prevalence, etiology, diagnosis, classification, managements specific diseases and abortion methods and more and more

1. This PowerPoint Presentation done by dr.Osama Khalil
Obstetrics and Gynecology Department
Ain Shams University

2. Heart disease in pregnancy is very rare but potentially serious and complicates
approximately 1% of all pregnancies. This Prevalence varies from one
community to another principally because the incidence of rheumatic heart
disease and undiagnosed or uncorrected congenital heart disease is higher in
developing countries.
Etiology
• Rheumatic valve “commonest in Egypt and developing countries”
• Congenital Heart diseases “commonest in developed countries”
• Others: e.g. Arrhythmia and ischemic heart diseases “rare”

3. A. Text
here
C. Text here
physiological changes in CVS during pregnancy
Irrespective of the underlying condition;
pregnancy imposes a significant burden
on the heart due to normal physiological
changes occur; both blood volume and
cardiac output are changed. The changes
are classified in: Vascular resistance
and blood pressure

4. The Heart
a. Lateral displacement of the Apex:
in late pregnancy (to the 4th intercostal space)
occur due to elevation of the diaphragm and the
heart by the fundus of growing uterus.
b. Functional systolic murmurs:
due to hyper dynamic circulation of the
dilutional anemia.

5. Cardiac Output
a. Preload: is increased due to associated
Rise in the blood volume " main cause".
b. Afterload: is reduced due to the
decline in systemic vascular resistance.
c. Maternal heart rate:
rises by 15-20 beats/min
rises to a peak at 28 to 34 weeks which is 30-50% above baseline because:

6. Vascular resistance and Blood pressure
BP typically fall early in gestation to about 5-10 mmHg below the baseline
in
the 2nd trimester "mean of about 105/60 mmHg". In 3rd trimester BP
gradually increases and may normalize to non-pregnant values by term.
The
fall in BP is reduced by a reduction in systemic vascular resistance due to:
a. Uteroplacental circulation. b. Systemic Vasodilatation
Supine Hypotension $
In the 2nd half of pregnancy; maternal hypotension
occurs in supine position due to pressure of pregnant
uterus on the IVC this leads to Decrease venous return
and cardiac output.

7. The Veins
Varicose veins, ankle edema and piles due to pressure by uterus on
pelvic veins, progesterone effect and increased blood volume.

8. NYHA (New York Heart Association) Functional grading of heart disease
Grade Symptoms Degree of compromise
I No limitation of physical activity- asymptomatic with
normal activity
Uncompromised
II : Mild limitation of physical activity -Symptoms with
normal physical activity
Slightly compromised
III : Marked limitation of physical activity -Symptoms
with less than normal activity, comfortable at rest
Markedly compromised
IV Severe limitation of physical activity- symptoms at
rest
Severely compromised
Grade I and II = 80% of the patientscompensated
heart
Grade III and IV 20% of the patients
decompensated heart

9. Diagnosis of Cardiac diseases during pregnancy including:
History Taking
Examinations
Investigations

10. History Taking
Clinical Features of Normal
pregnancy Mimic Heart Disease
SYMPTOMS :
1- Dyspnea.
2- Orthopnoea.
3- Paroxysmal Nocturnal Dyspnea.
4- Easy fatigue.
5- Dizziness.
Clinical indications of the Heart
Disease during pregnancy
SYMPTOMS :
1- Progressive Dyspnea or Orthopnoea.
2- Chest pain.
3- Nocturnal Cough.
4- Hemoptysis.
5- Syncope.

11. Examinations
Clinical Features of Normal
pregnancy Mimic Heart Disease
SIGNS :
1- Increased Pulse Rate.
2- Water Hummer Pulse.
3- Systolic Murmur.
4- Left Axis Deviation.
5- Edema.
6- congested Neck veins.
Clinical indications of the Heart
Disease
during pregnancy
SIGNS :
1- Cyanosis.
2- Clubbing Of fingers.
3- Persistent Arrhythmia.
4- Persistent Neck Veins.
5- criteria or Pulmonary HTN.
6- Cardiomegaly .
7- Diastolic Murmur.
8- Systolic Murmur more than or Equal grade 3/6.
9- Persistent split 2nd sound.

