A presentation made for Obgyn rotation by 4th year medical students from An- Najah National University- Palestine

1. Cardiac Diseases in
Pregnancy
Abdullah Matar Badran
Hasan Arafat

2. Subjects
• Introduction
• Heart Diseases in Pregnancy
• Management

3. Introduction
• Normal Cardiac Changes During
Pregnancy
• Pre- Pregnancy Counselling

4. Normal Cardiac Changes During Pregnancy
• Cardiac output increases up to 50% by 20 weeks ( i.e. Heart Rate ,
Stroke Volume are both Increased )
• CO is the lowest in supine position
• CO is the highest in the left lateral position
• CO increases progressively through the three stages of labor
• Systolic Ejection Murmur is present due to increased CO passing
through the aortic and pulmonary valves

5. Pre-pregnancy Counselling
• Women with heart disease should be aware of their condition prior
to pregnancy and they should be also assessed by Cardiologist “
managed or treated according to situation “
• Issues related to that :
- Risk of maternal death
- Possible reduction of maternal life expectancy
- Effects of pregnancy on cardiac diseases
- Risk of fetus developing Congenital Heart Disease
- Risk of preterm labor & Fetal Growth Restriction
- Intensive Maternal and Fetal monitoring during labor

6. Heart Diseases in
Pregnancy
• Rheumatic
• Congenital
• Arrhythmia
• Cardiomyopathy

7. Rheumatic Heart Disease
• The most common lesion is mitral stenosis
• Patients are at high risk for developing heart failure, subacute
endocarditis and thromboembolic disease
• Increased risk for fetal wastage
• Onset of pulmonary edema: 40 weeks of gestation
• Severe MS leads to atrial fibrillation, which can lead to CHF

8. Congenital Heart Diseases
• Include atrial and ventricular septal defects, primary pulmonary
hypertension and cyanotic heart disease
• Patients with complete surgical correction can tolerate pregnancy
• Patients with persistent septal defect generally tolerate pregnancy
• Patients with PH (primary or as a result of cyanotic heart disease)
should not get pregnant
• PH can lead to pulmonary congestion, heart failure and
hypotension, all of which can lead to sudden death

9. Cardiac Arrhythmia
• Supraventricular tachycardia is the most common type
• Occurs as a result of birth defects and changes in heart structure
• Atrial fibrillation and flatter are more serious forms, associated
with underlying cardiac diseases

10. Peripartum Cardiomyopathy
• Specific to pregnant or postpartum women
• Patient has no underlying heart disease
• Symptoms appear in the last week of pregnancy or within 6
months after delivery
• Dilatational cardiomyopathy, decreased ejection fraction
• Hx of preeclampsia, hypertension or poor nourishment
• Mortality rate: 20%, persistence: 30%- 50%, recurrence: 20%- 50%

11. Management
Depends on two factors
• The NYHA classification of heart
• The type of defect is important as well

12. New York Heart Association Functional Classification of Heart
Disease
Class I No signs or symptoms of cardiac decompensation
Class II No symptoms at risk, but minor limitation on
a physical activity
Class III No symptoms at rest, but major limitation on
o physical activity
Class IV Symptoms present at rest, increase with any
a kind of physical activity
Management

13. Management (Cont’d)
• Risk for types I and II is minimal
• Risk for types III and IV is marked
• Risk increases if cyanosis is present

14. Management (Cont’d)
• Risk also depends on the type of defect
• Mitral and aortic stenosis (obstructive diseases) carry a high risk for
decompensation
• Regurgitant diseases carry a lower risk
• Other high risk conditions: PH, Marfan syndrome, mechanical
valve, ventricular ejection fraction less than 40%, or a previous
history of cardiac event during pregnancy

15. Management: Antenatal
• Pregnant with significant Heart Disease should be managed in a joint
obstetrician/cardiac Clinic .
• Physicians have to distinguish Between Normal Pregnancy changes and
impending heart failure
• This is achieved by asking the pregnant woman about breathlessness -
esp at night -, changes in heart rate or rhythm, increased tiredness or
decreased exercise tolerance .
• Routine Physical examination “ Pulse rate and pressure , BP , JVP , and
sacral and ankle edema, presence of basal crackles “

16. Management: Antenatal (Cont’d)
• These women should be advised to reduce their normal physical
activities
• Echocardiography is good to assess Fxn and valves ,
Echocardiogram is usually done around 28 week - at the booking
visit -.
• Avoidance of excessive weight gain and edema
• Avoidance of Anemia

17. Management: Antenatal (Cont’d)
• The use of anticoagulants during pregnancy is a complicated issue .
• This is because Warfarin is teratogenic ‘ 1st trimester’ and linked
with fetal intracranial hemorrhage ‘3rd trimester’
• LMWH may be insufficient at preventing thrombosis in women w/
prosthetic heart valves ( risk >10% )
• Anticoagulation is essential in patients w/ congenital heart disease
who have pulmonary hypertension or artificial valve replacement ,
or for those at risk of atrial fibrillation
**

18. Fetal Risks of Maternal Cardiac Diseases
• Recurrence ( congenital Heart Disease )
• Maternal cyanosis  Fetal Hypoxia
• Iatrogenic Prematurity
• FGR
• Effects of Maternal Drugs ( Teratogenesis , Growth Restrictions ,
Fetal Loss )

19. Management: Labor and Delivery
• The aim of management is to await the onset of spontaneous labor
• Induction of labor should be considered for the usual obstetrician
Indications and in high risk women
• Epidural anesthesia is often recommended
• This regional anesthesia has some risk in some cardiac conditions
as it causes Hypotension
• Anesthetist should document an anesthetic management plan .

20. Management: Labor and Delivery (Cont’d)
• Prophylactic Antibiotics should be given to any woman with
cardiac defects to reduce risk of endocarditis
• Monitoring of Oxygen Saturation and Arterial Blood Pressure is
appropriate during labor
• The 2nd stage of normal labor may be intentionally shortened using
forceps or vacuum
• CS should only be done for normal obstetrician indications
• CS increases the risk of hemorrhage, thrombosis and infection

21. Management: Labor and Delivery (Cont’d)
• Postpartum Hemorrhage in particular can lead to major
Cardiovascular Instability
• 3rd stage of labor is managed actively by oxytocin ONLY
“ not w/ ergometrine “
• As oxytocin is a vasodilator, it should be administrated SLOWLY to
patients w/ significant heart disease
( w/ low-dose infusions preferable )
• High-level maternal surveillance is required until the main
hemodynamic changes following delivery have passed

22. Management: Labor and Delivery (SUMMERY)
• Avoid induction of labor if possible
• Use prophylactic Antibiotics
• Ensure Fluid Balance
• Avoid the supine position
• Discuss the type of anesthesia w/ senior anesthetist
• Keep the 2nd stage SHORT
• Use oxytocin judiciously

23. Thank You