This document discusses heart disease in pregnancy. It notes that rheumatic valvular heart disease is the most common cause of cardiovascular disease in pregnancy in developing countries. The most common rheumatic lesion is mitral stenosis. Congenital heart disease is the most frequent cardiovascular disease present during pregnancy in industrialized countries, with shunt lesions being predominant. Pregnancy can exacerbate pre-existing heart conditions and lead to complications like heart failure, arrhythmias, and pulmonary edema due to the increased cardiovascular demands. Careful management and monitoring during pregnancy and delivery are important for women with heart disease.

1. HEART
DISEASE IN
PREGNANCY
Dr.Nishant K. Thakur
MD Obstetrics &
Gynaecology

2. Incidence
At present, cardiac disease complicates 0.2–4% of all pregnancies in Western
countries. In developing countries like India, cardiac diseases complicate 2% of
pregnancies and contribute to about one-fifth of all maternal deaths.
Congenital heart disease is the most frequent cardiovascular disease present
during pregnancy (75–82%) in the industrialized world, with shunt lesions being
predominant (20–65%).

3. Rheumatic valvular heart disease is most common cause in developing countries, comprising 56–
89% of all cardiovascular diseases in pregnancy.
The commonest cardiac lesion is of rheumatic origin followed by the congenital ones.
The ratio between the two has fallen over the past two decades from 10: 1 to about 3: 1 or even
1: 1 in advanced countries.
Rheumatic valvular lesion predominantly includes mitral stenosis (80%).

4. Predominant congenital lesions include patent ductus arteriosus, atrial or ventricular
septal defect, pulmonary stenosis, coarctation of aorta and Fallot’s tetralogy
Rare causes are hypertensive, thyrotoxic, syphilitic or coronary cardiac diseases.
Cardiomyopathy is uncommon, but represents severe cause of cardiovascular
complications in pregnancy.

5. Peripartum cardiomyopathy (PPCM) is the most
frequent cause of severe complications.
Maternal heart disease is now the major cause of
death during pregnancy in developed countries.

6. EFFECT OF
CARDIOVASCULAR
PHYSIOLOGY ON
HEART LESION

7. A normal heart has got enough reserve power so that the extra load can well be
tackled. While a damaged heart with good reserve can even withstand the
strain but if the reserve is poor, cardiac failure occurs sooner or later.
Cardiac failure occurs during pregnancy around 30 weeks, during labor and
mostly soon following delivery.

8. Factors
responsible
for cardiac
failure:
Advanced age
Cardiac arrhythmias or left ventricular hypertrophy
History of previous heart failure
Appearance of “risk factors” in pregnancy like infection, anemia,
hypertension, excessive weight gain and multiple pregnancy.
Inadequate supervision.

9. EFFECTS OF
HEART
LESION ON
PREGNANCY

10. There is tendency of preterm delivery and
prematurity.
IUGR is quite common in cyanotic heart
diseases.

11. New York Heart Association Cardiac
Functional Classification
Class I No limitations of physical activity; ordinary physical activity
does not cause undue fatigue, palpitation, dyspnea, or
anginal pain.
Class II Slight limitation of physical activity; ordinary physical
activity results in fatigue, palpitation, dyspnea, or anginal
pain.
Class III Marked limitation of physical activity; less than ordinary
activity causes fatigue, palpitation, dyspnea, or anginal
pain.
Class IV Inability to perform any physical activity without
discomfort; symptoms of cardiac insufficiency or anginal
syndrome may be present, even at rest; any physical
activity increases discomfort

12. Risk of
Maternal and
Fetal Morbidity
Associated with
Pregnancy
Low Risk
1. Mitral valve prolapse without severe regurgitation
2. Atrial and ventricular septal defect previously
repaired or without pulmonary hypertension
3. Corrected congenital heart disease without
residual cardiac dysfunction
4. Patent ductus arteriosus
5. Pulmonary stenosis
6. Mild mitral or aortic valvular disease (stenosis or
regurgitation) with normal left ventricular
function: New York Heart Association class I or II

