2. Incidence of heart disease
• Varies between 0.1 – 4.0 %, average 1%
• Mortality due to heart disease has decreased
• Devpd countries – maternal mortality due to
heart disease has increased
• Pregnancy with heart disease has increased
• Devpd countries – rheumatic is decreasing
• Congenital heart disease with pregnancy is
also increasing
4. Critical periods
• Changes start from as – 6weeks
• Max changes around –30 weeks
• Intra partum period
• Just after delivery
• Second week of puerperium
5. Pregnancy changes mimic cardiac disease
• Symptoms – breathlessness, weakness,
oedema, syncope
• Tachycardia
• Splitting of 1st hear sound
• Murmur – systolic , breast bruit
• Displacement of apex beat – upwards to left
6. Symptoms of heart disease
• Progressive dyspnea or orthopnea
• Nocturnal cough
• Syncope
• Chest pain
• Hemoptysis
7. Clinical findings of heart disease
• Cyanosis
• Clubbing of fingers
• Persistent neck vein distention
• Systolic murmur grade 3/6 or greater
• Diastolic murmur
• Cardiomegaly
• Persistent arrythmia
• Persistent split second sound
• Pulmonary hypertension
9. NYHA (New York Heart Association)
Functional grading of heart disease
• Grade I: No limitation of physical activity-
asymptomatic with normal activity
• Grade II: Mild limitation of physical activity -
Symptoms with normal physical activity
• Grade III: Marked limitation of physical activity -
Symptoms with less than normal activity,
comfortable at rest
• Grade IV: Severe limitation of physical activity-
symptoms at rest
10. Classification of Heart Disease
according to etiology
• Congenital – non cynotic ( ASD, VSD, Pulm
stenosis, coarctation of aorta),
cyanotic (Fallots tetralogy, Eisenmenger’s
syndrome)
• Rheumatic heart disease – MS, MR, AS, AR
• Cardiomyopathy
• Ischaemic heart disease
• Others – conduction defects, syphilitic,
thyrotoxic, hypertensive,
11. Classification of Heart Disease during
pregnancy according to risk
• Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-
1,2, corrected FT
• Medium risk ( 5 – 15 %) – MS-3,4, MS
with atrial fibrillation, AS, uncorrected FT
• High risk ( 25 – 50%) – PH, Eisenmengers
Syndrome, aortic coarctation with
valvular involvement, Marfans with aortic
involvement
12. Poor prognostic indicators
• h/o heart failure, ischaemic attack, stroke
• Arrhythmias,
• Base line NYHA class 3 and 4
• MV area below 2cm sq, AV area below 1.5
• Ejection fraction less than 40%
14. Effect of pregnancy on heart disease
• Worsening of cardiac status
• CCF, bacterial endocarditis, pulmonary
edema, pulmonary embolism, rupture of
aneurism
• No long term effect on basic defect
15. Effect of heart disease on pregnancy
• Abortion
• Preterm labour
• IUGR
• Congenital heart disease in baby – 5%
• Intrauterine fetal demise
16. Management
Requires-
• High index of suspicion
• Timely diagnosis
• Effective management
• Team Approach-
• Obstetrician
• Cardiologist
• Anesthetist
• Neonatologist
• CTV surgeon
• Nursing Staff
17. Preconceptional Counseling
• No pregnancy unless must esp in high risk types
• Maternal mortality varies directly with functional
classification at pregnancy onset
• Optimal Medical/Surgical treatment pre-pregnancy
• Counselling-
– Maternal & Fetal risks
– Prognosis
– Social and cost considerations
– Hospital delivery- Preferable at tertiary care centre
18. Medical termination of pregnancy
• Termination advised in early pregnancy in high risk
group only – ( Primary pulmonary Ht, Eisenmenger
syndrome, Coarctation of aorta, Marfan syndrome
with dilated aortic root)
• Only in 1st trim, better before 8 weeks
• Suction evacuation preferred
• MTP also carries risk for life
19. Antenatal care
• Clear counseling of risk and prognosis
• ANC every 2 weeks upto 30 weeks then weekly
• On each visit-note-pulse rate, BP, cough dyspnea,
weight, anaemia, auscultate lung bases, re-
evaluate functional grade
• Ensure treatment compliance
• Exclude fetal congenital anomaly by level-III USG
and fetal ECHO at 20 weeks in maternal
congenital heart disease
• Fetal monitoring
20. Special Advice
• Rest, Avoid undue excitement/strain
• Diet/ Iron and vitamins
• Hygiene, dental care to prevent any infection
• Dietary salt restriction (4-6g/d)
• Avoid smoking, drugs – betamimetics
• Early diag and tmt of PIH, infections
• Therapeutic/prophylactic cardiac interventions as
applicable-
– Benzathine Penicillin 12 lacs at 3 weeks - to prevent
recurrence of rheumatic fever
– Diuretics, Beta Blockers, Digitalis, Anticoagulants
– Surgical treatment as applicable - balloon mitral valvotomy
21. Indications for admission
Elective admission-
• NYHA 1 – 2 weeks before EDD
• NYHA 2 – 28 to 30 weeks
• NYHA-III/IV- Irrespective of POG as soon as patient
comes
• To Change from oral anticoagulants to heparin-early
pregnancy, 36 weeks in patients on anticoagulant
Emergency admission-
• Deterioration of functional grade
• Symptoms and signs of complications- Fever/
persistent cough/ basal crepts/ tachyarrhythias (P/R
>100 min)/ JVP>2cm/Anaemia/ Infections/
PET/Abnormal weight gain /other medical disorders
22. Labor and Management
• Institutional delivery
• Induction of Labor
– Only for obstetric indications
– Oxytocin preferred- Higher concentration with
restricted fluid
– Intracervical foley instillation esp in congenital heart
disease
– PGE2 Gel may be employed- Vasodilatation - use with
caution
23. Management in first stage of labor
• Confined to bed- propped up or semi
recumbent
• Intermittent oxygen inhalation 5-6 l/min
• Sedation and analgesia- (Epidural,
pethidine, tramadol)
• Cautious use of I.V. fluids (not >75ml/hr
except in aortic stenosis and VSD)
• Stop anticoagulants
• Digitalise if in CHF,P.R.>110/ min,
R/R >24/min
24. Management in first stage of labor
• Diuretics in pulmonary congestion
• Deriphyllin if bronchospasm
• Prevention of infective endocarditis
• Cardiac monitoring and pulse oximetry
±pulmonary artery catheterisation-
continuous haemodynamic monitoring
• Evaluation by Anaesthetist and
cardiologist
25. SABE Prophylaxis
Prophylaxis
Not recommended for all
• At risk for infection
•Severe lesions
Ampicillin-2G IV/IM +
Gentamicin 1.5mg/kg (max120)
6 hours later- Ampicillin-1G I.V./IM
or 1G P.O.
