendency to
fall during pregnancy (particularly during mid-trimester) as
the systemic vascular/peripheral resistance falls
Mechanism: large arteriovenous shunts at placental bed
and physiologic vasodilation secondary to endothelial
prostacyclin and circulating progesterone
12

13. • Blood pressure : falls throughout the 1st two trimesters reaching
a nadir between 24 and 26 wks and reaches to non pregnant level
at term.
Systolic drops by 5 – 10 mm Hg
Diastolic by 10 – 15 mm Hg
• Mean arterial pressure, Pulmonary capillary wedge pressure and
CVP did not change.
• Ventricular function during pregnancy remains normal and
eudynamic inspite of increase in CO.

14. 14
Colloid oncotic pressure
• After delivery, decrease in plasma colloid oncotic
pressure takes place reaching a peak between 6 to 16
hours and returns towards intrapartum level after 24
hours.
• These changes can lead to dependant oedema
complicating diagnosis of cardiac decompensation.
14

17. Non pregnant Pregnancy near
term
Change
Cardiac output
(lit/min)
4.5 6.26 + 40%
Stroke volume (ml) 65 75 + 27%
Heart rate(per
min)
70 85 +17%
Serum colloid
osmotic
pressure(mm Hg)
20 18 - 14%
Systemic vascular
resistance(dyne/se
c/cm-5)
1530 1210 -21%
Pulm vascular
resistance(dyne/se
c/cm-5)
119 78 -34%
Femoral venous
pressure(cm
water)
8-10 20 +100%

18. 5

19. C O changes during labour
• I stage: 50% increase
• II stage: 60% increase
• Immediately after delivery: 75%

20. Hemodynamic Changes
Postpartum
Parameter Change Comment
Blood Volume Decrease Blood loss
CO Increase 60-80% immediate increase
followed by rapid decrease, returns
to normal levels in few weeks
SV Increase 300-600ML
HR Decrease
BP Unchanged
SVR Increase Loss of low resistance placenta

21. RULE OF FIVE
• 5 min- pul edema, active rheumatic carditis
• 5 hrs- cardiac failure
• 5 days – SBE
• 5 weeks – thromboembolic phenomena
• 5 months – peripartum cardiomyopathy

22. Approach
• Step1 : signs and symptoms of cardiac disease
• Step 2: NYHA grading
• Step 3:investigation and referral
• Step4 : CLARKS grading
• Step 5: cardiac status

23. 23
Pre-conceptional counselling
• risk of maternal death
• Prolonged hospital stay
• Risk of congenital heart disease
• Risk of IUGR and prematurity
23

24. Maternal Heart disease Risk of CHD in fetus
Marfan syndrome 50%
Aortic Stenosis 15-18%
Pulmonary Stenosis 6-7%
VSD 10-16%
ASD 5—11%
PDA 4%
Coarctation of aorta 14%
Fallot’sTetrology 2-3%

25. 25
25
Maternal mortality risk and cardiac disease
Group Cardiac disease Associated mortality risk
I Mitral /aortic stenosis, NYHA Class I, II
Atrial septal defect* <1%
Aortic/Mitral regurgitation
Pulmonary/tricuspid valve disease
Corrected tetralogy of Fallot
Bioprosthetic valve
Small –moderate VSD/PDA
II Uncorrected tetralogy of Fallot 5% - 15%
Marfan’s syndrome with normal aorta
Mechanical prosthetic valve
Severe Mitral stenosis with AF or NYHA Class III, IV
Severe Aortic stenosis
Previous myocardial infarction
III Pulmonary hypertension—primary or secondary 25% - 50%
Coarctation of aorta with valvular involvement
Marfan’s syndrome with aortic involvement
Peripartum cardiomyopathy

26. PREDICTORS OF CARDIAC EVENTS DURING
PREGNANCY
(Sui and Coleman 2004)
N : NYHA grade 3,4 or cyanosis
O : Obstructive lesion of left heart
MV area < 2 cm sq
Aortic valve area< 1.5 cm sq
pressure gradient > 30 mm of Hg
P : Prior cardiac event
CHF/ arrythmia/TIA/stroke
E : EF< 40%
Estimated risk of adverse cardiac event
0 ------- 5%
1 ------- 25%
>1 ------- 75%

