cardiac disease in pregnancy

1. Cardiac Disease
In Pregnancy
BY
DR SHAZIA A KHAN

2. Physiologic Changes During Pregnancy
CO increases by 40%  as SV increases
HR increases by  10 beats/min - 3rd trimester
CO peaks at 18-24 wks then stabilize
CO increase  grade II systolic flow murmur
along the left sternal border without radiation

3. Diastolic murmur  if present consider
pathologic  investigate the cause
Increase venous return  Cardiac fullness,
hypertrophy and displacement of heart
Apex beat  superiorly and laterally
In ECG
Lt axis deviation
Flattened T wave

4. Cardiac Disease
1. Rheumatic  accounts for 90% of heart
diseases in pregnancy. Reduces by 50% with
better treatment of RHD
2. Congenital  accounts for 10% to 35% heart
diseases in pregnancy

5. 3.Cardiac Arrhythmias
4.Peripartum & Postpartum Cardiomyopathy
5.Myocardial infarction

6. Rheumatic Heart Disease
Specific and most common valvular disease
 Incidence : 90 % heart disease cases
Mitral Stenosis
Rheumatic heart disease is a condition in which
the heart valves have been permanently damaged
by rheumatic fever. The heart valve damage may start
shortly after untreated or undertreated streptococcal
infection such as strep throat infection or scarlet fever.

7. Increase Risk of  Heart failure
infective endocarditis
 Thromboembolic disease
 Increase of fetal wastage
 During pregnancy  CO increase  obstruction
worsens
 Asymptomatic pt.  symptomatic
 Symptoms of cardiac decompensations or pulmonary
edema appear as pregnancy progresses
 Pt. with severe Mitral stenosis  Atrial fibrillation &
CCF.
 If Atrial fibrillation predates pregnancy  50% CCF.

8.  Moderate or severe MS is poorly tolerated during
pregnancy
 The risk of fetal morbidity include fetal growth
restriction, preterm birth and these rises with a
severity of MS from 14% with mild MS to 28%-33%
with moderate to severe MS.

9.  B-1 selective blocker
 Diuretics
 Digoxin
 Anti-coagulation
Medical Therapy

10.  Percutaneous mitral commissurotomy is preferably
performed after 20 weeks gestation
 It should only be considered in NYHA Class-III or
IV.
Surgical Intervention

11. Other valvular Lesion
Mitral insufficiency
Aortic stenosis
Aortic insufficiency

12. Congenital Heart Disease
1. Atrial septal defects
2. Ventricular septal defects
3. Fallot tetrology
4. Primary Pulmonary hypertension (eisenmenger’s
syndrome )

13.  Defects corrected in childhood with no residual
damage pregnancy progresses without
complication.
 Atrial and ventricular septal defects + tetralogy
of fallot tolerated pregnancy well after surgical
correction.

14. Cardiac Arrhythmias
Paroxysmal atrial tachycardia
Supraventicular tachycardia due to the
structural changes in heart
Benign

15. Atrial fibrillation
Atrial flutter
associated with underlying cardiac disease
Management  same in pregnant & non pregnant
Serious

16. Peripartum & Postpartum
Cardiomyopathy
No etiological factor found.
No underlying cardiac disease.
Symptoms of cardiac decompensation appear
during last weeks of pregnancy or ( 2-20wks)
postpartum.
Rare

17. Women prone to this condition gives h/o
Pre-eclampsia
Hypertension
Malnutrition

18. Cause Of Death in cardiac pts.
Overload

Pulmonary Congestion

Hypotension

Hypoxia

Sudden death

19. Management
 CLASS I  No limitation of activity. Ordinary physical
activity does not precipitate fatigue,
dyspnoea etc.
 CLASS II  No symptoms at rest but minor
limitation of physical activity.
 CLASS III  No symptoms at rest but marked
limitation of physical activity.
 CLASS IV  Symptoms present at rest increases
discomfort with any kind of physical
activity.
New York Heart Association Functional Classification (NYHA)
of Heart Disease

20. With I and II  Maternal and fetal  small risk
With III and IV  Increases risk in both

21. ANTENATAL MANAGEMENT
Management with the help of
cardiologist.(multidisciplinary approach)
Patient should be booked in tertiary care hospital
with facilities of CCU
Class I and II cardiac disease patients usually have
very less morbidity
Frequent antenatal visits and admissions in class
III and IV.

22. GUIDELINES FOR ANTENATAL MANAGEMENT
1. Avoid excessive weight gain and odema
2. Avoid strenuous activity
3. Avoid anemia
4. Early detection of a problem

23. AVOID EXCESSIVE WEIGHT GAIN &
ODEMA
Low sodium diet (2 gm/day)
Rest in left lateral position
Adequate sleep

24. AVOID STERNUOUS ACTIVITY
 Unable to increase CO  to meet demand of
exercise
 Extract more oxygen from arterial blood  large AV
difference  uteroplacental circulation suffer

25. AVOID ANEMIA
 Oxygen carrying capacity decreases  increase CO
 increase HR
• Always maintain Hb >10 gm/dl

26. EARLY DETECTION OF A PROBLEM
On each visit look for:-
 Infection
 Cardiac decompensation
 Pulmonary congestion
 Cardiac arrhythmias

27. On each visit pulse rate BP, JVP, heart sounds ,
ankle and pedal oedema and presense of basal
crepitations is to be noted
Echocardiography is helpful in assessing the
function of valves and it should be done at
booking visit and repeated around 28 weeks of
gestation.

28. MANAGEMENT OF LABOUR
 CO increases  40-50% of pre-labour level
 80% of pre-pregnancy
due to increase catecholamine release
 due to pain and apprehension
 due to abdominal and uterine muscle
contractions

29. Wait for spontaneous labour
C section for obstetric reasons only
Left lateral position
 decrease risk of supine hypotension
 increase oxygen carrying capacity of blood
Epidural analgesia is recommended as it reduces
pain related stress

30.  Prophylactic antibiotic (penicilline and gentamycin)
to reduce the risk of bacterial endocarditis
 Esp. in high risk patients.
 Early labour  postpartum
 Amoxicilline 2g iv and gentamycin 120mg iv
at onset of labour or prior to c section and then
oral amoxicilline for 5 days

31. Involvement Of Cardiologist Is Must
During Labour, Delivery And
Postpartum Period !!!

32. OBSTETRICAL MANAGEMENT
Labour and fetal monitoring by using ext.
electrode
Limit number of pelvic examination
Vaginal delivery preferred unless obstetrical
indication for C section
Shorten 2nd stage  outlet
 vacuum

33. Pushing avoided  increase CO due to increase VR
No ergometrine {causes vasoconstriction}
Delivery of placenta  increase 500 ml of blood so
lower extremities should kept at lower level
Syntocinon should be used in a slow low dose
infusion.
Avoid excessive fluids
Strict input and output record

34. IN SEVERE CARDIAC DISEASE (III & IV)
Multi disciplinary approach in CCU
Monitoring of CV status is essential with arterial
and swan- ganzcathetors
Fluid intake and urine output
Arterial blood gases
Electrolytes