13. Risk of Maternal
and Fetal
Morbidity
Associated with
Pregnancy
Continued...
Moderate Risk
1. Marfan’s syndrome with normal
aorta
2. History of peripartum
cardiomyopathy with no residual
ventricular dysfunction
3. Previous myocardial infarction

14. Risk of
Maternal and
Fetal Morbidity
Associated with
Pregnancy
Continued...
High Risk
1. Any condition with New York Heart Association
class III or IV. Moderate to severe systemic
ventricular dysfunction
2. Pulmonary hypertension from any cause
3. Tetralogy of Fallot; uncorrected or with residual
disease
4. Coarctation of the aorta
5. Mitral stenosis with atrial fibrillation
6. Severe aortic stenosis
7. Mechanical valve requiring anticoagulation
8. Marfan’s syndrome with aortic involvement
9. History of peripartum cardiomyopathy with
residual ventricular dysfunction

15. Risks of Maternal Mortality with Heart
Disease (NYHA, 1992)
Cardiac Disease Mortality(%)
Group 1 (minimal risk): ASD, VSD, PDA, Fallot tetralogy
(corrected), Mitral stenosis (NYHA– Grade I and II),
bioprosthetic valve
0-1%
Group 2 (moderate risk): MS (NYHA – III and IV) AS,
Marfan syndrome (Normal aorta), Fallot tetralogy
(uncorrected), M S with atrial f brillation, artif cial valve
5-15%
Group 3 (major risk): Pulmonary hypertension, Marfan
syndrome (aortic involvement), aortic coarctation with
valvular involvement
25-50%

16. PROGNOSIS

17. Maternal prognosis
1. Nature of lesion.
2. Functional capacity of the heart.
3. Quality of medical supervision provided during pregnancy,
labor and puerperium.
4. Presence of other risk factors.
5. Whether patient has undergone corrective surgery or not.

18. • Maternal mortality is lowest in rheumatic heart lesions and
acyanotic group of heart diseases—less than 1%.
• With elevation of pulmonary vascular resistance especially with
cyanotic heart lesions, the mortality may be raised to even
50% (Eisenmenger’s syndrome).
• Most of the deaths occur due to cardiac failure and the
maximum deaths occur following birth.

19. • The other causes of death are—(a) pulmonary edema (b)
pulmonary embolism (c) active rheumatic carditis (d) subacute
bacterial endocarditis and (e) rupture of cerebral aneurysm in
coarctation of aorta.
• Pregnancy does not affect the long term survival of a woman
with rheumatic heart lesion provided she survives pregnancy
itself.

20. Fetal prognosis
In rheumatic heart lesions, the fetal outcome is usually good and
in no way different from the patients without any heart lesion.
In cyanotic group of heart lesion, there is increased fetal loss
(45%) due to abortion, IUGR and prematurity.
Fetal congenital cardiac disease is increased by 3–10% if either
of the parents have congenital lesions.

21. Risk of Congenital Heart Defect in Offspring
of Women with Congenital Heart Disease
Congenital heart defect Neonatal risk(%)
Any defect 5-6
ASD 4-6
VSD 6-10
Tetralogy of Fallot 3-5
Transposition of great vessels 0
Aortic Coarctation 4
Aortic Stenosis 4-18
Pulmonary stenosis 3-4
Ebstein’s anomaly 4-6

22. DIAGNOSIS

23. Symptoms
Symptoms Signs
Breathlessness Chest murmurs—pansystolic, late systolic, louder ejection systolic or
diastolic associated with a thrill.
Nocturnal cough Cardiac enlargement, arrhythmia
Syncope CXR (using lead shield): Cardiomegaly, increased pulmonary vascular
markings, enlargement of pulmonary veins.
Chest pain Electrocardiography: T wave inversion, biatrial enlargement,
dysrhythmias
Echocardiography (color flow Doppler study): Structural
abnormalities (ASD, VSD), valve anatomy, valve area, function, left
ventricular ejection fraction, pulmonary artery systolic pressure
Cardiac MRI can delineate complex anatomy

24. MANAGEMENT

25. GENERAL MANAGEMENT
Principles:
• Early diagnosis and evaluation of anatomical type and
functional grade of the case.
• To detect the high risk factors and to prevent cardiac failure.
• Multidisciplinary team approach (obstetrician, cardiologist and
neonatologist) and mandatory hospital delivery.

