Heart disease with pregnancy

Prof Uma Singh

Incidence of heart disease

• Varies between 0.1 – 4.0 %, average 1%• Mortality due to heart disease has decreased• Devpd countries – maternal mortality due to

heart disease has increased• Pregnancy with heart disease has increased• Devpd countries – rheumatic is decreasing• Congenital heart disease with pregnancy is

also increasing

Hemodynamic changes in normal pregnancy

PARAMETER CHANGE (PERCENT)

Plasma volume +40

Cardiac output +43

Heart rate +17

Mean arterial pressure +4

Stroke volume +27

Systemic vascular resistance

-21

Pulmonary vascular resistance

-34

Critical periods• Changes start from as – 6weeks• Max changes around –30 weeks• Intra partum period• Just after delivery• Second week of puerperium

Pregnancy changes mimic cardiac disease

• Symptoms – breathlessness, weakness, oedema, syncope

• Tachycardia• Splitting of 1st hear sound • Murmur – systolic , breast bruit• Displacement of apex beat – upwards to left

Symptoms of heart disease

• Progressive dyspnea or orthopnea• Nocturnal cough• Syncope• Chest pain• Hemoptysis

Clinical findings of heart disease

• Cyanosis• Clubbing of fingers• Persistent neck vein distention• Systolic murmur grade 3/6 or greater• Diastolic murmur• Cardiomegaly• Persistent arrythmia• Persistent split second sound• Pulmonary hypertension

Investigations

• ECG – cardiac arrhythmias, hypertrophy• Echocardiography – cardiac status and

structural anomalies • X-ray chest – cardiomegaly, vascular

prominence • Cardiac catheterization - rarely

NYHA (New York Heart Association) Functional grading of heart disease

• Grade I: No limitation of physical activity- asymptomatic with normal activity

• Grade II: Mild limitation of physical activity -Symptoms with normal physical activity

• Grade III: Marked limitation of physical activity -Symptoms with less than normal activity, comfortable at rest

• Grade IV: Severe limitation of physical activity- symptoms at rest

Classification of Heart Disease according to etiology

• Congenital – non cynotic ( ASD, VSD, Pulm stenosis, coarctation of aorta), cyanotic (Fallots tetralogy, Eisenmenger’s syndrome)

• Rheumatic heart disease – MS, MR, AS, AR • Cardiomyopathy• Ischaemic heart disease• Others – conduction defects, syphilitic,

thyrotoxic, hypertensive,

Classification of Heart Disease during pregnancy according to risk

• Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-1,2, corrected FT

• Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT

• High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement

Poor prognostic indicators

• h/o heart failure, ischaemic attack, stroke• Arrhythmias,• Base line NYHA class 3 and 4• MV area below 2cm sq, AV area below 1.5 • Ejection fraction less than 40%

Additional risk factors• Anaemia• Infections• Hypertension• Physical labour• Weight gain• Multiple pregnancy• Caffein , alcohol intake• Pain• Drugs – tocolytic

Effect of pregnancy on heart disease

• Worsening of cardiac status• CCF, bacterial endocarditis, pulmonary

edema, pulmonary embolism, rupture of aneurism

• No long term effect on basic defect

Effect of heart disease on pregnancy

• Abortion• Preterm labour• IUGR• Congenital heart disease in baby – 5%• Intrauterine fetal demise

ManagementRequires-• High index of suspicion • Timely diagnosis• Effective management • Team Approach-

• Obstetrician• Cardiologist• Anesthetist• Neonatologist• CTV surgeon• Nursing Staff

Preconceptional Counseling• No pregnancy unless must esp in high risk types• Maternal mortality varies directly with functional

classification at pregnancy onset • Optimal Medical/Surgical treatment pre-pregnancy• Counselling- – Maternal & Fetal risks– Prognosis– Social and cost considerations– Hospital delivery- Preferable at tertiary care centre

Medical termination of pregnancy• Termination advised in early pregnancy in high risk

group only – ( Primary pulmonary Ht, Eisenmenger syndrome, Coarctation of aorta, Marfan syndrome with dilated aortic root)

• Only in 1st trim, better before 8 weeks• Suction evacuation preferred• MTP also carries risk for life

Antenatal care• Clear counseling of risk and prognosis • ANC every 2 weeks upto 30 weeks then weekly• On each visit-note-pulse rate, BP, cough dyspnea,

weight, anaemia, auscultate lung bases, re-evaluate functional grade

• Ensure treatment compliance• Exclude fetal congenital anomaly by level-III USG

and fetal ECHO at 20 weeks in maternal congenital heart disease

• Fetal monitoring

Special Advice• Rest, Avoid undue excitement/strain • Diet/ Iron and vitamins• Hygiene, dental care to prevent any infection• Dietary salt restriction (4-6g/d)• Avoid smoking, drugs – betamimetics• Early diag and tmt of PIH, infections• Therapeutic/prophylactic cardiac interventions as

applicable-– Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence

of rheumatic fever– Diuretics, Beta Blockers, Digitalis, Anticoagulants– Surgical treatment as applicable - balloon mitral valvotomy