12. Investigations
1- Echocardiogram. cardiac status and structural anomalies
2- ECG.
3- Catheterization rarely done, if done guided by
transesophageal U/S.

13. Next
Effect of pregnancy on heart disease
(medical complications)
Effect of heart disease on pregnancy
(Obstetric complications)
• Worsening of cardiac status:
Decomposition ( heart failure):
a) During pregnancy: Increase COP
at 28 -32 WKS.
b) During labor: due to stress of
labor .
c) After delivery: the most
dangerous period due to
sudden return the blood to
general circulation.
• Bacterial endocarditis,
pulmonary edema, pulmonary
embolism, rupture of aneurism
specially during labor.
•Polyhydromaninos as a part of systemic
venous congestion.
•PPH: atonic due to uterine ischemia.
•Puerperal sepsis and secondary
postpartum hemorrhage.
•Defective lactation.

14. The Fetus is at increased risk of growth restriction and preterm delivery in pregnancies
complicated by cyanotic congenital heart disease. When
total fetal lose rate may be as higher as 40%. Uncorrected coarctation of aorta is
associated with fetal growth restriction in more than 10% of cases due to reduced
placental perfusion. The incidence of congenital Heart disease in general population is8
per 1000 live born babies if a parent is affected the risk is increase to 5%.
Therefore all pregnant women with congenital heart disease should be Referred for
export fetal cardiology scanning
•Abortion especially with cyanotic heart disease or due to teratogenic drugs
•Congenital fetal malformation due to chronic hypoxia or teratogenic drugs
•IUGR.
•Congenital heart disease in baby 5%.
•Neonate anemia and hypoxia.

15. The three categories are lesions that produce
volume overload, lesions that produce pressure
overload, and lesions that produce cyanosis.
Other cardiac conditions which have their own
unique issues are Cardiomyopathy, coronary
artery disease and Marfans syndrome.
1-Volume overload lesions
•Atrial septal defects
•Ventricular septal defects
•Patent ductus arteriosus
•Mitral and aortic regurgitation (insufficiency
2-Pressure overload lesions
•Congenital aortic stenosis
•Coarctation of the aorta
•Pulmonary valve stenosis
•Rheumatic mitral stenosis
3-Cyanotic congenital disease heart
•Ebstein’s anomaly
•Tetralogy of Fallot

16. Atrial septal defects
The most common congenital lesions in adults are atrial
septal defects and they may be first diagnosed during
pregnancy The expected 50% increase in blood volume
during pregnancy causes further volume loading, although
usually without a concomitant increase in pulmonary
artery pressures. Most patients with an isolated ASD
tolerate pregnancy well; good left ventricular ejection
fraction and NYHA functional status are predictive of
uncomplicated and successful outcomes With larger defects
and shunts, there is risk for congestive heart failure,
atrial arrhythmias, peripheral venous thrombosis or
embolism, cerebral vascular accidents, and shunt reversal
with cyanosis from sudden systemic hypotension.
1-Volume overload lesions

17. 1-Volume overload lesions
Ventricular septal defects
Clinical sequelae and symptoms manifest as exercise
intolerance, dyspnea or congestive heart failure are most likely
to happen if the VSD is large in size and therefore exerts a
hemodynamic effect. Infective endocarditis, however, can occur
with any size of VSD. Similarly to ASD, VSD should be repaired if
symptomatic, large (a Qp:QS ratio of >1.5:1) or associated with
an elevation in pulmonary artery pressure. Isolated VSD are
usually well tolerated in pregnancy unless the size is large and
degree of shunting places a large volume burden on the system;
peripartum risks are determined by parameters which reflect
the degree of shunting: left ventricular size and function,
pulmonary artery pressures, and the patient’s functional class.
In hemodynamically significant shunts, complications include
congestive heart failure, atrial arrhythmias, worsening
pulmonary artery hypertension, and shunt reversal with
cyanosis due to systemic hypotension. In a study from
Connecticut, USA, in the 1970s, there were no maternal deaths
reported in 98 pregnancies resulting in 78 liveborn infants in 50
women with VSD ,In women with corrected lesions, no
increased risks are associated with gestation.