27. 1-2 visits
Every trimester
2-4 weeks

28. 28
Symptoms Degree of compromise
I No limitation of physical activity Uncompromised
II Ordinary physical
activity caues discomfort
Slightly
compromised
III Less than Ordinary physical Activity causes
symptoms
Markedly compromised
IV Unable to perform Any work
without Discomfort, dyspnoea At rest
Severely
compromised
NYHA classification

29. 29
Termination of pregnancy
ABSOLUTE:
• primary Eisenmenger’s syndrome
• Primary pulmonary hypertension
• Cor pulmonale
• Single ventricle
• Maternal mortality- 30-50%
RELATIVE:
• Parous woman with NYHA III/IV
• Previous history of CHF
• Severe aortic stenosis
• Cyanotic congenital heart disease
T1-Surgical evacuation
T2-Mifepristone & misoprostol can be used.

30. Admission criteria
• Class I & II: at least two weeks prior to expected date of delivery
• Grade III and IV: as soon as pregnancy is diagnosed.The patient
should be kept in hospital throughout pregnancy
Irrespective of the grade, any complication supervenes, patient to be
admitted immediately

31. 32
MODE OF DELIVERY
• Normal vaginal delivery is advised in
patients who are hemodynamically stable
class IC (ESC guidelines)
• Cesarean section is indicated in:
• Aortic dissection.
• Marfan syndrome with dilated aortic root.
• Hemodynamically Instability in particular
case of severe AS.
• Obstetric causes .
• Induction of labour is avoided unless
absolutely necessary
32

32. 33
MODE OF DELIVERY
Ist Stage
• Intensive Hemodynamic monitoring is recommended in
case of severe stenotic lesions or low EF.
• Left Lateral position is preferred to attenuate the
hemodynamic effect of the supine position, but propped
semirecumbent position is best
• Monitor pulse, BP, Oxygen saturation & chest
Examination every 30 mints
• Oxygen inhalation
• CVP monitoring is advisable
33

33. 34
• Careful attention to volume status is essential
• Nutrition mantained by oral fluids
• NS < 75 ml/hr 30ml/hr
• Inj. Frusemide , Digoxin
• Asses pulmonary basal crepts, JVP
• Treatment of arrhythmias
• Epidural analgesia – epidural narcotics (fentanyl) better than
xylocaine and bupivacaine to decrease risk of
hypotension>12 hrs after prophylactic and >24 hrs after
therapeutic
• Epidural avoided in cyanotic heart disease, severe aortic
stenosis
• Antiobiotic prophylaxis-ACOG
• Should not be more than 8hrs
Ist Stage

34. Indications for valvotomy
• 20-24 wks
• Critical mitral stenosis
• Progressive pulmonary hypertension
• Profuse and uncontrollable hemoptysis
• Pulmonary edema
• h/o CCF in prior pregnancy
• Failure to respond to medical treatment

35. 36
• Pulse , respiration are measured every 10 mnts
• Left Lateral position is preferred to attenuate the
hemodynamic effect of the supine position .
• Obstetric procedures (ventouse / forceps) to cut
short the 2nd stage of labour will decrease the
hemodynamic consequences.vaccum better- less
disturbing, put without putting legs in lithotomy
• Slight Blood loss is benificial, inj Frusemide
36
IInd Stage

36. 37
IIIrd Stage
• Active management of third Stage is not done
• If there is PPH 20 units synto IV drip or Prostaglandin IM is
given
• DOC: miso 600 microgram per rectal
• Ergometrin is better avoided
37

37. 38
Class I And II During Pregnancy
• Bed rest: At least 12 hours each night and 2 hours during theday.
• Light house work and walking is permitted but no heavy work.
• Avoid salt rich foods.
• Avoid contact with persons who have respiratory infections including common colds
and flu condition.
• Observe for signs and symptoms of deteriorating heart condition, if deterioration:
Induce abortion< 12 weeks.
• Active treatment of anemia, hemoglobin should be kept at or above 12 g/dl throughout
pregnancy.
• Patient weighed at every visit.
• All patients to be reassessed for cardiac status with cardiologist between 28-32wks.
• Fetal assessment: screening for malformations in 1st & 2nd trimester(fetal ECHO) and
NST, BPP beginning 28wks.

