The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births.

1. HEART DISEASES IN PREGNANCY
MUKESH SAH, MD
PGI
GOODSAM MEDICAL CENTER

3. CARDIAC DISEASE (1/4)
• Women with pre-existing cardiac disease, or developing
cardiac disease in pregnancy, has increased over recent years
due to many factors, including the increased age of
childbearing women and the association it has with co-
existing medical conditions such as diabetes, hypertension,
as well as obesity and smoking.
• Majority of pregnancies complicated by maternal cardiac
disease are expected to have a favorable outcome for both
the women and fetus.

4. CARDIAC DISEASE (2/4)
• Risk of morbidity and mortality depends on the nature of the
cardiac lesion, its effect on the functional capacity of the
heart and the development of pregnancy-related
complications such as hypertensive disorder pregnancy,
infection, thrombosis and hemorrhage.
• The majority of deaths secondary to cardiac causes occur in
women with no previous history.

5. CARDIAC DISEASE (3/4)
• It is vital that a midwife undertakes an accurate history from
the women at the first visit.
• Healthy pregnancy women are able to adjust to
physiological changes quite easy; for women with co-
existing cardiac disease, however the added workload can
precipitate complications.

6. CARDIAC DISEASE (4/4)
• The three sensitive periods of cardiovascular stress (28-32
weeks of pregnancy, during labor and 12-24 hours
postpartum)
• The cardiac failure occurs during pregnancy around 30
weeks, during labor and mostly soon following delivery.

7. Congenital heart disease
• The most common congenital heart disease (CHD) found in
pregnancy are atrial septal defect (ASD) , ventricular septal
defect (VSD), patent ductus arteriosus (PDA), pulmonary
stenosis, aortic stenosis and tetralogy of Fallot.
• The majority of these lesions should have been surgically
corrected in childhood

13. • Uncorrected lesions may cause pulmonary hypertension,
cyanosis and severe left ventricular failure.
• Congenital heart disease is also associated with increased
fetal complications such as fetal loss, IUGR, pre-term birth
and an increased risk of fetal CHD.

14. • Preterm delivery: primary related to increased incidence of cardiac dysfunction.
However, the precise factor predisposing to preterm delivery remain unclear.

15. ACQUIRED HEART DISEASE

16. Rheumatic heart disease
• Rheumatic heart disease causes inflammation and scarring of
the heart valves and results in valve stenosis, with or with
regurgitation.
• The mitral valve is most often affected with stenosis, with or
without regurgitation. The mitral valve is most often affected
with stenosis, occurring in two-thirds of cases.

17. • This condition is often diagnosed for the first time during
pregnancy, presenting as severe breathlessness and tired.
• During pregnancy, this involved bed rest, oxygen therapy
and the use of cardiac drugs, e.g. diuretics (to reduce the
fluid load), digoxin (to reduce and regulate the heart rate)
and heparin (to reduce the risk of thromboembolic disease).
• Balloon valvulo-plasty or valve replacement is done in case
of symptomatic disease.

18. Myocardial infarctions and ischemic
heart disease
• A myocardial infarction are most likely to occur in the third
trimester of pregnancy and the peripartum period, when
hemodynamic changes are their optimum creating higher
risk of thrombotic events due to the hypercoagulability.
• Maternal age, smoking, pre-existing hypertension, smoking,
family history and poor socioeconomic status.

19. Peripartum cardiomyopathy
• Peripartum cardiomyopathy is relatively rare but is
potentially fetal, with mortality rates ranging from 25-50%.
• Predisposing factors to peripartum cardiomyopathy
comprise of multiple pregnancies, family history, smoking,
diabetes, hypertension, pre-eclampsia, malnutrition,
pregnant teenagers or older pregnant women.

20. • Commonly women have no of previous history of heart
disease and diagnosis is usually made within specific period
of time between the last month of pregnancy and the first 5
months postpartum.
• Inflammation and enlargement of the myocardium
(cardiomegaly) give rise to left ventricular heart failure and
thromboembolic complications

21. Clinical manifestations
• Breathlessness, nocturnal cough
• Syncope
• Chest pain
• Cardiomegaly
• Enlargement of pulmonary vein.
• Orthopnea
• Palpitations
• Alterations of heart sound

22. Diagnosis of cardiac disease
• Full cardiovascular examination, including personal history
and assessment of lifestyle risk factors
• Blood tests: full blood count, clotting studies and cardiac
enzymes (troponin)
• 12-lead electrocardiogram (ECG)
• Echocardiogram
• Other imaging: computerized tomography (CT) scan or
magnetic resonance imaging (MRI) scan of the chest.

