1) Pregnancy places significant demands on the cardiovascular system due to increases in blood volume, cardiac output, heart rate and changes in blood pressure and chemistry. 2) Women with preexisting heart conditions like rheumatic heart disease may experience worsening symptoms during pregnancy due to these demands. Care during pregnancy involves monitoring, activity restriction, medication and potential termination if risk is too high. 3) Delivery requires close supervision by obstetricians and cardiologists due to risks of heart failure from labor and postpartum blood loss. Overall maternal mortality is low for mild conditions but can be over 7% for severe illnesses if not properly managed.

3. • Most pregnant women develop fatigue , shortness of breath,  exercise
capacity , palpitations .
• Some times peripheral edema , jagular venous distension ,audible
physiologic 3rd heart sound , audible systolic flow murmer .
• This is explained by : changes occurring during 1st 5 -8 weeks of pregnancy
and reach the peak by the end of 2nd trimester . These changes include :

4. 1. Changes in blood volume
 by 40 – 50 % during pregnancy and reach the peak at 32nd week remained
at high level to delivery occur .
2. Changes in cardiac output
 by 30 – 50 % above normal level and reach the peak by 20th – 24th week of
pregnancy after which a plateau till delivery occurs . these changes in cardiac
output occurs due to :
i.  preload due to  blood volume
ii.  afterload due to  systemic vascular resistance
iii.  heart rate
3. Changes in heart rate
heart rate  by 10 – 15 b/min

5. 4. Changes in blood pressure
remains normal however systolic and diastolic blood pressure may  in the
2nd trimester but becomes normal again in the 3rd trimester
systolic  by 5 – 10 mm/Hg
diastolic  by 10 – 15 mm/Hg
Due to vasodilatation caused by :
i. Prostacyclin and hormones of pregnancy
ii. Placenta acts as arterio – venous shunt thus  peripheral resistance .
5. Changes in blood chemistry
• Fibrinogen  by 50 % ,  in factors 7 , 8 , 9 ,10 , platelets remains normal .
• RBCs  , WBCs  ( up to 12,000/mm3 is normal )
•  in blood urea , serum creatinine , nitrogen and uric acid
6. Heart displacement
In late pregnancy , the apex is displaced upward and outward to be in the 4th
intercostals space outside the mid-clavicular line .

6. 7.  Liability to varicose vein
This occurs due to :
i. Pressure of gravid uterus on pelvic veins .
ii. Relaxation of smooth muscle fibers in the blood vessel wall by
progesterone .
iii.  in the blood volume .
Supine hypotensive Syndrome :
In late pregnancy when woman lies in supine position  fainting attack
Why ?  heavy gravid uterus compresses IVC leading to :
i. Poor venous return .
ii. Poor cardiac output .
iii. Low blood pressure .

7. 1-4 % , the most common non-obstetric cause of maternal mortality
Varies in countries :
Developing countries :
rheumatic heart diseases are the most common ( mitral stenosis is the most
common )
Developed countries :
congenital heart diseases ( ASD – VSD – PDA )
• Ischemic heart disease : rare but now  due to :
i.  use of COCs
ii.  smoking
iii. Older age of pregnancy
iv. DM

8. Grade I :
Asymptomatic , no limitation of activity
Grade II :
Symptoms ( Dyspnea , palpitation , anginal pain ) on ordinary work
Grade III :
Symptoms with less than ordinary work but comfortable at rest
Grade IV :
Symptoms at rest with evidence of congestive heart failure

9. Pregnancy deteriorates the patient one clinical grade
1. Heart failure :
i. between 28th – 32nd week  maximum  in blood volume , cardiac
output and heamodilution (anaemic heart failure )
ii. During labour  contraction  load on heart ( in 2nd stage of labour
more than 1st stage) , stress and anxiety
iii. 3rd stage of labour or immediately postpartum :
• after placental delivery 500 – 900 ml of blood passed to general
circulation   load on heart
• sudden release of pressure on IVC  cardiac output is doubled
• acute pulmonary edema with maternal mortality 70 %

10. 2. Cardiac arrhythmias   threshold for arrhythmias ( atrial fibrillation
especially with mitral stenosis )
3. Reactivation of rheumatic activity
4. Subacute bacterial endocarditis especially during peurperium
5. Postpartum thromboembolic complications especially with caesarian
section ( 5 – 7 day postpartum )  pelvic thromophlebitis
6. Pulmonary embolism up to 7th day postpartum