38. INDICATION FOR CESAREAN
• Marfan syndrome with dialatation > 4.5 cm
• Patients on oral anticoagulant in preterm labor
• Acute or chronic aortic dissection
• Acute intractable heart failure
• Severe aortic stenosis
• Severe form of pulmonary hypertension
• Urgent delivery in a patient on therapeutic oral
anticoagulants to reduce the risk of ICH in fully
anticoagulated fetus

39. PRETERM
• Atosiban -1 st line
• Donot use ritodrine or salbutamol
• Breast feeding CI in class 4 and most cases of class 3

40. Contraception
• Post natal 3 monthly injections of depot MPA
150mg.
• Progestin only pills can be used in all cardiac
patients.
• Low dose OCP can be considered in stable
patients six months after delivery.
• IUCD preferably LNG IUD is acceptable.

41. Sterilisation
• Vasectomy preferred.
• Tubectomy can be done postpartum.
• LS is not advised asgeneral anaesthesia has to be given
with risk of CO2 insufflation causing embolism. Minilap is
preferred

42. Complications of heart disease
a) Congestive cardiac failure
b) Arrhythmias
c) Infective Endocarditis
d) Thromboembolism
e) Pregnancy with prosthetic valves

43. a) Acute CHF during pregnancy
Precipitating events:
• Anemia
• Infection
• Arrhythmias
• Excessive physical activity
• Pre-eclampsia
• Tachyarrythmias
• Thyrotoxicosis
• IE

44. Management of CHF
ANC
• Weight gain not exceed 0.6 kg in any one week
• Earliest signs-JVP, liver, pedal edema
• Prophylactic: diuretics(chorthazide), digitalization(MS with
enlarged LA,paroxysmal AF), anticoagulation(CHD,mechanical
valve,chr or recurrent arrhythmia
• Penidure prophylaxis
• Reducing cardiac work with bed rest
• Decreasing pre-load with diuretics
• Improving cardiac contractility with digitalis/
dopamine/dobutamine
• Reducing afterload with vasodilators

45. • Rule out correctable precipitating events
• Bed rest
• Propped up position
• Oxygen inhalation
• Morphine 5mg iv repeat 5-10 min max 15mg
• Intake output charting
• Salt restricted diet
Diuretics :
• Main- stay of therapy.
• Furosemide 40-80mg i.v. immediately and maintained
6-8 hourly.

46. Digitalis :
• Atrial fibrillation, LV/RV systolic dysfunction
• Digoxin is preferred- rapid, short half life. Diltiazem and
beta blockers- heart block,hypotension, bradycardia, fetal
effects
• Loading dose- 0.25 mg IV every 2 hrs upto 1.5 mg
• Maintenance- 0.125mg-0.25mg daily
• Therapeutic level- 1-1.5ng/ml
• Therapy adjusted according to clinical response, serum
levels and ECG changes.
• SE: nausea, vomiting, pulses bigemeni, arrythmias
Vasodilator therapy :
• Hydralazine
• Nitroglycerine

47. b) Arrhythmias
• Both new & pre existing arrhythmias are common.
• Bradyarrhythmias including complete heart block are compatible
with successful pregnancy outcome. Occasionally for syncope
during labour & delivery temporary cardiac pacing is necessary.
• Women with permanent artificial pacemakers tolerate pregnancy
well.
• PSVT : adenosine, CCB, beta blocking agents.
• Electrical cardioversion is not contraindicated in pregnancy.
• Atrial flutter or fibrillation : heparin recommended by some if it is
chronic & persists during pregnancy.

48. 49
Pregnancy can Precipitate or Exacerbate arrhythmia and
the risk is increased during labour
• Acute atrial flutter or atrial fibrillation, should be
treated promptly.
• If possible, all antiarrhythmic drugs should
be avoided during the first trimester, and those
known to be teratogenic should be avoided
throughout pregnancy.
• Because of their safety profiles, preferred drugs include
digoxin, beta-blockers and adenosine.
• Electrocardiovertion is ussualy safe during pregnancy and
can be used when indicated.
49
Arrhythmia