18. Patent ductus arteriosus
the risks of pregnancy are related to shunt size and
degree of pulmonary hypertension. Clinical symptoms and
complications are also similar to those associated with
VSD. In corrected or uncorrected patent ductus arteriosus,
pulmonary hypertension significantly increases maternal
and fetal morbidity and mortality rates
1-Volume overload lesions

19. 1-Volume overload lesions
Mitral and aortic regurgitation (insufficiency)
Valvular regurgitation may be due to rheumatic disease, prolapse or endocarditis. It can
also occur in relation to ischemic heart disease and dilated cardiomyopathies. Trivial or
physiologic regurgitation of the mitral valve is present in up to 70% of normal patients on
echocardiography; it is not audible and is of no clinical significance. Complications occur
from valvular regurgitation as a result of chronic volume overload and related atrial or
ventricular strain and can include arrhythmias (especially atrial fibrillation in the setting of
mitral regurgitation), pulmonary hypertension (particularly from chronic severe mitral
insufficiency or congestive heart failure. If found in isolation, these lesions are usually well
tolerated in pregnancy. Due to the favorable effects of decreased systemic vascular
resistance and consequent afterload reduction in pregnancy, even severe regurgitation does
not exhaust the cardiac reserve. On the other hand, those patients with chamber
enlargement or ventricular dysfunction have higher rates of peripartum heart failure and
this should be anticipated

20. Rheumatic mitral stenosis
Patients with mild stenosis are asymptomatic. Those
with moderate stenosis are asymptomatic at rest.
Symptoms can include limited exercise tolerance,
dyspnea on exertion or, when supine, hemoptysis,
and pedal edema. Unless the mitral stenosis is
severe, most patients are asymptomatic.
2-Pressure overload lesions

21. Coarctation of aorta Risk of
rupture in late pregnancy or
labor
Coarctation of the aorta
The risks of pregnancy in women with aortic coarctation include
worsening hypertension, new-onset heart failure and, rarely but
ominously, aortic dissection and rupture .Ideally, moderate-to-
severe aortic coarctation should be repaired, with balloon
angioplasty or stenting, or replacement prior to pregnancy
2-Pressure overload lesions

22. aortic stenosis
Left-sided congestive failure
Congenital aortic stenosis
Isolated mild-to-moderate valvular aortic stenosis is well tolerated in
pregnancy, but severe aortic stenosis (aortic valve area (AVA)
<1.0 cm2 – the normal aortic valve area is 3–4 cm2) is associated with
increased maternal and fetal morbidity and mortality rates.
2-Pressure overload lesions

23. Pulmonary valve stenosis
Patients with unrepaired mild-to-moderate pulmonary stenosis (gradients
less than 40 mmHg; normally there should be no gradient across any valve)
are usually asymptomatic and tolerate the hemodynamic burden of
pregnancy with a low incidence of complications In patients with more
severe obstruction and worsening clinical function, Percutaneous balloon
valvuloplasty can be done during pregnancy.
2-Pressure overload lesions

24. Ebstein’s anomaly
In this uncommon congenital heart lesion, a malformed tricuspid valve
is apically displaced to a variable extent with resultant tricuspid
regurgitation, atrial dilation, and limited right ventricular function.
Severe cases present in infancy, but many cases will first present in
teenagers or adults. Complications include CHF, arrhythmias, and
paradoxical embolism. Associated abnormalities are frequent and
include ASD (50%) and the Wolff–Parkinson–White (WPW) syndrome
(30%) . Most patients can be treated medically but more severe forms
may develop right heart failure and require surgical correction.
Preconception repair is preferred to reduce morbidity and mortality
Approximately 70% of women with Ebstein’s anomaly have an
interatrial shunt, and therefore these women are also at risk for
paradoxic emboli (venous thromboembolism that passes through an
ASD into the left atrium and thereby the systemic-arterial
circulation to cause stroke or peripheral embolism).
3-Cyanotic congenital disease heart

