For undergraduates

1. HEART DISEASE IN PREGNANCY
DEPT OF OG

2. INCIDENCE :
• The incidence of cardiac lesion is less than 1% amongst
hospital deliveries.
TYPES
• Rheumatic heart disease- mitral stenosis (80%).
• Congenital heart disease - patent ductus arteriosus,
atrial or ventricular septal defect, pulmonary stenosis,
coarctation of aorta and Fallot’s tetralogy
• Others:Mitral valve prolapse, Peripartum
cardiomyopathy,arrythmias, myocarial infarction,
hypertensive, thyrotoxic, syphilitic etc

3. • The commonest cardiac lesion is of rheumatic
origin followed by the congenital ones.
• The ratio between the two has fallen over he
past two decades from 10: 1 to about 3: 1 in
advanced countries.
• Adequate treatment of rheumatic fever
• Advancement in cardiac surgery for
congenital heart lesions are responsible for
the change in the profile

4. Cardiovscular changes in pregnancy
• Increase in pulse rate to about 15 per minute
• Systolic blood pressure is unchanged or slighty lowered
until 20 weeks of pregnancy and then rises to prepregnancy
levels
• Decrease in diastolic blood pressure (BP) and mean
arterial pressure (MAP) by 5–10 mm Hg.
• Femoral venous pressure is markedly raised especially in
the later months. It is due to pressure exerted by the
gravid uterus on the common iliac veins, more on the right
side due to dextrorotation of the uterus
• Plasma volume increases by 40-45% between 12 and 32
weeks of pregnancy
• Red cell volume increases by 15-20%

5. Cardiovscular changes in pregnancy
CARDIAC OUTPUT:
• Starts to increase from 5th week of pregnancy and
• Reaches its peak 40–50% at about 30–34 weeks.
• Thereafter the CO remains static till term.
• Increases further during labor (+50%) and
immediately following delivery (+70%) over the pre-
labor values.
• CO returns to pre-labor values by 1 hour following
delivery and to the pre-pregnant level by
another 4 weeks time.

6. EFFECT OF PREGNANCY ON HEART LESION:
• A normal heart has got enough reserve power so that the extra load
can well be tackled.
• While a damaged heart with good reserve can even withstand the
strain but if the reserve is poor, cardiac failure occurs sooner or
later.
• Cardiac failure occurs during pregnancy around 30 weeks, during
labor and mostly soon following delivery.
• Factors responsible for cardiac failure:
1. Advanced age
2. Cardiac arrhythmias or left ventricular hypertrophy
3. History of previous heart failure
4. Appearance of “risk factors” in pregnancy are: infection, anemia,
hypertension, excessive weight gain and multiple pregnancy
5. Inadequate supervision.

7. EFFECTS OF HEART LESION ON PREGNANCY:
MATERNAL:
The prognosis depends on:
(1) Nature of lesion
(2) Functional capacity of the heart
(3) Quality of medical supervision provided during
pregnancy, labor and puerperium
(4) Presence of other risk factors mentioned earlier
(5) Whether patient has undergone corrective
surgery or not.

8. • Maternal mortality is lowest in rheumatic heart lesions and acyanotic
group of heart diseases—less than 1%.
• With elevation of pulmonary vascular resistance especially with cyanotic
heart lesions, the mortality may be raised to even 50% (Eisenmenger’s
syndrome).
• Causes of death are—
 Cardiac failure
 Pulmonary edema
 Pulmonary embolism
 Active rheumatic carditis
 Subacute bacterial endocarditis
 Rupture of cerebral aneurysm in coarctation of aorta.
However, with improved medical care, surgical correction of the congenital
lesions and better obstetric care, the maternal mortality has been reduced
markedly.
• Pregnancy however, does not affect the longterm survival of a woman
with rheumatic heart lesion provided she survives pregnancy itself.

9. FETAL:
• Rheumatic heart lesions, the fetal outcome is usually
good and in no way different from the patients without
any heart lesion.
• There is a tendency of preterm delivery and
prematurity.
• IUGR is quite common
• Cyanotic group of heart lesion, there is increased fetal
loss (45%) due to abortion, IUGR and prematurity.
• Fetal congenital cardiac disease is increased by 3–10%
if either of the parents have congenital lesions.