26. Prepregnancy:
• Ideally in patients with significant heart disease, pregnancy is
a planned event.
• The patient’s cardiologist should be an active participant.
• Maternal disease status should be determined.
• A careful history is obtained to identify previous cardiac
complications, including arrhythmias.
• The patient’s functional status should also be established by
New York Heart Association (NYHA) classification system.

27. Most cases falls in groups I & II disease with favorable outcomes , but deterioration
may occur.
Grade III & IV disease have very high maternal mortality, nearly 85%.
Coexisting conditions that may aggravate preexisting heart disease, such as anemia,
arrhythmias, and hypertension, should be appropriately treated and controlled.
Ideally, necessary cardiac surgery is carried out before conception.

28. Prenatal
Most evaluation and counseling will be initiated at the first prenatal visit
as very few cases visits doctors during their prepregnancy period.
Cardiac surgery, although not contraindicated, is usually not required
during pregnancy, If possible, it is best delayed until postpartum.
When the maternal mortality rate is excessive, termination of the
pregnancy should be discussed.

29. Therapeutic
Termination
Absolute indications:
•Primary pulmonary hypertension
•Eisenmenger’s syndrome and
•Pulmonary veno-occlusive disease.
Relative indications:
•Parous woman with grade III and IV cardiac lesions
•Grade I or II with previous history of cardiac failure in early months
or in between pregnancy.
The termination should be done within 12 weeks by
suction evacuation (MVA) or by conventional D & E.

30. The patients with heart disease should be supervised in a tertiary care hospital.
Initial assessment should be made in consultation with a cardiologist.
During prenatal care, the patient should be routinely questioned and examined for signs or
symptoms of cardiac failure:
•Infections—Urinary tract, dental and respiratory tract.
•Anemia, Obesity, Hypertension, Arrhythmias , Hyperthyroidism, Drugs— Betamimetics.
•Dietary indiscretion: Excess intake of caffeine, alcohol, high calorie diet, excess salt.

31. Injection Penidure LA-12 (benzathine penicillin) is given at intervals of 4 weeks
throughout pregnancy and puerperium to prevent recurrence of rheumatic fever.
Counseling is to be done regarding prognosis and risks.
Anticoagulants are indicated in cases with: (a) Congenital heart disease, (b)
pulmonary hypertension, (c) mechanical heart valve, (d) atrial fibrillation.

32. The patient taking warfarin should discontinue it as soon as pregnancy is diagnosed and to replace
it by heparin 5,000 units twice daily subcutaneously up to 12th week.
Low molecular weight heparin (LMWH) can also be used. This is then replaced by warfarin tablet
3 mg. daily to be taken at the same time each day and continued up to 36 weeks.
Thereafter it is replaced by heparin up to 7 days postpartum. Warfarin is then to be continued.
UFH, LMWH and Warfarin therapy do not contraindicate breast-feeding.

33. Cardiac surgery in pregnancy is indicated when there is failure of medical
treatment for Intolerable symptoms & Intractable cardiac failure .
Elective:
•Grade–I : At least 2 weeks prior to the expected date of delivery
•Grade–II : At 28th week especially in case of unfavorable social surroundings
•Grade III and IV : As soon as pregnancy is diagnosed. The patient should be kept in the
hospital throughout pregnancy.