Indications for admissionElective admission-• NYHA 1 – 2 weeks before EDD• NYHA 2 – 28 to 30 weeks• NYHA-III/IV- Irrespective of POG as soon as patient comes• To Change from oral anticoagulants to heparin-early

pregnancy, 36 weeks in patients on anticoagulant Emergency admission-• Deterioration of functional grade• Symptoms and signs of complications- Fever/ persistent

cough/ basal crepts/ tachyarrhythias (P/R >100 min)/ JVP>2cm/Anaemia/ Infections/ PET/Abnormal weight gain /other medical disorders

Labor and Management

• Institutional delivery• Induction of Labor– Only for obstetric indications– Oxytocin preferred- Higher concentration with

restricted fluid– Intracervical foley instillation esp in congenital heart disease – PGE2 Gel may be employed- Vasodilatation - use with

caution

Management in first stage of labor• Confined to bed- propped up or semi

recumbent • Intermittent oxygen inhalation 5-6 l/min• Sedation and analgesia- (Epidural,

pethidine, tramadol)• Cautious use of I.V. fluids (not >75ml/hr

except in aortic stenosis and VSD)• Stop anticoagulants• Digitalise if in CHF,P.R.>110/ min,

R/R >24/min

Management in first stage of labor

• Diuretics in pulmonary congestion • Deriphyllin if bronchospasm• Prevention of infective endocarditis• Cardiac monitoring and pulse oximetry

±pulmonary artery catheterisation- continuous haemodynamic monitoring

• Evaluation by Anaesthetist and cardiologist

SABE Prophylaxis

ProphylaxisProphylaxis

Not recommended for Not recommended for allall• At risk for infection At risk for infection •Severe lesionsSevere lesions

Ampicillin-2G IV/IM + Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg Gentamicin 1.5mg/kg (max120) 6 hours later- (max120) 6 hours later- Ampicillin-1G I.V./IM or 1G Ampicillin-1G I.V./IM or 1G P.O.P.O.

If Allergic to If Allergic to Penicillin -Penicillin -Vancomycin-1G I.V. Vancomycin-1G I.V. or Clindamycin or Clindamycin – 600mg IV– 600mg IV

+ Gentamicin-1.5mg/kg + Gentamicin-1.5mg/kg

Management of second stage of labor

• Delivery in propped up position • Avoid forceful bearing down• Adequate pain relief-epidural/pudendal block

avoid spinal/Saddle block• Cut short second stage of labor- episiotomy,

vacuum, forceps – not always must• Strict Cardiovascular monitoring

Third stage of labor-

• AMTSL-10 U oxytocin IMI• Avoid bolus syntocinon/Ergometrine• Propped Up, oxygen inhalation• Furosemide I.V. 40 mg• Pethidine/morphine (15mg)• Watch for signs of CHF & Pul. Edema• Treat PPH energetically

First Hour After Delivery • Propped up/sitting position, oxygen• Watch for signs of pulm edema• Sedation• Antibiotics

Indications for LSCS-

• Mainly obstetrical • Coarctation of aorta• Marfan syndrome with dilated root of aorta– Prefer epidural anaesthesia – Narcotic conduction analgesia/GA in Pulmonary

hypertension and pts having intracardiac shunts

• Advice at time of discharge:• Continue medical treatment• Avoid infection• Reassesment after 6 weeks or earlier if some

complication occurs• Iron supplementation• Cardiological consultation for definitive

management of heart disease

• Contraceptive advice at time of discharge:

• Contraception- Barrier,• Progesterone – good option- DMPA, Norplant • IUCD-Less preferred• COC - contraindicated • Sterilization- vasectomy-best• Tubal ligation-Interval, puerperial can be done

MCQs

Text book of Obstetrics, Dr J B Sharma, 1st edition

Page 529 to 536

1. Pregnancy is contra indicated with •Mitral stenosis•Aortic stenosis•Fallots tetralogy•Eisenmengers syndrome

2. Pregnancy is contra indicated with •Mitral stenosis•Aortic stenosis•Fallots tetralogy•Eisenmengers syndrome

2. Third stage of labour in a case of heart disease should be managed by •Ergometrine•Oxytocin•Misoprostol•Carboprost

Third stage of labour in a case of heart disease should be managed by •Ergometrine•Oxytocin•Misoprostol•Carboprost

3. In pregnancy with heart disease risk of cardiac failure increases at •10-12 weeks•20-22 weeks•30-32 weeks•40-42 weeks

3. In pregnancy with heart disease risk of cardiac failure increases at •10-12 weeks•20-22 weeks•30-32 weeks•40-42 weeks

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is •NYHA Class 1•NYHA Class 2•NYHA Class3•NYHA Class 4

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is •NYHA Class 1•NYHA Class 2•NYHA Class3•NYHA Class 4

5. Which of the following contraceptive is contraindicated in a woman with heart disease?

• OCP• POP• Lng IUS• Diaphragm

5. Which of the following contraceptive is contraindicated in a woman with heart disease?

• OCP• POP• Lng IUS• Diaphragm

6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at

a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at

a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is

a) class 1 b) class 2 c) class 3 d ) class 4

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is

a) class 1 b) class 2 c) class 3 d ) class 4