25. 3-Cyanotic congenital disease heart
Tetralogy of Fallot
The most common cyanotic congenital heart defect found in children, adults,
and pregnant women In a recent retrospective study of 50 pregnancies that did
not end in abortions in 26 women, the maternal complication rate was 12% (of
pregnancies) and 19% (of patients) cardiac complications included symptomatic
right-sided heart failure in two cases and arrhythmias (three ventricular and
three supraventricular) All patients were NYHA class I prior to pregnancy. The
two patients with heart failure were noted to have severe pulmonary
insufficiency which would further increase the volume load on the right
ventricle . On the other hand, uncorrected or palliated lesions can be expected
to have clinical deterioration during pregnancy, resulting in increased maternal
and fetal complications In these patients, maternal risks include increased right-
to-left shunting via a residual VSD due to the normal fall in systemic vascular
resistance and, thus, worsening cyanosis during gestation and delivery;
biventricular heart failure; arrhythmias; and cerebral vascular accidents from
paradoxic emboli. Fetal risk is correlated with maternal hypoxia and includes a
very high rate of prematurity, low birthweight, and spontaneous abortion .

26. Maternal cardiac arrhythmias
Maternal cardiac arrhythmias are occasionally
encountered during pregnancy. Paroxysmal atrial
tachycardia is the most commonly encountered
maternal arrhythmia and is usually associated
with overly strenuous exercise. Underlying cardiac
disease such as mitral stenosis should be
suspected when atrial fibrillation and flutter are
encountered
Other cardiac disease

27. Peripartum Cardiomyopathy:
Peripartum Cardiomyopathy is an unusual but
especially severe cardiac condition identified in
the last month of pregnancy or the first 6
months following delivery. It is difficult to
distinguish from other cardiomyopathies (e.g.,
myocarditis) except for its association with
pregnancy. In many cases, no apparent cause can
be determined.
Other cardiac disease

28. Eisenmenger’s syndrome.
if right-to-left shunt—pulmonary
hypertension.
Other cardiac disease
•Artificial valves—thrombosis

29. Coronary artery disease
Atherosclerotic coronary artery disease is rare in premenopausal
women, but with increases in smoking, obesity, diabetes and delayed
childbearing, ischemic heart disease is now being seen in pregnancy
more frequently. Pregnancy increases the risk of myocardial infarction
3–4-fold. Acute myocardial infarction was reported to occur with a
frequency of 10/100,000 deliveries and a Medline search of case
reports suggests a very high maternal mortality rate (19–35%)
Other cardiac disease

30. Cardiac transplantation
The number of women deciding to become pregnant after cardiac transplantation has increased as more recipients are surviving longer and with an
improved quality of life. Pregnancy does not appear to have an adverse effect with respect to cardiac function or episodes of rejection
Other cardiac disease

31. Marfan’s syndrome
Pregnancy in women with the Marfan syndrome carries risk for worsening aortic dilation,
aortic valve regurgitation, congestive heart failure, and, more ominously, acute aortic
dissection and death Preconception aortic replacement or pregnancy termination should be
strongly considered for patients with ascending aortic diameters greater than or equal to
4.5 cm On the other hand, women without aortic dilation or cardiovascular complications
appear to tolerate pregnancy well
Other cardiac disease

32. Ehlers–Danlos type IV
Type IV or vascular EDS is the most dangerous type of EDS and may result in death related
to arterial, intestinal and uterine fragility or rupture. The heredity pattern is autosomal
dominant. Overall life expectancy is estimated to be 40–50 years, and most deaths are
secondary to arterial rupture. Maternal mortality rate is approximately 12%, with the
greatest risk of complications occurring during labor, delivery and early postpartum periods.
Although uterine rupture has been cited as the most common cause of maternal mortality
related to EDS type IV.
Other cardiac disease

33. For all women with CHD, counseling about future pregnancies and contraception should
begin in adolescence to prevent accidental and potentially dangerous pregnancies. To
obtain correct and complete information for risk stratification, a thorough evaluation should be
performed including
• Review of past medical records,
• Assessment of current functional status,
• Physical examinations,
• Pulse oximetry,
• Electrocardiogram,
• Imaging studies,
• Cardiopulmonary
• Exercise test and the use of Halter monitors.