34. Emergency:
• Deterioration of the functional grading
• Appearance of dyspnea or cough or basal crepitations or
tachyarrhythmias
• Appearance of any pregnancy complication like anemia,
preeclampsia.

35. DURING LABOR
Most patients with cardiac disease go into spontaneous labor and
deliver without any difficulty.
Induction (vaginal PGE2 ) may be employed in very selected cases for
obstetric indications.
One should guard against infection and pulmonary edema due to fluid
overload.

36. First stage:
• Position: The patient should be in lateral recumbent position to minimize
aortocaval compression
• Oxygen is to be administered (5–6 L/min) if required
• Analgesia in the majority, is best given by epidural
• Prophylactic antibiotics against bacterial endocarditis
• Fluids should not be infused more than 75 mL/hour to prevent pulmonary edema.

37. Careful watch of the pulse and respiration rate. If the pulse rate exceeds 110 per minute in
between uterine contractions, rapid digitalization is done by intravenous digoxin 0.5 mg.
Cardiac monitoring and pulse oximetry can detect arrhythmias and hypoxemia early.
Central venous pressure monitoring may be needed in selected cases.

38. Prophylactic antibiotics for bacterial endocarditis.
Antibiotic prophylaxis during labor and 48 hours after delivery is considered appropriate.
The recommended regimens include intravenous ampicillin 2 g and gentamicin 1.5 mg/kg (not to
exceed 80 mg), at the onset or induction of labor followed by repeat doses 8 hours interval.

39. Second stage:
•No maternal pushing.
•Second stage of labor is to be curtailed by forceps or ventouse under pudendal and/or
perineal block anesthesia.
•Ventouse is preferable to forceps as it can be applied without putting the patient in
lithotomy position (raising the legs increases the cardiac load).
•Intravenous ergometrine with the delivery of the anterior shoulder should be withheld
to prevent sudden overloading of the heart by the additional blood squeezed out from
the uterus.

40. Third stage:
Slight blood loss is not detrimental but if it is in excess, oxytocin can be given by
infusion. This may be accompanied by aggressive diuresis by IV frusemide.
It is better to administer oxytocin in preference to ergometrine in all cases of
heart disease in third stage.

41. Usually Vaginal delivery is encouraged unless indication for Cesarean:
• Coarctation of aorta
• Aortic dissection or aneurysm
• Aortopathy with aortic root >4cm
• Warfarin treatment within 2 weeks
• Preferred choice or anaesthesia is Epidural or General anaesthesia.

42. PUERPERIUM:
Observation closely for the first 24 hours.
Oxygen is administered.
Hourly pulse, BP and respiration are recorded.
Diuretic may be used if there is volume overload.
Breastfeeding is not contraindicated unless there is heart failure.
Anticoagulant therapy is not a contraindication of breastfeeding.

43. CONTRACEPTION:
•Barrier method of contraceptives (condom) is the best.
•Progestin only pills or parenteral progestins are safe and effective.
•Intrauterine device (copper IUCD or LNG-IUS) is often avoided for fear of infection though
WHO permits its use.
•Permanent sterilization should be considered with the completion of the family at the end of
first week in the puerperium under local anesthesia through abdominal route by Minilap
technique.
•If the heart is not well compensated, the husband is advised for vasectomy.

44. MANAGEMENT OF CARDIAC
FAILURE IN PREGNANCY

45. Propped up position
O2 administration
Monitoring with ECG and pulse oximetry
Diuretic: Frusemide (Loop) (40–80 mg) IV (anticipatory aggressive diuresis is needed to avoid pulmonary congestion)
Mechanical ventilation
Injection morphine 15 mg IM
Digoxin 0.5 mg IM followed by tab digoxin 0.25 mg P.O. (Digoxin crosses the placenta and is excreted in breast milk)
Dysrhythmias—quinidine or electrical cardioversion
Tachyarrhythmias—Adenosine (3–12 mg) IV or DC conversion

46. PREDICTORS OF ADVERSE MATERNAL
OUTCOMES
Prior cardiac failure, arrhythmia or transient ischemic attack.
Baseline NYHA class > 2 or associated cyanosis.
Left heart obstruction: Mitral valve area < 2 cm2 , aortic valve area < 1.5 cm2 , or peak
ventricular outfow gradient > 30 mm Hg by echocardiography.
Left ventricular ejection fraction < 40%.