49. 50
50
Symptoms include dizziness, syncope, chest
discomfort, dyspnea and palpitations.
Unilateral carotid sinus massage for 10 seconds.
The patient should lie supine with IV fluids
running and by ECG, if there is no response, try
massaging the opposite side (not simultaneously).
The patient may attempt a valsalva's maneuver
during the carotid sinus massage. If this fails, the
case is managed as with atrial fibrillation.
Paroxysmal Supra Ventricular Tachycardia
(PSVT)

50. 51
51
If the patient of AF is hemodynamically stable
cardiac conversion is usually achieved by
verapamil (e.g. Isopten) administered
intravenously.
If hemodynamically compromised or
pharmacological conversion is not achieved
direct current (DC) cardioconversion can be
resorted to.
Beta-blockers can be of help when the above
measures are ineffective.
Anticoagulation is necessary if history of
TED.
Atrial Fibrillation: Treatment

51. 52
52
Pulmonary edema is common with MS and
most likely to develop immediately postpartum
Propping up the patient to semi sitting position
Oxygen by a face mask or nasal prong
Furosemide (Lasix) IV 10 to 40 mg
Morphine 5 mg IV slowly. If hypotension does
not occur, 10 mg can be given 15 minutes later.
Treatment of Pulmonary Edema

52. c) Infective endocarditis
• Uncommon during pregnancy.
• Subacute endocarditis due to low virulence : viridans group
streptococci or Enterococcus species.
• Acute form : coagulase positive staphylococci
• Fever, anorexia, fatigue, flulike symptoms, onset of new
murmur.
• Diagnosis : blood culture, Echocardiography.
• Treatment with parenteral antibiotics according to sensitivity
reports for 4-6 wks.
• Mortality rate of 25-35%

53. Infective Endocarditis prophylaxis
Indications
High risk lesions :
• Prosthetic cardiac valves
• Previous bacterial endocarditis
• Complex congenital heart
disease
• Surgically consructed systemic
pulmonary shunt conduits
• Repaired CHD with residual
defects
Moderate risk lesions :
•RHD with valvular
dysfunction
•Hypertrophic
Cardiomyopathy
•Mitral valve prolapse with
valvular regurgitation

54. AHA Regimens(2007)
1. HIGH RISK
• Ampicillin 2 g IV/ IM and gentamicin 1.5mg/kg IV within
30 min before delivery followed by ampicillin 1g IV/IM or
orally 6 hrs later
• If allergic to penicillin: Vancomycin 1g IV over 1-2 hrs
along with Gentamicin 1.5 mg/kg iv/im

55. 2. MODERATE RISK:
• Amoxicillin 2gm orally 1 hr before procedure or ampicillin 2
gm iv/im within 30 min of delivery.
• If allergic to ampicillin/ amoxicillin : Vancomycin 1 gm iv over
1-2 hrs.
Complete infusion within 30 min of delivery.

57. 58
RHEUMATIC HEART DISEASE
• Acute Rheumatic Fever
• Carditis & CCF may be fatal in pregnancy
• Needs admission and treatment of carditis as
recommended by WHO
• Continue Penicillin prophylaxis against streptococcal
infection, Inj Penidure 2.4 Mega units every 3 weeks.
58

58. Rheumatic Fever
• The high prevalence rheumatic fever and RHDs in developing
countries is due to the prevalence of streptococcal throat
infection in children and crowdedness of the population.
• Rheumatic fever is an inflammatory autoimmune disease, as a
delayed sequela of throat infection with group-A. β hemolytic
streptococci.

59. Rheumatic Fever
• Rheumatic fever is manifested by damage to the collagen fibrils and the
ground substance of connective tissue.
• The disease process is widespread and affects primarily the joints, the
heart, CNS, skin, subcutaneous tissue and renal glomeruli.
• Active antibiotic treatment of throat infections, & tonsillitis will
diminish the incidence of acute rheumatic fever.