11. Fetal complications :
i. Abortion
ii. IUGR
iii. IUFD
iv. Preterm labour
v. CFMF
vi. Early neonatal death
Maternal complications :
i. Polyhydraminos ( part of systemic venous congestion )
ii. Preterm labour ( cervix is congested )
iii. Postpartum hemorrhage

12. SCREENING
Any pregnant female should be examined at least once for heart
( EVEN IF SHE IS ASYMPTOMATIC )
Symptoms suggesting heart disease with pregnancy :
i. Dyspnea
ii. Palpitation
iii. Warm extremities
iv. Lower limb edema
v. Intolerance to exertion
vi. Syncopal attack
vii. Plethoric face
viii. Sinus tachycardia
ANY PATIENT WITH DYSPNEA AS A COMPLAINT MUST BE TAKEN SERIOUSLY

13. ONCE THESE SYMPTOMS DISCOVERED 
Sure signs of heart disease with pregnancy ( by a cardiologist ) :
i. Diastolic murmer and opening snap
ii. Systolic murmer and if > grade III  palpable thrill
iii. Accentuated 1st heart sound , fixed paradoxic split of 2nd heart sound
iv. Diastolic gallop
v. Pericardial rub
vi. cardiomegally
Investigations :
i. Electrocardiogram ECG
ii. Chest radiography
iii. Echocardiography

14. Before conception : ( pre-conception counseling )
 Reassurance of the patient about maternal and fetal risk during pregnancy,
suitable method for contraception , maternal morbidity and mortality
 Women with NYHA class III , class IV are liable to :
i. Maternal mortality up to 7 %
ii. Maternal morbidity up to 30 %
So they should be strongly cautioned against pregnancy

15. After conception : ( management of pregnant woman with a
cardiac disease )
Antenatal care ANC : should be in a special clinic under supervision of both
obstetrician and cardiologist . medical treatment depend on the NYHA class
of the patient .
NYHA class I , class II ( compensated patient ) :
1. ANC : every 2 weeks and hospitalized between 28th , 32nd weeks
2. Rest : more time of rest mental and physical – more time of sleep 2 hours
in the afternoon and 8 hours at night
3. Diet : as any normal pregnancy   proteins ,  carbohydrates ,  fat , salt
free diet and avoid weight gain
4. Drugs :
guard against 
i. heart failure by treatment of anaemia if present ( patient Hb must be not
less than 11 gm/dL ) iron + folic acid + calcium
ii. infections  long acting penicillin , dental care  prophylaxis of SABE
iii. arrhythmia  proper sedation
iv. thromboembolic disorders  give anti-coagulant when needed

16. NYHA class III , class VI ( decompensated patient ) :
A) if < 12 weeks 
1. Termination of pregnancy
HOW ?
Before 12 weeks and never after 12 weeks  because the risk of termination
> risk of continuation by Suction under heavy sedation
2. Cardiac surgery
Closed cardiac surgery Open cardiac surgery
Mitral valvotomy  can be done Mitral or aortic valve replacement
between 20 – 24 weeks 1) Heterograft
2) Metallic valve
3) Human graft
Little risk on mother Great fetal risk  not preferred
Slight risk on fetus

17. OTHER INDICATIONS OF TERMINATION OF PREGNANCY : ( < 12 weeks when
cardiac surgery is not possible )
i. Esinmenger's syndrome  40 % mortality rate and pulmonary
hypertension due to any cause .
ii. Heart failure in previous pregnancy or before this pregnancy .
iii. History of rheumatic activity or subacute bacterial endocarditic in the
last 2 years .
iv. History of atrial fibrillation .
b) if > 12 weeks  Hospitalization
1. Hospitalization through the whole time of pregnancy +
bed rest in semi-sitting position
2. Diet : as any normal pregnancy   proteins ,
 carbohydrates ,  fat , salt free diet and avoid
weight gain
3. Drugs : the same as grade I , II + maintained anti-failure treatment ( digitalis
+ diuretics + potassium + aminophylline + O2 inhalation )

18. Route of Delivery :
1. Vaginal delivery : usually easy and rapid due to :
i. Small baby
ii. Cervical congestion
2. Caesarean section :
i. obstetric indications
ii. in patients with severe mitral stenosis , aortic stenosis ,
pulmonary hypertension and Esinmenger's some advice
elective caesarean section to avoid contraction and straining
( controverse )