34. Risk stratifications of preconception management
Risk assessment, by modified World Health Organization (WHO) risk classification, was
recommended by the European Society of Cardiology (ESC) to estimate the risk of pregnancy in
women with heart disease Four risk classes (WHO I, II, III and IV) were defined according to both
specific heart lesions and the clinical cardiac status The categories ranged from the very low risk of
WHO class I to the highest risk of WHO class IV, which was considered the contraindication for
pregnancy.
The table in the Next slide

35. WHO I
No significant risk elevation
WHO II
depending on individual
Mildly to moderately
elevated risk
WHO III
Significantly elevated risk
WHO IV
High risk
(pregnancy contraindicated)
•Uncomplicated, small or mild
-pulmonary stenosis
-patent ductus arteriosus
-Mitral valve prolapse
• Successfully repaired simple
lesions
-atrial or ventricular
septal defect,
-patent ductus arteriosus-anomalous p
ulmonary
venous drainage.
•Atrial or ventricular ectopic beats,
isolated WHO II Mildly elevated
Risk.
•Unoperated atrial or
ventricular septal defect (no
elevated pulmonary artery
pressure)
• Repaired tetralogy of Fallot
(without relevant residua
or sequelae)
• Most arrhythmias
• Mild left ventricular
Impairment.
•Hypertrophic
Cardiomyopathy.
•Native or tissue valvular
heart disease not
Considered WHOI or IV
•Marfan syndrome
without aortic dilatation.
•Aorta < 45 mm in aortic
disease associated with
bicuspid aortic valve.
•Repaired coarctation
•Non-severe systemic ventricular
dysfunction.
•Mechanical valve.
•Systemic right ventricle.
•Cyanotic heart disease
(unrepaired without pulmonary
hypertension).
•Other complex congenital heart
Disease.
•Aortic dilatation 40-45 mm in
Marfan syndrome.
• Aortic dilatation 45-50 mm in
aortic disease associated with
bicuspid aortic valve.
•Pulmonary arterial
hypertension of any cause
• Severe systemic ventricular
dysfunction (LVEF < 30%,
NYHA III-IV).
• Previous peripartum
Cardiomyopathy with any
residual impairment of left
ventricular function.
•Severe mitral stenosis, severe
symptomatic aortic stenosis,
severe coarctation.
•Marfan syndrome with aorta
dilated > 45 mm.
• Aortic dilatation > 50 mm in
aortic disease associated with
bicuspid aortic valve
• Native severe coarctation

36. The flowchart for preconception assessment and counseling for women with congenital heart
disease. CPX, cardiopulmonary exercise test; PE and WHO

37. Antenatal Management
•Place
In most of cases, patients are followed up in special cardiac out patient clinic under
Under supervision of both obstetricians, cardiologists and anesthesiologist .
Antenatal care visits more frequent for adequate follow up of maternal cardiac state
And fetal well-being.
Indication of hospitalization includes:
1) Cases of class II at 24-32 weeks of pregnancy.
2) Cases of class III and IV are admitted earlier and for longer periods.
3) Near term to plan for delivery.