47. RHEUMATIC HEART
DISEASE

48. Asia, Africa, and South America have high prevalence rates.
Rheumatic heart disease is a complication of rheumatic fever.
Cardiac valve damage results from an immunologic injury initiated by a group A β-hemolytic streptococcal
infection.
During pregnancy, the increased maternal blood volume and heart rate can lead to heart failure and
pulmonary edema. Arrhythmias also frequently complicate pregnancy.

49. • Rates of IUGR and prematurity are increased with complicated
rheumatic heart disease.

50. General
management
Principle:
• Aim is to prevent cardiac
failure and bacterial
endocarditis.
• Volume status is monitored,
and activity should be limited.
• Antibiotics can be given prior
to cesarean section.

51. MITRAL
STENOSIS

52. Either alone or in combination with other lesions, is the most common valvular disorder associated
with rheumatic heart disease.
Normal mitral valve area ranges between 4 and 6 cm2 .
Symptoms usually appear when stenosis narrows this to less than 2.5 cm2 .
Women with mitral valve area ≤1 cm2 , have the high rate of pulmonary edema (55%) and
arrhythmia (33%).

53. In pregnancy, the increased intravascular volume can further elevate pressures and lead to
pulmonary edema and arrhythmias, even in previously asymptomatic patients.
In asymptomatic cases, the mortality is < 1% but once it is significantly symptomatic,
mortality ranges between 5% and 15%.
The severity of the stenosis is the best predictor of cardiac compromise.

54. MANAGEMENT

55. PREPREGNANCY
Define the severity of cardiac compromise.
Two-dimensional echocardiography and color-flow Doppler are used to determine cardiac function
and the degree of stenosis.
Severe stenosis is defined by a valve area of less than 1.0 cm.
Valve areas of 1.2 cm or less are associated with an increased risk of complications during
pregnancy.

56. • In symptomatic patients or those with
severely stenotic valves, surgical
correction should take place before
conception.
1. Surgical commissurotomy (traditional
treatment modality).
2. Percutaneous mitral valve
commissurotomy (an alternative in
patients without calcified valves or
significant regurgitation).

57. PRENATAL
Goal is to avoid cardiac decompensation.
Special attention should be paid to volume status.
Weight gain should be closely monitored.
Restriction of physical activity.
β-Blocker may be used to control heart rate.
Atrial fibrillation can be managed with digoxin (category C) or cardioversion, as necessary.

58. Persistent or long-standing AF may require anticoagulation to prevent atrial
thrombi.
Percutaneous mitral balloon valvulotomy may be necessary to treat patients with
significant functional deterioration or refractory pulmonary edema, despite optimal
medical management.
Best time of surgery is between 14 weeks and 18 weeks.

59. LABOR AND
DELIVERY
During the intrapartum and postpartum periods, volume status and
cardiac output are critical concerns.
β-blockers (most category C) may be necessary to control heart rate
and maintain cardiac output during labor.
Epidural is both safe and effective mode for analgesia and anaesthesia.
Cesarean delivery is typically reserved for obstetric indications.
If abdominal delivery is necessary, epidural is the anesthetic method of
choice.
Although forceps delivery is advocated to shorten the second stage of
labor and reduce bearing down, it is not always required.
Endocarditis antibiotic prophylaxis should be given prior to cesarean
section.

60. Family planning
Combined hormonal contraceptive methods should be used only in
patients with mild stenosis and no atrial fibrillation.
Standard IUDs should be used with caution owing to a potential
increased risk of endocarditis.
The levonorgestrel intrauterine contraceptive system is preferable
because it is associated with a very low risk of infection.