60. Diagnosis of Acute Rheumatic Fever
The Major Criteria:
Migratory polyartheritis
Carditis (with mitral or aortic valve
dysfunction)
Chorea (restlessness, anxiety, and
involuntary choreiform movements)
Subcutaneous nodules
Erythema marginatum.
The Minor Criteria :
 Fever
 Arthralgias
 Heart block
 Preexisting rheumatic fever or
rheumatic heart disease
 Presence of acute phase
reactants in the serum
(elevated ASO).
The diagnosis: 2 major criteria or
one major and 2 minor criteria

61. Acute Rheumatic Fever (ARF)
• ARF may be especially severe during pregnancy.
• Pregnancy tends to reactivate chorea (chorea gravidarum) and
predisposes to its recurrence in subsequent pregnancy which can be
fatal.
• The long-term prognosis is excellent if there is no acute carditis.
• Acute carditis: The sequela is Valvular infiltrations that is
progressively replaced by fibrosis mainly MS & AR with liability of
recurrences of ARF and additional cardiac damage.

62. Acute Rheumatic Fever (ARF)
•
Treatment
• Bed rest
• Salicylates
• Glucocorticoids
• Penicillin therapy for any residual streptococcal infection.
• Prophlaxis: Deep IM injection of 1.2 million units of long
acting (benzathine) penicillin / 4 weeks or erythromycin 250
mg orally twice daily.

63. Rheumatic Heart Disease in Pregnancy
• Mitral stenosis 90%
• Mitral regurgitation 6.6%
• (Most often in conjunction with MS)
• Aortic regurgitation 2.5%
• Aortic stenosis 1%

64. Surgical Management of RHD
This is better done before pregnancy.
The main indications in pregnancy are:
1) Pulmonary edema not responsive to medical management
2) A reliable history of previous pulmonary edema while under good
medical management
3) profuse and uncontrollable hemoptysis
or
4) progressive pulmonary hypertension.

65. Surgical Management of RHD
• When commissurotomy is the procedure of choice?
• Mitral valve is not calcified & no incompetence
• Symptomatic young women who are considering pregnancy.
• Patients usually benefit for 5 to 20 years after commissurotomy.
• If the symptoms recur later mitral valve replacement will be
needed

66. Surgical Management of RHD
• Mitral valve replacement
• Operative mortality of 6%.
• A porcine or human allograft (7-10 year duration) does not require
chronic anticoagulant therapy and is recommended for women who
desire to have other pregnancies.
• A mechanical valve (life) is recommended for those not desiring
children as it requires continuous anticoagulant therapy.

67. d)Thromboembolism
Anticoagulation required in
• Chronic atrial fibrillation
• Paroxysmal atrial fibrillation
• Post partum Cardiomyopathy
• Mechanical prosthetic heart valves

68. American college of chest physicians guidelines for
Anti-coagulation
For pregnant women with mechanical heart valves :
• Adjusted dose of LMWH twice daily throughout pregnancy
• Adjusted dose of UFH administered every 12 hours throughout
pregnancy. Dose to be adjusted to keep aPTT atleast twice the
control or anti-Xa heparin level of 0.35 to 0.70 U/ml
• LMWH or UFH as above until 12 weeks with warfarin substitution
until close to delivery when LMWH/ UFH is resumed.

69. • Warfarin stopped at around 36wks and heparin restarted .
• Heparin is discontinued before (4-6 hrs)delivery
• If delivery supervenes when anti-coagulation is still effective,
protamine sulphate IV is given- 1 mg of drug neutralizes 100
units of heparin
• Anticoagulant therapy can be resumed 6 hours after vaginal
delivery
• Wait for atleast 12 hours, after cesarean delivery
• Warfarin and heparin safe for breast feeding women.

70. • Warfarin crosses placenta and causes warfarin embryopathy –
nasal hypoplasia and chondrodysplasia punctatum.
• Risk of embryopathies in first trimester- 6-10%
• Risk of embryopathy is higher in women who are on dosage
>5mg/day
• Exposure in 2nd trimester- CNS defects
• Exposure in 3rd trimester- fetal, placental and neonatal
heammorhage

71. • UFH and LMWH do not cross placenta- no fetal anamolies
• In women requiring high doses of OACs, patient may be
switched over to UFH or LMWH from 6-12 weeks
• UFH should be initiated in high doses- 17,000-20,000U every
12hrly s.c.or i.v
or
• 5000 IU i.v bolus f/b 1000 IU per hr
• LMWH 1MG/KG twice daily sc

