Cardiac Diseases in Pregnancy: Implications and Management

 
CARDIAC DISEASES IN
PREGNANCY
 
 
DR. RAZAQ  MASHA,FRCOG
DR. RAZAQ  MASHA,FRCOG
Assistant Professor & Consultant
Assistant Professor & Consultant
Department of Obstetrics & Gynaecology
Department of Obstetrics & Gynaecology
 
Normal pregnancy results in many physiologic changes
that can stress the cardiovascular system
 
By 6-8 weeks of gestation, increase in plasma volume has started and
By 6-8 weeks of gestation, increase in plasma volume has started and
may be up to 45% greater by 30-34 weeks.
may be up to 45% greater by 30-34 weeks.
Red cell volume increases but only by 25% resulting in physiologic
Red cell volume increases but only by 25% resulting in physiologic
anaemia.
anaemia.
Cardiac output increases by 30% to 50% during the first half of
Cardiac output increases by 30% to 50% during the first half of
pregnancy – stroke volume and heart rate increase.
pregnancy – stroke volume and heart rate increase.
Cardiac output increases by another 30% during active labour and by
Cardiac output increases by another 30% during active labour and by
45% during pushing.
45% during pushing.
Systemic vascular resistance decreases during pregnancy (2
Systemic vascular resistance decreases during pregnancy (2
nd
nd
 trimester)
 trimester)
and returns to pre-pregnancy levels in the third trimester.
and returns to pre-pregnancy levels in the third trimester.
During labour each uterine contraction results in an auto transfusion of
During labour each uterine contraction results in an auto transfusion of
300-500 ml of blood
300-500 ml of blood
At delivery, cardiac output increases as a result of auto transfusion
At delivery, cardiac output increases as a result of auto transfusion
caused by relief of caval compression by the involuting uterus.
caused by relief of caval compression by the involuting uterus.
 
Class I :  Patients are asymptomatic in all situations
Class I :  Patients are asymptomatic in all situations
Class II:  Patients are symptomatic with greater-than normal
Class II:  Patients are symptomatic with greater-than normal
exertion
exertion
Class  III:  Patients are symptomatic with normal activities
Class  III:  Patients are symptomatic with normal activities
Class  IV:  Patients are symptomatic at rest
Class  IV:  Patients are symptomatic at rest
For most patients, any change in cardiac classification during the
For most patients, any change in cardiac classification during the
pregnancy, even from Class I to II, can be ominous and should
pregnancy, even from Class I to II, can be ominous and should
prompt a thorough evaluation and aggressive management.
prompt a thorough evaluation and aggressive management.
 
Women with cardiovascular disease may tolerate these physiologic
changes poorly.
The New York Heart Association (NYHA) classification scheme is used
for quantifying symptomatology
 
Rheumatic Heart Disease
Results from rheumatic fever, caused by Group A, 
Results from rheumatic fever, caused by Group A, 
haemolytic streptococcus.  Even though the prevalence of
haemolytic streptococcus.  Even though the prevalence of
rheumatic heart disease has decreased significantly,
rheumatic heart disease has decreased significantly,
rheumatic valvular disorders still account for a substantial
rheumatic valvular disorders still account for a substantial
proportion of heart disease in reproductive age women.
proportion of heart disease in reproductive age women.
 
 
a.  Mitral stenosis
a.  Mitral stenosis
  
  
This is the most common form of rheumatic heart disease
This is the most common form of rheumatic heart disease
in women.  Even though rheumatic fever may occur at age 6-
in women.  Even though rheumatic fever may occur at age 6-
15 years, symptoms may not begin until the early 30’s.  Initial
15 years, symptoms may not begin until the early 30’s.  Initial
symptoms include fatigue and dyspnoea exertion 
symptoms include fatigue and dyspnoea exertion 
 dyspnoea
 dyspnoea
at rest, and haemoptysis.
at rest, and haemoptysis.
 
The stenosis impairs left ventricular filling reducing cardiac output.
The stenosis impairs left ventricular filling reducing cardiac output.
Left atrial volume and pressure increase, pulmonary venous
Left atrial volume and pressure increase, pulmonary venous
pressure increases and eventually pulmonary hypertension,right
pressure increases and eventually pulmonary hypertension,right
ventricular hypertrophy and failure.  Other serious complications
ventricular hypertrophy and failure.  Other serious complications
are atrial fibrillation and pulmonary oedema-which can lead to
are atrial fibrillation and pulmonary oedema-which can lead to
death.
death.
Treatment:
Treatment:
Beta blockers for tachycardia
Beta blockers for tachycardia
Digoxin and heparin if there is atrial fibrillation
Digoxin and heparin if there is atrial fibrillation
Some may require surgery – balloon valvuloplasty
Some may require surgery – balloon valvuloplasty
During labour, cardiac monitoring is essential avoiding overloading.
During labour, cardiac monitoring is essential avoiding overloading.
Pain must be managed effectively – Epidural can be useful if you avoid
Pain must be managed effectively – Epidural can be useful if you avoid
overload
overload
Antibiotic prophylaxis for SBE – ampicillin and gentamycin 30 minutes
Antibiotic prophylaxis for SBE – ampicillin and gentamycin 30 minutes
before delivery.
before delivery.
 
b.
Mitral insufficiency
Mitral insufficiency
 
 
This results in regurgitation of blood from the left ventricle3
This results in regurgitation of blood from the left ventricle3
back into the left atrium, with resulting left atrial
back into the left atrium, with resulting left atrial
enlargement.
enlargement.
 