61. AORTIC
STENOSIS

62. It can be congenital or rheumatic in origin, or it may be due to an age-
related calcification of the aortic valve .
It accounts for only 5% to 10% of cases of rheumatic heart disease in
pregnancy and is usually seen in conjunction with mitral valve disease.
Normal aortic valve area is 3–4 cm2 . When it is reduced to less than or
equal to 1 cm2 , stenosis is significant.

63. Management
PREPREGNANCY
•Before pregnancy, the severity of aortic stenosis should be determined by echocardiography.
•Severe disease should be corrected surgically before conception.
PRENATAL
•Physical activity should be limited.
•Patients should be observed for signs of congestive heart failure or arrhythmias.
•Serial fetal ultrasounds should be scheduled to detect evidence of growth restriction.

64. LABOR AND DELIVERY AND POSTNATAL
• Fluid management is the critical component of intrapartum care.
• Patients should labor and deliver in the lateral position .
• Epidural anesthesia is contraindicated.
• During labor, fluid therapy (125–150 mL/h) should not be restricted.
• Blood loss to be monitored closely and replaced as necessary.

65. Overaggressive diuresis if pulmonary oedema develops.
Oxygen supplementation, morphine (category B), and inotropic agents, such as dopamine
(category C) or dobutamine (category C), may be needed to maintain cardiac output.
Bacterial endocarditis prophylaxis is recommended for cesarean delivery.
Close monitoring of volume status is essential in the postpartum period.

66. Cardiomyopathies

67. Peripartum
cardiomyopathy
Important diagnostic criteria are:
• Cardiac failure within last month of pregnancy or within 5
months postpartum.
• No determinable cause for failure.
• Absence of previous heart disease.
• Left ventricular dysfunction as evidenced on
echocardiography—
• Ejection fraction less than 45% and
• Left ventricular end diastolic dimension more than 2.7
cm/m2 .
Peripartum cardiomyopathy is a diagnosis of
exclusion.

68. The patients are usually multiparous and young (20–35 years).
Symptoms:
• Weakness,
• Shortness of breath,
• Cough,
• Nocturnal dyspnea and
• Palpitation.

69. Signs
•Tachycardia,
•Arrhythmia,
•Peripheral edema and
•Pulmonary rales.
Pregnancy is poorly tolerated in women with dilated cardiomyopathy.

70. Management

71. Prepregnancy
Pregnancy is strongly discouraged in patients with a history of peripartum cardiomyopathy, particularly those with residual cardiac
dysfunction.
The patient should be informed of the potential for worsening cardiac function during pregnancy, which may not completely
resolve postpartum.
Combined hormonal contraceptives should be avoided in patients with residual ventricular dysfunction.
Depo-Provera or IUDs can be safely used.
Permanent sterilization may also be considered.

72. Prenatal
If pregnancy occurs, echocardiography should be performed to
document ventricular size and function as well as the presence of mural
thrombi.
Termination should be offered, especially to patients who have
persistent echocardiographic abnormalities.

73. Labor and Delivery and postpartum
Treatment:
• Bed rest,
• Digoxin,
• Diuretics (preload reduction),
• Hydralazine or ACE inhibitors (postpartum) (afterload reduction),
• β blocker and
• Anticoagulant therapy.

74. Vaginal delivery is preferred.
Epidural anesthesia is ideal.
There is no contraindication of breastfeeding.
Mortality is high (20–50%)—due to CCF, arrhythmia or thromboembolism.
It may recur in subsequent pregnancies.

75. CONGENITAL
HEART DISEASE

76. A. Acyanotic
a) ASD(Ostium secundum-most common)
b) VSD
c) PDA
d) Mitral valve prolapse
B. Cyanotic
a. Fallot’s Tetralogy
b. Eisenmenger’s syndrome

77. C. Others
a) Coarctation of aorta
b) Primary Pulmonary Hypertension
c) Marfan’s syndrome