72. 73
ProstheticValve
Those having Bio prosthetic Valve( Procaine Tissue
Valve) do not require Anti coagulation so Pregnency
is safer but degeneration during pregnancy can lead
to heart failure
Those with mechanical Prosthetics require life long
anti coagulation
Because of high maternal and perinatal morbidity
and mortality pregnancy is under taken only after full
councelling
73

73. 74
WarfarinTherapy
• Warfarin freely crosses the Placental barrier harm the
foetus
• Warfarin in the first trimester of pregnancy is
associated with increase -
• Foetal wastage
• Prematurity
• Low birth weight
• Risk of valve thrombosis (3.9%)
• Warfarin Embryopathy (Abnormalities of foetal born
& cartilage formation) in 6.4% of live births.
74

74. 75
Fetal intracranial bleeding: 4 - 10% throughout
pregnancy, during vaginal delivery
Study of 55 pregnancies – Warfarin < 5 mg
No cases of embryopathy
75

75. 76
ESC Guidelines
76
• Warfarin is the favored anticoagulant
during the 2nd, 3rd trimesters until the 36th
wk
• (Class IC ESC guidelines).
• Warfarin is favored in the 1st trimester if the
dose <5mg /24hrs(Class IIaC ECS
guidelines)

76. 77
ANTICOAGULATION
• Adjusted dose UFH bid subcutaneous throughout pregnancy to
achieve mid-interval aPTT at least twice control
• Adjusted dose LMWH bid subcutaneous 1mg/kg throughout
pregnancy to achieve a peak anti-Xa level of 0.7-1.2 U/ml 4 hours
after injection
• UFH or LMWH (as above) until 12 weeks' gestation, change to
warfarin until the middle of the third trimester, and then restart UFH
or LMWH
77

77. 78
ANTICOAGULATION
• Current practical guidelines
• Warfarin during entire pregnancy but substitute heparin
during peak teratogenic period (6th to 12th week)
• Warfarin upto 36 wks
• Switch over to heparin 2 weeks before labour
78

78. 79
Heparin & LMWH
• Heparin does not cross placenta, no teratogenic effect
• Subcutaneous high dose (16,000 to 24,000 units/ day) to
maintain APTT 1.5 to 2
• Maternal thrombocytopenia, osteoporosis, sterile abscesses,
hematoma, maternal death 6-7%
79

79. 80
Heparin & LMWH
LMWH – 1 mg/kg body wt (Enoxaparin)
Effective, easier to use & safe
Expensive, clinical trials needed
80

80. 81
ANTICOAGULATION
Heparin discontinued at least 12 hrs before induction or
reversed with protamine & resumed 6 - 12 hrs post partum
81

81. 82
ANTICOAGULANT THERAPY IN PREGNANCY
MATERNAL
DEATH
THROMBOE
MBOLISM
EMBRYOPATHY
THERAPY
1.8%
3.9%
6.4-10%
Vit k antagonist
throughout
pregnancy
40%
60%
0%
Low dose UFH
throughout
pregnancy
6.7%
25%
0%
Adjusted dose
UFH throughout
pregnancy
4.2%
9.2%
3.4%
UFH in 1st
trimester then
Vit k antagonist
up to 36wk 82

82. 83
83

83. 84
PREGNANCY AND DRUGS
STENOTIC LESIONS REGURGITATION LESIONS
 Bblocker: metoprolol
,propranolol (class C
),atenolol (class D ).
 C channel antagonist:
verapamil , diltiazem (class
C)
 Digoxin : (class C).
 Diuretic: for patient with pulmonary
congestion.
 Vasodilators: only If BP is high :
 Hydralazine:(class C ).
 Nitrate :(class C ).
 Diuretic:
 Thiazide: ( class B).
 Loop diuretic: (class C ).
 Avoid hypotension &
placental hypoperfusion
ACE inhibitor ,ARBS (class X ).
84

84. 85
Classification System for Fetal Risk Associated
wih medication used during pregnancy
 Cat A: controlled study in women show no risk to
the feouts in Ist trim (no evidence of risk in later
trim) feoutel harm appears remote
 Cat B: Either animal reproduction studies show
no feoutal risk but there are no cotroled studies in
Pregnant women or animal reproduction studies
show an adverse effect that was not confirmes in
contorled studies in Ist trim and no evidence of
risk in later trim
85