If Allergic to Penicillin -
Vancomycin-1G I.V.
or Clindamycin – 600mg IV
+ Gentamicin-1.5mg/kg
26. Management of second stage of labor
• Delivery in propped up position
• Avoid forceful bearing down
• Adequate pain relief-epidural/pudendal block
avoid spinal/Saddle block
• Cut short second stage of labor- episiotomy,
vacuum, forceps – not always must
• Strict Cardiovascular monitoring
27. Third stage of labor-
• AMTSL-10 U oxytocin IMI
• Avoid bolus syntocinon/Ergometrine
• Propped Up, oxygen inhalation
• Furosemide I.V. 40 mg
• Pethidine/morphine (15mg)
• Watch for signs of CHF & Pul. Edema
• Treat PPH energetically
28. First Hour After Delivery
• Propped up/sitting position, oxygen
• Watch for signs of pulm edema
• Sedation
• Antibiotics
29. Indications for LSCS-
• Mainly obstetrical
• Coarctation of aorta
• Marfan syndrome with dilated root of aorta
– Prefer epidural anaesthesia
– Narcotic conduction analgesia/GA in Pulmonary
hypertension and pts having intracardiac shunts
30. • Advice at time of discharge:
• Continue medical treatment
• Avoid infection
• Reassesment after 6 weeks or earlier if some
complication occurs
• Iron supplementation
• Cardiological consultation for definitive
management of heart disease
31. • Contraceptive advice at time of
discharge:
• Contraception- Barrier,
• Progesterone – good option- DMPA, Norplant
• IUCD-Less preferred
• COC - contraindicated
• Sterilization- vasectomy-best
• Tubal ligation-Interval, puerperial can be done
32. MCQs
Text book of Obstetrics, Dr J B
Sharma, 1st edition
Page 529 to 536
33. 1. Pregnancy is contra indicated with
•Mitral stenosis
•Aortic stenosis
•Fallots tetralogy
•Eisenmengers syndrome
34. 2. Pregnancy is contra indicated with
•Mitral stenosis
•Aortic stenosis
•Fallots tetralogy
•Eisenmengers syndrome
35. 2. Third stage of labour in a case of
heart disease should be managed by
•Ergometrine
•Oxytocin
•Misoprostol
•Carboprost
36. Third stage of labour in a case of
heart disease should be managed by
•Ergometrine
•Oxytocin
•Misoprostol
•Carboprost
37. 3. In pregnancy with heart disease
risk of cardiac failure increases at
•10-12 weeks
•20-22 weeks
•30-32 weeks
•40-42 weeks
38. 3. In pregnancy with heart disease
risk of cardiac failure increases at
•10-12 weeks
•20-22 weeks
•30-32 weeks
•40-42 weeks
39. 4. A pregnant women suffering from
heart disease gets breathless on doing
minimal activity but is comfortable at
rest. Her cardiac function status is
•NYHA Class 1
•NYHA Class 2
•NYHA Class3
•NYHA Class 4
40. 4. A pregnant women suffering from
heart disease gets breathless on doing
minimal activity but is comfortable at
rest. Her cardiac function status is
•NYHA Class 1
•NYHA Class 2
•NYHA Class3
•NYHA Class 4
41. 5. Which of the following contraceptive is
contraindicated in a woman with heart
disease?
• OCP
• POP
• Lng IUS
• Diaphragm
42. 5. Which of the following contraceptive is
contraindicated in a woman with heart
disease?
• OCP
• POP
• Lng IUS
• Diaphragm
43. 6. A 24 year old pregnant Gr2 P1 woman, having
prosthetic valve was being given warfarin. She
should be switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
44. 6. A 24 year old pregnant Gr2 P1 woman, having
prosthetic valve was being given warfarin. She
should be switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
45. 7. A pregnant woman suffering from mitral
stenosis is breathless even when lying down.
Her NYHA cardiac function status is
a) class 1
b) class 2
c) class 3
d ) class 4
46. 7. A pregnant woman suffering from mitral
stenosis is breathless even when lying down.
Her NYHA cardiac function status is
a) class 1
b) class 2
c) class 3
d ) class 4