10. Anatomical and Physiological Changes During Pregnancy that
Mimic Cardiac Disease
• Hyperdynamic circulation
• Systolic ejection murmur at left sternal border (due to
increased blood flow across the aortic and pulmonary
valves)
• Dyspnea, decreased exercise tolerance,
fatigue,syncope
• Tachycardia, shift of ventricular apex
• Continuous murmur at 2nd to 4th intercostal space—
mammary souffle
• Loud first sound with splitting

11. New York Heart Association (NYHA) Classification of
Heart Disease (Depending Upon the Cardiac Response
to Physical Activity)
• Class-I: Uncompromised and no limitation of physical
• activity
• Class-II: Slightly compromised with slight limitation of
physical activity. The patients are comfortable at rest
but ordinary physical activity causes discomfort
• Class-III: Markedly compromised with marked
limitation of activity. The patients are comfortable at
rest but discomfort occurs with less than ordinary
activity
• Class-IV: Severely compromised with discomfort even
at rest

12. Diagnosis of Heart Disease in Pregnancy
• Symptoms: Breathlessness, nocturnal cough,syncope,
chest pain
• Signs:Cyanosis,Clubbing,Eevated Jugular venos
pressure, hypotension,fourth heart sound,Chest
murmurs—pansystolic, late systolic louder ejection
systolic or diastolic associated with a thrill,diastolic
murmur, pulmonary edema,pleural
effusion,arrhythmia
• Chest radiography (using lead shield):Cardiomegaly,
increased pulmonary vascular markings, enlargement
of pulmonary veins.

13. • Electrocardiography: T wave inversion, biatrial
enlargement, dysrhythmias
• Echocardiography (color flow Doppler study):
Structural abnormalities (ASD, VSD), valve
anatomy,valve area, function, left ventricular
ejection fraction,pulmonary artery systolic
pressure
• Cardiac MRI can delineate complex (anatomy
when it is not well-evaluated by
echocardiography)

14. Risk categorization
HIGH RISK /PREGNANCY CONTRAINDICATED-25-
50%
• Pumonary vascular obstructive
disease(eisenmenger syndrome)
• NYHA class III/IV
• Severe systemic ventricular dysfnction
• Severs aortic stenosis
• Marfan syndrome with sgnificant aortic
root/valve involvement

15. INTERMEDIATE RISK(1-5%)
• Mitral vale prosthesis
• Single ventricle physiology
• Systemic right ventricles and previous atrial
switch procedures
• Unrepaired cyanotic lesions
• Unrepaired severe coarctation of aorta
• Mitral stenosis
• Aortic stenosis
• Severe pumonary stenosis

16. LOW RISK(<1%)
• Repaired lesions without residual cardiac
dysfunction
• Uncomplicated left to right shunts
• Mitral valve prolapse
• Funtionally normal bicuspid aortic valve
• Mld to moderate pulmonary stenosis
• Aortic or mitral regurgitation with good
ventricular

17. GENERAL MANAGEMENT PRINCIPLES
— Early diagnosis and evaluation of anatomical
type and functional grade of the case.
— To detect the high risk factors and to prevent
cardiac failure.
— Multidisciplinary team approach
(obstetrician, cardiologist and neonatologist)
and mandatory hospital delivery.

18. PLACE OF THERAPEUTIC TERMINATION:
ABSOLUTE INDICATIONS
(a) primary pulmonary hypertension
(b) Eisenmenger’s syndrome and
(c) pulmonary veno-occlusive disease.
RELATIVE INDICATIONS
(a) Parous woman with grade III and IV cardiac lesions
(b) Grade I or II with previous history of cardiac failure in early
months or in between pregnancy.
• The termination should be done within 12 weeks by suction
evacuation (MVA) or by conventional D & E.

19. ANTENATAL CARE:
• Supervised in a tertiary care hospital.
• Initial assessment should be made in consultation with a cardiologist.
• Counseling is to be done regarding prognosis and risks.
• Class III and IV : As soon as pregnancy is diagnosed. The patient should be kept in
the hospital throughout pregnancy.
• Class–I and II Fortnightly AN visits till 30weeks,weekly thereafter
• Special care in each antenatal visit is to detect and to treat the risk factors that
precipitate cardiac failure in pregnancy.
• Risk factors for cardiac failure are
• Infections—Urinary tract, dental and respiratory tract.
• Anemia
• Obesity
• Hypertension
• Arrhythmias
• Hyperthyroidism
• Drugs—Betamimetics.
• Dietary indiscretion: Excess intake of caff eine, alcohol, high calorie diet, excess
salt.

20. ROLE OF ANTICOAGULANTS:
• Anticoagulants are indicated in cases with:
a) Congenital heart disease,
(b) pulmonary hypertension,
(c) mechanical heart valve,
(d) atrial fibrillation.
• warfarin should discontinue it as soon as pregnancy is diagnosed
and to replace it by heparin 5,000 units twice daily subcutaneously
up to 12th week.
• Low molecular weight heparin (LMWH) can also be used.
• This is then replaced by warfarin tablet 3 mg. daily to be taken at
the same time each day and continued up to 36 weeks.
• Thereafter it is replaced by heparin up to 7 days postpartum.
• Warfarin is then to be continued.
• UFH, LMWH and Warfarin therapy do not contraindicate breast-
feeding.

