Heart disease and its management during pregnancy

1. BY:
MS. LAMNUNNEM HAOKIP
SR. TUTOR (OBG)
SSNSR, SU

2. PRELUDE
⫸Pregnancy in most women with heart disease has a favorable
maternal and fetal outcome. With the exception of patients with
Eisenmenger syndrome, pulmonary vascular obstructive
disease, and Marfan syndrome with aortopathy, maternal
death during pregnancy in women with heart disease is rare.
⫸However, pregnant women with heart disease do remain at risk
for other complications including heart failure, arrhythmia, and
stroke.

3. Cardiovascular changes during
pregnancy
⫸Increases in blood volume by 30 – 50%
in pregnancy
⫸Increases Cardiac output overall by 40%
⫸Stroke volume increases
⫸Heart Rate increases by 20%
⫸Blood pressure decreases – due to
decrease in peripheral vascular
resistance.

4. Physical changes in CVS examination
⫸Apex beat at the 4th intercostal space lateral to the mid
clavicular line
⫸Straightening of the left heart border
⫸Loud heart sounds
⫸Exaggerated splitting of S1
⫸Ejection systolic murmur grade 2
⫸Tachycardia

6. Diagnosis of Heart Disease
in Pregnancy
⫸Symptoms: Breathlessness, nocturnal cough, orthopnoea,
syncope and chest pain.
⫸Signs: Chest murmurs – Pansystolic, late systolic, louder
ejection systolic or diastolic associated with a thrill.
⫸Cardiac enlargement, arrhythmia
⫸Chest radiography (using lead shield): cardiomegaly,
enlargement of pulmonary veins

7. Changes in Cardiac Output during
Pregnancy
Starts rising by 5 weeks of pregnancy
⫸In the antenatal period – max. at 28 to 32 weeks
⫸During labour – 50% additional increase in CO with each
contraction.
⫸Immediately Postpartum – 80% additional 800 ml of blood moves
into systemic circulation again causing extra load on heart.
⫸Remains high for 28 to 48 hours after delivery
⫸Return to normal by 10 days.

8. Specific Heart Disease during pregnancy and
its Management
RHEUMATIC HEART
DISEASE
• Mitral Stenosis
• Aortic Stenosis
CONGENITAL HEART DISEASE
• Acyanotic: ASD, PDA, VSD, MVP
• Cyanotic: Fallot’s Tetralogy and
Eisenmenger’s syndrome
• Other: Coarctation of aorta, primary
pulmonary HTN, Marfan’s syndrome.
• Cardiomyopathies: MI, Peripartum
Cardiomyopathy

9. MITRAL STENOSIS

10. AORTIC STENOSIS

13. MITRAL VALVE PROLAPSE

18. NYHA classification of HD depending upon
the Cardiac Response to Physical Activity
⫸Grade I: Uncompromised and no limitation of physical activity.
⫸Grade II: Slightly compromised with slight limitation of PA,
comfortable at rest and discomfort with activity.
⫸Grade III: Markedly uncompromised with marked limitation
of activity.
⫸Grade IV: Severely compromised with discomfort even at rest

19. GENERAL MANAGEMENT
PRINCIPLES
⫸Early diagnosis and evaluation of anatomical type and
functional grade of the case.
⫸To detect high risk factors and prevent cardiac failure.
⫸Multidisciplinary team approach and mandatory hospital
delivery.

20. PLACE OF THERAPEUTIC TERMINATION: Considering high
maternal deaths, Absolute indications are:
▶Primary Pulmonary HTN
▶Eisenmenger’s Syndrome
▶Pulmonary Veno-Occlusive disease
Relative Indications are:
▶Parous women with grade III and IV
▶Garde I and II with prev. history of cardiac failure

21. Antenatal Care
▶The patients with heart disease should be supervised in a
tertiary care hospital.
▶Initial assessment should be done by the Cardiologist.
▶Inj. Penidure LA-12 (Benzathine Penicillin) given at 4 weeks
interval throughout the pregnancy and puerperium to prevent
the recurrence of Rheumatic Fever.
▶Counseling – prognosis and risks.

22. Special care in each ANV is to detect and treat the risks factors
that precipitate cardiac failure in pregnancy. Risk factors for
cardiac failure are:
Infections: UTIs, Dental and Respiratory tract.
Anemia, Obesity, HTN, Arrhythmias, Hyperthyroidism,
Drugs ( Betamimetics)
Dietary indiscretion: Excess intake of caffeine, alcohol, high
calorie diet, excess salt.