85. 86
Cat C: Either studies in nimal for adverrse feoutal
affects and there are no contorled studies in woman
drugs shoulbe given only potentioal benefit justifies
the potential risk to the feouts.
Cat D: ther is a +ve evidence of human feotutal risk
but the benefit fro the use in pregnant woman only
accepatble despite the risk.
Cat X; studies in amimal or humans show foeutal
abnormalities drug is contra indicated who ever
pregnant

86. SPECIFIC CARDIAC LESIONS
Mitral Stenosis :
• Mostly rheumatic origin
• Normal mitral valve surface area 4 cm2
• When < 2.5 cm2 symptoms develop
• Severe stenosis < 1 cm2, aastd with IUGR
Pathophysiology:
oStenotic valve impedes flow from LA to LV -> LA pressure
chronically elevated(LA enlargement)-> Passive Pulm venous htn.
oTachycardia in preg->decreased diastolic LV filling time
Above mechanisms contribute to pulm congestion & edema
• Fixed cardiac output

87. Management
• If RHD, continue penicillin prophylaxis
• Limit physical activity.
• If f/s/o pulmonary congestion:
- Dietary sodium restriction
- Diuretics
- Beta blockers
• If new onset AF develops i.v.Verapamil 5-10 mg or electrocardioversion.
• Anticoagulants , digoxin or Ca channel blockers started if chronic atrial
fibrillation & h/o embolic event.
• Candidates for surgery : those who respond poorly to medical treatment,
recurrent episodes of pulmonary edema.
• Closed mitral valvotomy, ballon mitral valvuloplasty, open heart surgery & valve
replacement.
• During labour: Epidural analgesia ideal, vaginal delivery preferred.
Severe MS- Insertion of pulmonary catheter guides management.

88. Mitral insufficiency
• 6-8% of all women in reproductive age group
Etiology:
• Chronic: RF, MVP, IHD, SLE endocarditis
• Acute: rupture of chordae tendinae, papillary muscle infarction
• Pregnancy well tolerated due to decreased peripheral vascular
resistance.
• Most patients do not require treatment
• If recurrent arrythmias: beta blockers

89. Aortic stenosis
• Most cases due to congenital bicuspid valve, few cases due to RHD.
• Normal aortic orifice 2-3 cm2.
• Severe obstruction is reduction in valve area to 1/4th its normal size.
• Mild to moderate cases tolerate pregnancy well, severe disease is life
threatening.
• It is fixed cardiac output state, so cornerstone of management is bed
rest.
• Epidural anesthesia should be avoided, epidural narcotics can be used.
• In contrast to other patients during labour they are managed on
“wet side” rate of i.v. fluid 125-150ml/hr.

90. Left to Right Shunt
1. Atrial Septal Defect
• May be undiscovered before
pregnancy since symptoms often
absent
• Secundum type accounts for 70%
• Surgical closure of ostium secundum
ASD done before pregnancy
• Pregnancy is well tolerated unless
pulmonary hypertension develops,
which is rare

91. • ComplicatedASD
Advanced age, uncorrected large ASD, chronic
arrhythmia (AF), RV dysfunction, pulmonary
hypertension
• Pregnancy not advised if these sequelae present
• SBE uncommon with ostium secundum and prophylaxis
not warranted
• Rare risk:paradoxical embolism
• Maintain adequate hydration & avoid hypotension.

92. Left to right shunt
2. Ventricular septal defect:
• Dependent upon size, location (muscular
vs. membranous)
• If defect is less than 1.25cm2 Pulm htn
and failure rarely develop
• Usually tolerate pregnancy well with left
to right shunt.
• Unrepaired large defects develop failure
and Pulm Htn, SBE prophylaxis indicated
• Higher the PVR, the greater the risk of
Eisenmenger’s and patient may be best
served by early termination

93. Left to Right Shunt
3. Patent ductus arteriosus :
• Loud continuous systolic diastolic machinery murmur
• Usually corrected in infancy
• SBE prophylaxis required for uncorrected lesions
• Uncomplicated PDA usually well tolerated but the
development of pulmonary hypertension is an indication
for termination
• Hypotension may lead to fatal collapse

94. Cyanotic Congenital Heart Disease
I.Tetralogy of Fallot :
1. Large defect high in the ventricular septum
2. Pulmonary stenosis
3. An overriding aorta
4. Right ventricular hypertrophy
Maternal mortality upto 50%
Fetal loss increased : abortion, preterm delivery, IUGR,IUD.
Successfully repaired cases with no cyanosis do well in pregnancy.