21. ADMISSION
• Class III and IV : As soon as pregnancy is
diagnosed
• Class–I and II: At least 2 weeks prior to the
expected date of delivery
• Emergency:
(1) Deterioration of the functional grading
(2) Appearance of dyspnea or cough or basal
crepitations or tachyarrhythmias
(3) Appearance of any pregnancy complication
like anemia, preeclampsia.

22. MANAGEMENT DURING LABOR
• PLACE OF INDUCTION: Most patients with
cardiac disease go into spontaneous labor and
deliver without any difficulty.
• Induction (PGE2) may be employed in very
selected cases for obstetric indications. One
should guard against infection and pulmonary
edema due to fluid overload.

23. LABOR: First stage:
• Position: The patient should be in lateral recumbent
position to minimize aortocaval compression
• Oxygen is to be administered (5–6 L/min) if required
• Analgesia in the majority, is best given by epidural
• Prophylactic antibiotics against bacterial endocarditis
• Fluids should not be infused more than 75 mL/hour to
prevent pulmonary edema.
• Careful watch of the pulse and respiration rate. If the pulse
rate exceeds 110 per minute in between uterine
contractions, rapid digitalization is done by intravenous
digoxin 0.5 mg.
• Cardiac monitoring and pulse oximetry can detect
arrhythmias and hypoxemia early.
• Central venous pressure monitoring may be needed in
selected cases.

24. • Prophylactic antibiotics for bacterial endocarditis: Antibiotic
prophylaxis during labor and 48 hours after delivery is
considered appropriate. This is to prevent bacterial
endocarditis. The recommended regimens include
intravenous ampicillin 2 g and gentamicin 1.5 mg/kg (not to
exceed 80 mg), at the onset or induction of labor followed
by repeat doses 8 hours interval.
• High risk patients are:
(a) Structural heart disease
(b) Rheumatic heart disease
(c) Cyanotic congenital heart disease
(d) Presence of dental and respiratory tract infections
(e) Hypertrophic cardiac myopathy
(f ) Prosthetic heart valves
(g) Prior history of infective endocarditis
(h) Cardiac transplant.

25. • Second stage: No maternal pushing and the
tendency to delay in the second stage of labor
is to be curtailed by forceps under pudendal
and/or perineal block anesthesia.
• Intravenous ergometrine should be avoided

26. • Third stage: Conventional AMTSL
management to be followed.
• Slight blood loss is not detrimental but if it is
in excess, oxytocin can be given by infusion.
• Aggressive diuresis by IV frusemide.

27. CARDIAC INDICATIONS OF CESAREAN DELIVERY:
1. Coarctation of aorta
2. Aortic dissection or aneurysm
3. Aortopathy with aortic root > 4 cm
4. Warfarin treatment within 2 weeks
5. Endocarditis necesitating valve replacement at or near term
6. Severe aortic stenosis
• In coarctation of aorta, elective cesarean section is indicated to
prevent rupture of the aorta or mycotic cerebral aneurysm.
• Anesthesia should be given by expert anesthetist using either
epidural (preferred) or general anesthesia.

28. PUERPERIUM:
• The patient is to be observed closely for the
first 24 hours.
• Oxygen is administered.
• Hourly pulse, BP and respiration are recorded.
• Diuretic may be used if there is volume
overload.
• No contraindication of breastfeeding.

29. CONTRACEPTION:
• Steroidal contraception is avoided as it may cause thromboembolic
phenomenon.
• Intrauterine device (copper IUCD or LNG-IUS) with IE prophylaxis
• Progestin only pills or parenteral progestins are safe and effective.
They may cause irregular bleeding especially if the patient is
anticoagulated.
• Barrier method of contraceptives (condom) is the best.
• Sterilization should be considered with the completion of the family
at the end of first week in the puerperium under local anesthesia
through abdominal route by minilap technique.
• If the heart is not well compensated, the husband is advised for
vasectomy

30. MANAGEMENT OF CARDIAC FAILURE IN PREGNANCY:
The principles of management are the same as in nonpregnant
state.
• Propped up position
• O2 administration
• Monitoring with ECG and pulse oximetry
• Diuretic: Frusemide (Loop) (40–80 mg) IV (anticipatory aggressive
diuresis is needed to avoid pulmonary congestion)
• Mechanical ventilation
• Injection morphine 15 mg IM
• Digoxin 0.5 mg IM followed by tab digoxin 0.25 mg P.O. (Digoxin
crosses the placenta and is excreted in breast milk)
• Dysrhythmias—quinidine or electrical cardioversion
• Tachyarrhythmias—Adenosine (3–12 mg) IV or DC conversion