19.  Intra partum management :
Managed by ( Obstetrician + Cardiologist + ICU specialist )
A) During 1st stage of labour :
i. Rest in semi-sitting position to aid respiration
ii. Oxygen inhalation
iii. Analgesia : the best  epidural anesthesia or pethidine to avoid
tachycardia resulting from labour pain
iv. Concentrated glucose as a nutrient
v. Start antibiotic therapy  combination of ampicillin 2 gm + gentamycin
1.5 mg / kg IV or IM and repeated after 8 hours ( vancomycin in case of
ampicillin sensitivity )

20. B) During 2nd stage of labour :
i. Put the patient in semi-sitting position
ii. Oxygen inhalation in between contractions
iii. Analgesia  maintain epidural anesthesia
iv. No bearing down , no straining to avoid rising in blood pressure
v. If 2nd stage is prolonged more than 20 minutes  ( forceps – ventose )

21. C) During 3rd stage of labour :
There should be no hurry , Time should be allowed for post partum circulatory
adjustment .
i. Oxytocin is given to all patient unless there is a heart failure
ii. Ergometrine is avoided unless there is severe bleeding ( The risks of atonic
postpartum haemorrhage must be balanced against the risk ergometrine )
iii. Misopristol in case of severe bleeding ( relative contra-indication )
iv. Lactation is allowed in NYHA class I , II and suppressed in NYHA class III , VI
v. Close observation for at least two hours
vi. Continue antibiotic therapy
 Puerperium :
i. Hospitalization one week for NYHA class I , II and 3 weeks for NYHA III , IV
ii. Prophylaxis against subacute bacterial endocarditis by ampicilline +
gentamycin
iii. Sedation in the 1st few days after labour to reduce tachycardia
If the patient developed a heart failure , she is not allowed to get pregnant

22. Management of post-partum acute pulmonary edema :
If the patient quickly developed 
• Dyspnea
• Frothy sputum
• Haemoptysis
We should quickly do the following 
1. Proppe the patient up
2. if possible, the legs allowed to hang over the edge of the bed
3. Morphine (5-15 mg) may be given intra-muscularly
4. frusemide (20-40 mg) given intravenously
5. Venous return can be reduced by applying inflatable cuffs to the limbs
6. Quickly call ICU specialist for further management

23. Safe During Breast-
Drug Use Side Effects Safety in Pregnancy
feeding
Oligohydramnios,
IUGR, PDA,
prematurity,
neonatal
ACE inhibitors Hypertension No Yes
hypotension, renal
failure, anemia,
musculoskeletal
abnormalities
Hypertension, Fetal bradycardia,
arrhythmias, MI, low birth weight,
Beta-blockers Yes Yes
hyperthyroidism, hypoglycemia,
cardiomyopathy respiratory
depression
Low birth weight,
Digoxin Arrhythmia, CHF Yes Yes
prematurity
Fetal distress with
Nitrates Hypertension Yes No data
maternal
hypotension

24. Safe During Breast-
Drug Use Side Effects Safety in Pregnancy
feeding
Reduced
Diuretics Hypertension, CHF Unknown
uteroplacental Yes
perfusion
Arrhythmia, Neonatal CNS
Lidocaine Yes Yes
anesthesia depression
Hypercoagulable states, Hemorrhage, bone
LMWH Limited Limited data
DVT, mechanical valves, density
atrial fibrillation
Warfarin
Hypercoagulable
embryopathy,
states, DVT, No Yes
Warfarin fetal CNS
mechanical valves,
abnormalities,
atrial fibrillation
hemorrhage
Hypercoagulable Maternal
Unfractionated states, DVT, osteoporosis,
Yes Yes
heparin mechanical valves, hemorrhage,
atrial fibrillation thrombocytopenia
, thrombosis
Sodium Hypertension, aortic Fetal thiocyanate
No No data
nitroprusside dissection toxicity

25. 1. Preterm labour in a cardiac patient ( very common )
B-mimetic are contra-indicated
2. Pregnancy-induced hypertension in a cardiac patient
Never use magnesium sulphate and depend only on diazepam
2. Anesthesia in a cardiac patient
• For all vaginal delivery  the best is epidural anesthesia , pudendal nerve
block and sedation
• For C.S  epidural anesthesia , careful
general anesthesia and local infiltration
anesthesia

26. Overall maternal mortality rate :
• NYHA class I , II  0.4 %
• NYHA class III , IV  7 %
Factors affecting prognosis :
i. Nature of cardiac disease : very high risk with mitral or aortic stenosis
ii. Clinical Class of the patient , her age and parity
iii. Social factors , degree of antenatal care , socio-economic conditions and
ability of the patient to get bed rest
iv. Presence of other bad signs ; cardiomegally . SABE and rheumatic
activity