38. Antenatal Management
•Drug therapy
a) Prophylaxis against rheumatic activity  antibiotics
Indication: patients with rheumatic heart lesion
Drug used:
1) Long acting penicillin or daily penicillin
2) Erythromycin (if sensitive to penicillin)
b) Prophylaxis against of infective endocarditis  antibiotics
Indications:
- Patients need prophylaxis : patient with problems affecting the structure of the
Heart (e.g. replacement heart valve congenital heart disease hypertrophic Cardiomyopathy.
patient with pervious history of Invective Endocarditis.
- Conditions need prophylaxis: Before any minor surgery (e.g. tooth extraction) and labor or CS
Drug used:
a) At onset of labor or ROM to prior to CS or minor surgery by ½ hour.
 Amoxicillin 1or 2 gm IV plus
b) Then: amoxicillin 500 mg oral after 6 hours
c) For women who are allergic to penicillin: vancomycin 1 gm IV.
Next

39. Antenatal Management
•Drug therapy
c) Prophylaxis against thrombosis antithrombotic drugs
Indication: for patients with metallic valves.
Drug used: choice of 3 regimens:
1) LMWH through out pregnancy, weight-adjusted dose with anti-Xa level monitoring
2) Warfarin through out pregnancy, if can keep warfarin less than or equal 5 mg e.g. INR 2-3 in
aortic prosthesis, sinus rhythm, change to LMWH or UFH at 36 weeks.
3) LMWH until 13 weeks, and then warfarin and aspirin until 36 weeks; change to LMWH or UFH
until labor. Monitoring anti-Xa level with LMWH.
d) Treatment of heart failure and Acute pulmonary edema:
 Fowler position
 Opioid (morphine)
 Oxygen
 Drugs: Digitalis Diuretics  Frusemide 20-25 mg. Dilators  Hydralazine in hypertension

40. Antenatal Management
•Surgery in Pregnancy
A) Balloon catheterization or even closed heart operation: could be done in 2nd trimester
in case of severe mitral stenosis.
B) Valve Replacement: indicated only in life threaten cases during pregnancy; as it need open
heart surgery with heart-lung machine

41. Antenatal Management
•Follow Up
a) Maternal condition:
 Routine antenatal tests.
 Cardiac assessment and early detection of heart failure
 Recognition of risk factors “anemia, infection Or hypertension”.
 Investigations “Echocardiogram, ECG, CBC and sputum culture for chest infection
b) Fetal condition:
Follow up of fetal kicks with regular tests of fetal wellbeing.
•Other instructions and interventions
 No heavy work and bed rest; 9 hours by night, 2 hours by day.
 Guard against excessive weight gain.
 Salt restrictions.
 Correction of anemia.
 Dental care and use of an umbrella of antibiotics when there is tooth extraction
 Control of any Risk Factors eg. Anemia, infection Or hypertension.
 Antenatal corticosteroids if preterm labor occurs or is indicated.

42. Termination of pregnancy
•Indications:
a) Gestational age:
 Pregnant women with cardiac disease who are considered functionally normal be allowed to go in to labor
spontaneously
 If there are any concerns about the functional adequacy of the heart and circulation, labor should be induced under
controlled conditions the timing of induction is individualized taking into account the patient cardiac status inducibility
of the cervix fetal lung maturity.
b) Maternal condition:
development of obstetric or medical complication inducing delivery.
c) Fetal condition:
Non-reassuring fetal rate evaluation, non-reassuring biophysical scores, IUFD or malformation
Incompatible with life
d) Other indication for termination: e.g the patient is in labor

43. Termination of pregnancy
•Mode of termination:
a) Vaginal delivery:
 Virtually all women with cardiac disease can expect to attempt vaginal delivery because it poses less cardiac risk than cesarean delivery.
A long induction in a woman with an unfavorable cervix should be avoided
b) Cesarean delivery:
 Should be reserved for obstetric indications such as :
- Fetal heart tracing is non-reassuring and vaginal delivery is not imminent.
- Vaginal delivery is contraindicated eg. Placenta previa, prior classical cesarean delivery
- Vaginal delivery is unsuccessful “ Failure to progress”
 Cesarean delivery in cardiac diseased women is indicated in
- Pre-term labor in patient on oral anti-coagulants.
- Marfan and other ascending aortic aneurysms.
- Aortic dissection.
- Severe Aortic stenosis.
- Eisenmenger’s syndrome.
The concerns about cesarean delivery
- General anesthesia, if required, incurs the risk of hemodynamic
instability.
-CS is accompanied by blood loss that is about twice as great as with
vaginal delivery.
-There are increased risks of wound and uterine infection.
-Postoperative thrombophlebitis is more common after CS.
-The risk of postoperative incisional bleeding is high in patients requiring
anticoagulants.