31. PREDICTORS OF ADVERSE MATERNAL OUTCOMES:
• Prior cardiac failure, arrhythmia or transient
ischemic attack
• Baseline NYHA class > 2 or associated cyanosis
• Left heart obstruction:
Mitral valve area < 2 cm2,
aortic valve area < 1.5 cm2, or
peak ventricular outflow gradient > 30 mm Hg
by echocardiography
• Left ventricular ejection fraction < 40%.

32. SPECIFIC HEART DISEASE DURING PREGNANCY
RHEUMATIC HEART DISEASE
MITRAL STENOSIS:
• Mitral stenosis is the commonest heart lesion met during
pregnancy.
• Normal mitral valve area ranges between 4 and 6 cm2.
• Symptoms appear when stenosis narrows this to less than 2.5 cm2.
• Women with mitral valve area ≤1 cm2, have the high rate of
pulmonary edema (55%) and arrhythmia (33%).
• In asymptomatic cases, the mortality is < 1% but once it is
significantly symptomatic, mortality ranges between 5% and 15%.
• During labor continuous epidural analgesia is ideal and intravenous
fluid overload is to be avoided

33. PLACE OF CORRECTIVE SURGERY:
• It is better to withheld elective cardiac surgery
during pregnancy.
• Surgery should be considered in cases of
unresponsive failure with pregnancy beyond 12
weeks.
• Best time of surgery is between 14 weeks and 18
weeks.
• Valve replacement, commissurotomy, balloon
valvotomy
• Atrial fibrillation is a complication.

34. AORTIC STENOSIS:
• Most cases of aortic stenosis are congenital, some are rheumatic in
origin.
• Normal aortic valve area is 3–4 cm2.
• When it is reduced to less than or equal to 1 cm2, stenosis is
significant.
• Maternal mortality ofsignificant aortic stenosis is about 15–20%
with perinatal loss of about 30%.
• Epidural anesthesia is contraindicated.
• During labor, fluid therapy (125–150 mL/h) should not be restricted.
Left ventricular after load is high and the pregnant patient is
sensitive to hemorrhage.
• Common symptoms are angina, syncope and left ventricular failure.
• Medical management is not helpful in a symptomatic patient.
• Valve replacement is the definitive treatment. Mechanical valves
need anticoagulation.
• Open heart surgery is preferably avoided in pregnancy.
• Aortic balloon valvuloplasty may be done as a palliative procedure

35. CONGENITAL HEART DISEASE:
• With increasing number of surgical correction of
the congenital heart lesions , pregnancies with
congenital lesions s increased
• Corrected esions pose little problem in obstetrics.
• Pregnancy in uncorrected congenital lesions,
especially in a cyanotic group,mortality is high
• Risk to the offspring of congenital heart disease is
high (3–13%). All women should have fetal
echocardiography examination at mid pregnancy

36. Acyanotic (L to R shunt)
Atrial Septal Defect (ASD):
• ASD (ostium secundum type) -most common congenital heart
lesion during pregnancy.
• Even uncorrected ASD tolerates pregnancy and labour well.
• Congestive cardiac failure unresponsive to medical therapy
requires surgical correction.
• Shunt reversal is the major risk -develop in hypovolemia.
• Such cases may occur in hemorrhagic conditions and following
injudicious administration of epidural anesthesia.
• In the absence of arrhythmias, and pulmonary hypertension,
ASD does not usually complicate pregnancy.

37. Patent Ductus Arteriosus (PDA):
• Presence of continuous murmur at the upper left
sternal border is suggestive of diagnosis.
• Most patients with PDA tolerate pregnancy well.
• Pulmonary hypertension may cause maternal death.
• Surgical correction during pregnancy can be performed
provided there is no pulmonary hypertension.
• Epidural analgesia is better avoided to minimize shunt
reversal due to systemic hypotension.
• Fetal loss may be up to 7% and there is 4% chance that
the child of this parent will suffer from the same
abnormality.
• Endocarditis prophylaxis should be given.