95. II. Transposition of GreatArteries :
• Discordance between the ventricles & great arteries
• Usually corrected in childhood- Mustard operation, an atrial
switch procedure.
• Serial echocardiography during pregnancy to evaluate function
of systemic right ventricle.
• Volume overload avoided during labour.

96. Marfan’s Syndrome
• Incidence 2-3 per 10,000
• Autosomal dominant inheritance, abnormal fibrillin-a constituent of
elastin.
• Mutations in FBN1 gene on chromosome 15q21
• Prenatal diagnosis through linkage analysis or mutation detection.
• Aortic dilatation & dissecting aneurysm are most serious
abnormalities.
• If aortic root >4cm , if in early pregnancy offer MTP. If pregnancy
advanced beta blocker therapy.

97. Coarctation of aorta
• 1/4th of affected patients have bicuspid aortic valve, 10%
have cerebral aneurysms.
• Arm-leg BP gradient > 20mmHg
• Maternal mortality rates 2-9.5%
• Complications- CHF, aortic rupture,IE
• Beta blockers for hypertension
• Caesarean section

98. Eisenmenger’s Syndrome
• Secondary pulmonary hypertension with right to left
shunting causing arterial blood desaturation.
• High maternal mortality of 30-50%
• Fetal wastage 42%
• Advised against pregnancy

99. Ischemic heart disease
• Acute MI during pregnancy extremely rare.
• 1 in 10,000 pregnancies
• Causes : coronary atherosclerosis, coronary thrombosis.
• Maternal mortality 21%, fetal mortality 13%
• Symptoms chest pain, nausea, dyspnea
• Diagnosis : ECG, serum troponin A levels
• Delivery following MI should be delayed for minimum of 2 wks.
• Vaginal delivery preferred.
• CHF, angina, severe arrhythmias may complicate course of future
pregnancy in 50% cases.

100. Peripartum Cardiomyopathy
• Incidence: 1 in 1300- 1 in 15000 live births
• Diagnosis of exclusion.
• Diagnostic criteria:
a) Symptoms of CHF that become apparent in last month of
pregnancy or within 5 months postpartum
b) Absence of identifiable cause of cardiac failure.
c)Absence of heart disease prior to last month of pregnancy
d) LV systolic dysfunction demonstrated by echocardiographic criteria:
-ejection fraction <45% or fractional shortening of <30%.
-LV end diastolic dimension >2.7 cm/m square

101. Risk factors :
• Usually older, multiparous, African descent, chronic hypertension,
pre-eclampsia, Obesity, multifetal gestation
• 25-50% mortality
• Infant mortality 10-30%
Recurrence rate:
• 21% in those whose LV function returns to normal within 6
months of delivery.
• 44% in those who have persistent LV dysfunction

102. Treatment : Similar to any cause of CHF
• Preload reduction (Na and fluid reduction, diuretics, nitrates)
• Afterload reduction (hydralazine, ACE inhibitors )
• Inotropes- digoxin
• Prophylactic anti-coagulation

103. Special precautions in individual lesions

104. CONCLUSION
• Heart disease complicating pregnancy is a high risk situation
and demands special attention throughout pregnancy.
• An expert supervision and management by the obstetrician
along with physician and fullest cooperation by the patient
throughout antenatal , intranatal and postnatal period
acheives optimum maternal and perinatal outcome .

105. References
• Williams obstetrics- 23rd edition
• De Swiet's Medical Disorders in Obstetric Practice-5ht edition
• Normal and problem pregnancy- Steven G Gabbe
• Practical guidelines to high risk pregnancy and delivery- 3rd
edition..Fernando Arias, Shirish daftary
• Practical obtetric problems- Ian donald, 6th edition
• High Risk Pregnancy – James 4th edition
• Review of medical physiology – Ganong 22 edition
• Text book of Obstetrics – D.C.Dutta
• Heart Disease in Pregnancy-Celia Oakley,Carole AWarnes Second
edition

106. THANK
YOU