23. Role of Anticoagulants
This drugs are indicated in cases with
⫸Congenital Heart Disease
⫸Pulmonary HTN
⫸Mechanical Heart Valve
⫸Atrial Fibrillation

24. As soon as pregnancy is diagnosed, Warfarin should be
discontinue and be replace by Heparin 5000 units twice
daily SC till 12 weeks of pregnancy.
After 12 weeks, Warfarin 3 mg can be continue till 36th
weeks of pregnancy.
Postpartum: Heparin to be continue till 7 days of
Postpartum.

25. Admission: Elective
Grade-I: At least 2 weeks prior to the expected date of delivery.
Grade-II: at 28th week especially in case of unfavourable social surrounding.
Grade-III & IV: As soon as pregnancy is diagnosed. The patient should be
admitted in hospital throughout pregnancy.
Emergency
Deterioration of the functional grading
Appearance of dyspnea or cough or basal crepitations or tachyarrhythmias
Appearance of any pregnancy complications – Anemia and Pre-elampsia.

26. MANAGEMENT DURING LABOUR

27. 1st Stage of Labour
Position: lateral recumbent position to prevent aortocaval
compression.
Oxygen: 5-6 L/min
Analgesia: best given by epidural
Prophylactic antibiotics: against bacterial endocarditis
Fluids: not to infuse more than 75 ml/hour to prevent
pulmonary Edema
Careful watch
Cardiac monitoring & pulse oximetry

28. Prophylactic antibiotics for bacterial endocarditis
Antibiotic Prophylaxis during labour and 48 hours after
delivery is considered appropriate.
Regimen: IV Ampicillin 2g and Gentamicin 1.5 mg/kg at
onset of labour followed by repeat doses 8 hours interval.
High risks patient are: Structural Heart Disease, RHD,
Cyanotic Congenital HD, Hypertrophic Cardiac Myopathy
and Cardiac Transplant.

29. 2nd stage of Labour
Forceps/ventouse under pudendal nerve and / perineal
block anaesthesia.
IV Ergometrine with delivery of the anterior shoulder
should be withheld to prevent sudden overloading of the
heart by the additional blood squeezed out from the uterus.

30. 3rd stage of Labour
• Conventional management is to be followed.
• Slight blood loss is not detrimental but if it is in excess,
Oxytocin can be given by infusion.
Cardiac Indications of CD
Coarctation of Aorta
Aortic Dissection or Aneurysm
Aortopathy with aortic root >4cm
Warfarin treatment within 2 weeks

31. Puerperium
Careful watch for the first 24 hours.
Oxygen
Monitor vitals every 30 minutes.
Diuretics if there is volume overload.

32. Management of cardiac failure during
Pregnancy
• Popped up position
• Oxygen Administration
• Monitoring ECG and Pulse oximetry
• Diuretics: Inj. Furosemide 40-80 mg.
• Digoxin 0.5 mg IM followed by Tab. Digoxin 0.25 mg PO
• Dysrhythmias: Quinidine
• Tachyarrhythmias: Adenosine 3-12 mg IV or DC
conversion.

33. Conclusion
• Cardiovascular disease is a leading cause of maternal death. Cardiovascular
training programs are increasingly providing education on the management of
cardiovascular disorders during pregnancy .
• There are, however, many unanswered questions on optimal care and clinicians
are often working in data-free zones. It is therefore likely that more data will
become available over time on the optimal treatment of these women during
pregnancy to improve outcomes for both mother and fetus.

34. Bibliography/References
• Annamma Jacob, text book of comprehensive text book of ‘MIDWIFY and
GYNECOLOGY nursing ‘ JAYPEE publication 3rd edition.
• D.C. DUTTA text book of obstetrical including perinatary and contraception
central publication 7th edition
• Lily Podder, fundamentals of Midwifery and Obstetrical Nursing, ELSEVIER
publication.
• Mudaliar and Menon’s. Clinical Obstetrics, Universities Press 12th Edition.
• https://www.uscjournal.com/articles/management-cardiovascular-disease-
during-pregnancy
• https://pubmed.ncbi.nlm.nih.gov/26026739/
• https://www.msdmanuals.com/professional/gynecology-and-
obstetrics/pregnancy-complicated-by-disease/heart-disorders-in-pregnancy