44. Termination of pregnancy
•Intra-partum Management :
 Delivery in semi-sitting (Fowler) position with adequate oxygenation.
 Staining is prohibited, to minimize venous return and decrease heart rate.
 Proper pain relief to minimize anxiety and tachycardia.
 Close observation to avoid PPH.
 Avoid early ROM and Excessive PV to avoid infection.
 Fluid restriction and anti-failure measures in cases at high risk for heart failure.
 Antibiotic prophylaxis against Infective Endocarditis.
 Shorten the second stage by low-forceps when necessary.
Epidural anesthesia may sometimes cause systemic hypotension, so it
contraindicated in cases with right-left shunt. Also it is not suitable for patients on
anticoagulants

45. Termination of pregnancy
•Post-Partum Management :
 Measures to avoid PPH:
- Oxytocin should be infused slowly (less than 2 units/min) to avoid hypertensive effect.
- Ergometrin should be avoided in most patients (high rate of vasoconstriction and elevation of blood pressure
 Hemodynamic monitoring of the mother is warranted for 12-24 hours after delivery.
 In patients requiring prolonged bed rest:
- Meticulous leg care.
- Elastic support stockings.
- Early ambulation are important preventive measures that reduce the risk of VTE.
 Warfarin is started 2-3 days post-partum if patient is on anticoagulant therapy.
 Prophylaxis and treatment of expected anemia.
 Prophylactic antibiotics against sepsis.
 Anti-D Ig should be given to all non-sensitized RhD-negative women.
 Care of the neonate.
 Breast-feeding is contraindicated only if there is heart failure.
 Proper selection of a method of contraception, for adequate pregnancy spacing.

46. In pregnant women with cardiac disease
Which cardiac patients should be referred to hospital for an abortion?
• Congenital – Cyanotic disease, right/left ventricular dilatation, uncontrolled
tachyarrhythmia
• Coronary disease  History of AMI, treatment angina.
• Cardiomyopathy Dilated, hypertrophic, history of peripartum CMP.
• Valvular disease  Significant aortic/mitral stenosis
 Aortic/mitral regurgitation with LV dilatation.
Abortion in women with significant cardiac disease
• Identify the women with cardiovascular disease by -European Society of Cardiology
guidelines or WHO Classifications
• Consult a cardiologist – Not all cardiac diseases are alike
• Consult an anesthesiologist experienced in cardiac anesthesia
– Follow selected patients (pulmonary hypertension!) long enough(at least overnight)

47. Medical vs. surgical abortion in women with significant cardiac disease
The medical abortion method is also referred to as the “abortion pill” method. Medical abortion is an
abortion caused by medicine rather than surgery. Two medications are used in medical abortions:
Mifepristone and misoprostol. It is only available in women who are less than 7 weeks pregnant
Cervical
Ripening
MIFEPRISTONE
Causes progesterone blockade
Decidual
Necrosis
Detachment
MISOPROSTOL
Causes uterine cramping & expulsion

48. A surgical abortion also known as aspiration abortion, empties the contents of your uterus and
is usually performed within 12-14 weeks from your last normal menstrual period.
Two types of surgical abortion:
Vacuum Aspiration
Manual Vacuum Aspiration (MVA) removes the fetus/embryo by suction using a manual syringe.
Electric Vacuum Aspiration (EVA) which uses an electric pump to remove the fetus/embryo.
Dilation and Evacuation is done in the second 12 weeks (2nd trimester) of pregnancy. It
usually includes a combination of vacuum aspiration, dilation and curettage (D&C), and the use
of surgical instruments (such as forceps).
Medical vs. surgical abortion in women with significant cardiac disease

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