1. Patients with heart disease require careful intrapartum management including monitoring of vital signs, fluid balance, and fetal heart rate. Epidural analgesia is preferred to avoid hemodynamic changes from pain. Vaginal delivery is preferred for most, and antibiotics are given before procedures to prevent endocarditis.
2. NYHA classification stratifies heart disease severity from Class I (no limitation) to Class IV (severe limitation even at rest).
2. 1% of all pregnancies
One of the leading indirect causes of
maternal mortality
3. Increase in cardiac output by 40%
Incr in stroke vol by 10%
Incr in heart rate by 10% (15 bpm)
Incr in blood volume by 40%
Decrease in peripheral resistance & diastolic BP
4. Rheumatic - more in dev countries, 90% MS
Congenital – ASD commonest
7. Echocardiography
◦ Structural lesion,
◦ Valve area & severity
◦ Valve gradient
◦ Ventricular function
Safe, non invasive
ECG diagnoses arrythmias only
8. Collapsing pulse – wide pulse pressure in preg
Increase in HR, ectopic beats
JVP waves more prominent
Heart size increases
Apex beat displaced up & laterally
Loud S1,third heart sound
Ejection systolic murmurs(gr 2 & 3)
Venous hums in neck & mammary souffle ov breast
Peripheral edema
ECG – left axis deviation, mild ST changes
9. NYHA Classification
Class I Uncompromised/no limitation in physical activity
Class
II
Slight limitation of physical activity/dyspnoea on severe
exertion
Class
III
Marked limitation of physical activity/dyspnoea on mild exertion
Class
IV
Severely compromised/Dyspnoea at rest
10. Myocardial dysfunction(Ejection fraction <40% or
cardiomyopathy)
Prior heart failure, arrythmia or stroke
Previous arrythmia needing treatment
NYHA class 3 or 4 or cyanosis
L sided obstruction(mitral area <2sq.cm/peak LV
outflow tract gradient above 30mm Hg/Aortic valve
<1.5sq cm)
11. Based on risk stratification
Given intrapartum to women at high &
moderate risk only in presence of suspected
bacteremia or active infection
Optional in women at high risk undergoing
uncomplicated delivery & not for mod risk gp
12. High risk Moderate risk
Prosthetic valves Most other congenital cardiac
malformations
Previous endocarditis Rheumatic valvular heart disease
Complex cyanotic heart disease Hypertrophic cardiomyopathy
Surgically constructed shunts or
conduits
Mitral valve prolapse with
regurgitation or thickened leaflets
13. Given 30 – 60 min before the procedure
Ampicillin 2 g or cefazolin/ ceftriaxone 1gm IV
If sensitive to penicillin, clindamycin 600mg IV
Oral – 2gm amoxycillin
Vancomycin also if enterococcus suspected
14. Isolated atrium septum secondum
Surgical repair of ASD, VSD & PDA
Prev coronory bypass graft surgery
Mitral valve prolapse without regurgitation
Previous Kawasaki disease without valvular
dysfunction
Cardiac pacemaker
15. Eisenmenger syndrome
Primary pulmonary hypertension
Uncorrected severe coarctation
Marfans with aorta dilated >45mm
Severe MS with complications
Severe symptomatic aortic stenosis
Prev peripartum cardiomyopathy with residual
LV dysfunction
16. Preconceptional counselling
V imp in artificial valves on oral anticoagulants
Cong lesions & MS better corrected surgically first
Mild MS, complete family early
17. Combined clinic, tertiary care centre, cardio+obst
Two issues
◦ ?need for termination
◦ ? Need for surgery
◦ If surgery needed best in 2nd trimester
Fetal surveillance with growth scans
18. Mostly uneventful
No need of early hospitalisation
Physical activity to be kept within the pt’s cardiac
reserve
Adequate rest, frequent follow ups
Look out for nocturnal cough & persistent basal
crepitations heart failure
Sudden reduction in ability to carry out usual
duties and dyspnoea
Prevent respiratory infections
19. Antiobiotics at first sign of infection
Look for asymptomatic bacteriuria & treat