38. Ventricular Septal Defect (VSD):
• If the defect is less than 1.25 cm2, pulmonary hypertension and
heart failure do not develop.
• Pregnancy is well tolerated with small to moderate left to right
shunt or with moderate pulmonary hypertension.
• The major risk is shunt reversal leading to circulatory collapse and
cyanosis. Hypotension is to be avoided.
• Fetal loss may be up to 20%.
Mitral Valve Prolapse (MVP):
• Is the commonest congenital valvular lesion.
• Most of them are asymptomatic.
• Women tolerate pregnancy and labor well.
• Endocarditis prophylaxis is given

39. Cyanotic (R to L shunt)
Fallot’s tetralogy:
• It is the most common form of cyanotic heart lesion.
• It is a combination of (a) ventricular septal defect, (b) pulmonary
valve stenosis, (c) right ventricular hypertrophy and (d) an
overriding aorta.
• After surgical correction, patients tolerate pregnancy well.
• Surgically uncorrected patients are at increased risk.
• Complications like bacterial endocarditis, brain abscess and cerebral
embolism are more common.
• Maternal mortality is 5–10% and the perinatal mortality is 30–40%.
• IUGR is common.
• Systemic hypotension is dangerous which may lead even to death.
• Epidural or spinal anesthesia is avoided.

40. Eisenmenger’s syndrome:
• Patients with Eisenmenger’s syndrome have pulmonary
hypertension with shunt (right to left) through an open
ductus, an atrial or ventricular septal defect.
• Maternal mortality is about 50% and so also the
perinatal loss 50%.
• Termination of pregnancy should be seriously
considered.
• Heparin should be used throughout pregnancy as there
is risk of systemic and pulmonary thromboembolism.
• Epidural anesthesia is contraindicated.
• Inhaled nitric oxide or I.V. prostacyclin is used as a
pulmonary vasodilator.

41. Other congenital heart lesions
Coarctation of aorta:
• Maternal mortality is high 3–9%. Fetal loss is also
increased to 25%.
• Hypertension, aortic dissection, bacterial
endocarditis and cerebral hemorrhage due to
ruptured intracranial aneurysms
• Surgical correction should be done prior to
pregnancy.
• Termination of pregnancy should be seriously
considered.
• Elective cesarean section is preferred to minimize
dissection associated with labor

42. Primary pulmonary hypertension
• The cause remains unknown. Maternal mortality
is about 50%, majority die (75%) postpartum.
• Termination of pregnancy is indicated.
• Bed rest should be imposed from 20 weeks of
pregnancy.
• Anticoagulant (heparin) is administered.
• Sildenafil is used as a potent vasodilator as it
increases endogenous nitric oxide. Oral nifedipine
or I.V. prostacyclin helps pulmonary
vasodilatation.
• Epidural morphine gives effective analgesia
without any hemodynamic change.

43. Marfan’s syndrome:
• Marfan’s syndrome is an autosomal dominant
condition.
• There is 50% chance of transmission to the offspring.
• Dilatation of aorta more than 40 mm -contraindication
of pregnancy
• Beta blocking drugs should be used to maintain resting
heart rate around 70 bpm.
• Hypertension should be avoided to prevent aortic
dissection.
• Vaginal delivery is desirable with shortening of second
stage.
• Women with aortic diameter more than 5.5 cm should
have graft and valve replacement before pregnancy.

44. Cardiomyopathies
Peripartum cardiomyopathy:
Important diagnostic criteria
(i) Cardiac failure within last month of pregnancy or
within 5 months postpartum.
(ii) No determinable cause for failure.
(iii) Absence of previous heart disease.
(iv) Left ventricular dysfunction as evidenced on
echocardiography—
(a) Ejection fraction less than 45%
(b) Left ventricular end diastolic dimension more
than 2.7 cm/m2.
Peripartum cardiomyopathy is a diagnosis of exclusion.

45. • The patients are usually multiparous and young (20–35
years).
• Pregnancy is poorly tolerated in women with dilated
cardiomyopathy.
• Mortality is high 20–50%—due to CCF, arrhythmia or
thromboembolism
• The treatment is bed rest, digoxin, diuretics (preload
reduction), hydralazine or ACE inhibitors (postpartum)
(afterload reduction), β blocker and anticoagulant
therapy. Vaginal delivery is preferred.
• Epidural anesthesia is ideal.
• There is no contraindication of breastfeeding.
• It may recur in subsequent pregnancies.

46. Myocardial infarction
• is rare in pregnancy.
• Management is mostly as in nonpregnant state.
• Coronary angioplasty, stenting and thrombolytic
therapy have been done in pregnancy when indicated.
• Percutaneous transluminal coronary angioplasty can be
done successfully around 36 weeks of pregnancy if
needed
• Labour managed as with standard cardiac care.
• Elective delivery within two weeks of infarction should
be avoided.
• Regional analgesia for pain in labor and β blockers for
tachycardia may be used.

47. Thank you