23. MANAGEMENT

24. Pre-conception care:
• Women with a pre-existing cardiac problem should receive
pre-conception counselling to inform them of any potential
risks that a pregnancy may have on their health and that of
their unborn baby in terms of inheriting any congenital
malformations.
• This will enable them to make informed decisions and plan
their pregnancy monitoring more carefully to reduce any
subsequent morbidity and mortality.

25. • Genetic screening by chorionic villous biopsy (CVS) can be
offered fetal echocardiography between the 19th and 22nd
week of pregnancy.
• Measurement of nuchal fold thickness around the 12th to 13th
week of pregnancy is an early screening test for Down
syndrome in women over 35 years of age.

26. Antenatal care
• The aim is to maintain a steady hemodynamic state and
prevent complications, as well as promote physical and
psychological wellbeing.
• The fetal wellbeing is assessed by the following means:
- Ultrasound examination to confirm gestational age and any
congenital malformation
 Injection Benzathine penicillin is given at intervals of 4
weeks throughout pregnancy and puerperium to prevent
recurrence of rheumatic fever.

27. - Clinical assessment of fetal growth and amniotic fluid
volume and by ultrasound.
- Monitoring of the fetal heart rate by CTG
- Measurement of fetal and maternal placental blood flow
indices by Doppler ultrasonography.

28. Antithrombotic therapy
• The hypercoagulable state in pregnancy increases the risk of
thromboembolic disease in women who have arrhythmias,
mitral valve stenosis or who have had mechanical cardiac
valve replacements.
• Warfarin is commonly used as an antithrombotic, but as it is
teratogenic.
•

29. • Warfarin also predispose the women and her fetus to
hemorrhage when used in the third trimester.
• Subcutaneous low molecular weight heparins, such as
enoxaparin, are useful for thrombophylaxis but may not be
suitable for women with mechanical heart valves.
• As a consequence, the advice of a hematologist should be
sought.

30. INTRAPARTUM CARE

31. First stage of labor
• Vaginal birth is preferred unless there is an obstetric
indication for caesarean section as hemodynamic stability is
greater and there is less chance of postoperative infection
and pulmonary complications.
 Oxygen should be administered 5-6L/min.

32. Labor induction:
• if induction is indicated and the cervix is favorable artificial
rupture of the membranes (ARM) is undertaken with an IVI
of oxytocin.
• A prolonged induction should be avoided.

33. • If the cervix is unfavorable, synthetic prostaglandin is used
to soften.
• In some situations, epidural anesthesia may be the analgesic
of choice for its effectiveness in relieving pain and
decreasing cardiac output and heart rate.
Positioning: cardiac disease are particularly sensitive to
aortocaval compression by the gravid uterus if adopting the
supine position. It is recommended that midwives encourage
an upright or left lateral position for women to adopt during
labor and birth whenever possible.

34. Second stage of labor
• Prolonged pushing with held breath should be discouraged.
• Encourage the women to breath as normal and follow her
natural desire to bear down giving several short pushes
during each contraction.
• Instrument birth using forceps or ventouse may be
undertaken to shorten the second stage of labor.
• Avoid lithotomy position.

35.  Frequent assessment of the women with a multidisciplinary
approach involving midwives, obstetricians, cardiologist
and anesthetics.
 Intubation set should be ready for an emergency.

36. Third stage of labor
• An active third stage of labor is usually advocated with a
slow IVI of 2 U/min oxytocin administered after the birth of
the placenta to prevent hemorrhage.
• Prostaglandin F analogues are useful to treat PPH, unless an
increase in pulmonary artery pressure (PAP) is undesirable.
• Ergometrine is contraindicated in women with cardiac
disease as it can cause vasoconstriction and hypertension.

37. Postnatal care
• The first 24 hours following the baby’s birth are critical for
the women with significant cardiac disease.
• Total blood volume may be diminished by the amount lost at
birth and during the postnatal period.
• Close monitoring of hemodynamic changes is required .
• Midwife should identify early signs of infection, thrombosis
or pulmonary edema.

38. • Observation of the condition of the women’s legs, the use of
antiembolic stocking and early ambulation are important.
• Breastfeeding should be encouraged as cardiac output is not
affected by lactation.

39. ■ Myles. Textbooks for midwives. 16thed.UK:elsevier; 2014. 265-269p
■ Dutta’s DC. Textbooks of obstetrics including perinatology and
contraceptive. 7thed. Jaypee brothers medical publishers (p) ltd; 2013.
275-280 p.