Dental hygiene
Prevent anaemia
Hypertension to be managed incr pre load
Arrythmias to be treated
Fetal echo especially in congenital heart
diseased pts
21. At high risk
Ideally should be pregnant only after surgical
correction
If seen in 1st trimester adv MTP
If continuing preg, counsel regarding risks
Hospitalised for the rest of the pregnancy
Delivery in an experienced unit
22. Vaginal delivery preferred except
◦ Coarctation of aorta
◦ Marfan’s with aortic diameter 45mm or more
Spontaneous labour best
EAS,Oxytocin, ARM if Cx favourable
PGs theoretical risk of coronary vasospasm &
arrythmias
23. Analgesia
Position - semi recumbent
Fluid management(not more than 75 ml/hr)
Monitoring
◦ BP, Heart rate
◦ Pulse oxymetry
◦ Continuous ECG?arrythmias
? Swan Ganz catheter in some cases
Continuous electronic fetal heart monitoring
24. Outlet forceps
Frusemide 40 mg IV soon after baby born
THIRD STAGE
Ergometrine & Methergin contra indicated
Oxytocin IV/IM can be used
25. Can decompensate
Observed in labour ward 48 hours
Fluid balance to be monitored
Look out for PPH, Infection & Thrombo embolism
Thrombo prophylaxis with heparin
Early ambulation
Lactation
26. Barrier preferred
LNG IUS(MIRENA) safe & effective
COCs not preferred in pts prone for
thrombosis(MS, Artificial valves)
Progesterone injectables & Minipills may be
used but fluid retention problem
Vasectomy for male partner
Interval sterilisation GA, not laparoscopic
28. Previously, closed mitral valvotomy,
Now, Balloon valvuloplasty, if valve pliable &
not calcified & minimal regurgitation
Radiation exposure
Safest time after 20 wks
Indications in pregnancy
1. Failure of medical T/T in intractable heart
failure
2. Recurrent episodes of ac pulmonary edema
29. Maternal
Factors affecting
NYHA functional class
Presence of pulmonary hypertension
Cyanotic heart disease
Type of lesion
Fetal outcome
Prematurity
IUGR
Risk of congenital heart disease
30. Mitral stenosis
90%
Critical stenosis- valve area <1cm2(N=4cm2)
Moderate stenosis – 1 – 2.5cm2
Mortality high in NYHA class III & IV
L atrial presspulm HT ventricular failure,pulm
edema
Cardiac surgery best before pregnancy
Or balloon valvuloplasty after 20 wks
31. Limited physical activity
Na restricted, diuretics,β blockers
If new onset atrial fibrillation – verapamil,electroversion
Digoxin, β blockers for chr fibrillation
If persistant fibrillation/L atrial thrombus –
heparin
Vaginal delivery preferred
Epidural analgesia, avoid overload
Bacterial endocarditis prophylaxis
33. Discontinue warfarin at 6 wks
In high risk,IV heparin infusion,low risk,SC heparin
Restart warfarin at 14 wks
34 – 36 wks – restart IV heparin infusion
Labour to be planned
Stop heparin 6 hrs before delivery
Restart heparin 6 hrs after vaginal, 12 hrs after CS
Start warfarin after 3days,withdraw heparin once
INR adjusted(safe in lactation)
Infective endocarditis prophylaxis mandatory
34. ASD,corrected VSD, PDA usually safe
Eisenmenger syndrome – preg contraindicated
Tetralogy of Fallot- high risk if uncorrected
Coarctation of aorta – corrected,good prognosis
Residual HT in 30%- risk of aortic dissection &
paroxysmal HT in 2ndstage rupture aneurysm,ICH
Marfan’s – risk of aortic dissection & ao rupture
Primary Pulm HT – preg contra indicated
35. Cardiac failure in the last month of preg or within
5 mths foll delivery.
Absence of another identifiable cause
Absence of recognisable heart disease bef last
mth of preg
ECHO – LV systolic dysfunction(EF <45%, M mode
fractional shortening < 30% & L V end diastolic
dimension > 2.7cm/m2
Mat outcome not very good, pulm embolism,
cereb thrombosis
36. 1. What is the intrapartum management of a
patient with heart disease in pregnancy?
2. Describe NYHA classification.
Editor's Notes
Risk of pulmonary edema or death higher with even one of these