 
If pulmonary oedema, embolism, atrial tachycardia and
If pulmonary oedema, embolism, atrial tachycardia and
infective endocarditis occur during pregnancy, then such
infective endocarditis occur during pregnancy, then such
patients can develop complications .
patients can develop complications .
 
 
Avoid overload, atrial fibrillation, hypertension. Manage
Avoid overload, atrial fibrillation, hypertension. Manage
pain of labour with epidural.
pain of labour with epidural.
 
 
Antibiotic prophylaxis for SBE.
Antibiotic prophylaxis for SBE.
 
Aortic Insufficiency
 
This causes a chronic increase in left ventricular volume,
This causes a chronic increase in left ventricular volume,
leading to increased end-diastolic pressure and pulmonary
leading to increased end-diastolic pressure and pulmonary
congestion and oedema.
congestion and oedema.
Most pregnant women with AI are relatively asymptomatic
Most pregnant women with AI are relatively asymptomatic
because of
because of
a.
a.
 
 
Decreased systemic vascular resistance
Decreased systemic vascular resistance
b.
b.
 
 
Increased heart rate of pregnancy
Increased heart rate of pregnancy
 
During labour, the changes may lead to decomposition if systemic
During labour, the changes may lead to decomposition if systemic
vascular resistance is increased by pain.
vascular resistance is increased by pain.
Pain relief by epidural.  No overload of fluid. Antibiotic prophylaxis
Pain relief by epidural.  No overload of fluid. Antibiotic prophylaxis
for SBE.
for SBE.
 
Aortic Stenosis
 
This tends to occur in women over 40 years.  If it however
This tends to occur in women over 40 years.  If it however
occurs in the reproductive age, the symptoms include angina,
occurs in the reproductive age, the symptoms include angina,
syncope and shortness of breath. Can result in left ventricular
syncope and shortness of breath. Can result in left ventricular
failure and infective endocarditis.
failure and infective endocarditis.
Maintain adequate fluid volume.  Pain relief by narcotics,
Maintain adequate fluid volume.  Pain relief by narcotics,
epidural may cause decreased systemic resistance which is
epidural may cause decreased systemic resistance which is
poorly tolerated.
poorly tolerated.
 
Congenital Heart Disease
 
Women who have undergone surgical correction have normal
Women who have undergone surgical correction have normal
hemodynamics and tolerate pregnancy well.  Women with
hemodynamics and tolerate pregnancy well.  Women with
uncorrected lesions require special management.  The most
uncorrected lesions require special management.  The most
uncontrolled lesions are:
uncontrolled lesions are:
Atrial Septal Defects (ASD)
Atrial Septal Defects (ASD)
Patent Ductus Arteriosus (PDA)
Patent Ductus Arteriosus (PDA)
Ventricular Septal defect (VSD)
Ventricular Septal defect (VSD)
Pulmonary Stenosis
Pulmonary Stenosis
Coarctation of the aorta
Coarctation of the aorta
Tetralogy of Fallot
Tetralogy of Fallot
Both maternal and fetal outcomes depend on the nature of the
Both maternal and fetal outcomes depend on the nature of the
cardiac lesion.  In the presence of cyanosis, there is an increased
cardiac lesion.  In the presence of cyanosis, there is an increased
risk of functional deterioration, congestive heart failure, maternal
risk of functional deterioration, congestive heart failure, maternal
mortality, IUGR, preterm birth, miscarriage and still-births.
mortality, IUGR, preterm birth, miscarriage and still-births.
 
Left to Right  Intra Cardiac Shunts
 
These shunts can result from ASDs, VSDs, or PDAs.  If there is no
These shunts can result from ASDs, VSDs, or PDAs.  If there is no
pulmonary hypertension and the patient is asymptomatic,
pulmonary hypertension and the patient is asymptomatic,
pregnancy does not impose significant increased risk.
pregnancy does not impose significant increased risk.
If however, the shunt is substantial resulting in many years of
If however, the shunt is substantial resulting in many years of
increased pulmonary blood flow, pulmonary hypertension and right
increased pulmonary blood flow, pulmonary hypertension and right
heart failure can develop and the shunt reverses.  The combination
heart failure can develop and the shunt reverses.  The combination
of pulmonary hypertension and right-to-left shunt through any
of pulmonary hypertension and right-to-left shunt through any
communication between the systemic and pulmonary circulation is
communication between the systemic and pulmonary circulation is
know as Eisenmenger syndrome.
know as Eisenmenger syndrome.
- Maternal mortality rate of 40% to 60%
- Maternal mortality rate of 40% to 60%
- Perinatal mortality rate of 28% to 55%
- Perinatal mortality rate of 28% to 55%
-Should be discouraged to get pregnant
-Should be discouraged to get pregnant
- Delivery : Excellent pain management
- Delivery : Excellent pain management
- Shorten 2
- Shorten 2
nd
nd
 stage of labour
 stage of labour
- Antibiotic prophylaxis for SBE
- Antibiotic prophylaxis for SBE
 
Peripartum Cardiomyopathy
 
Congestive heart failure characterized by dilatation of the four
Congestive heart failure characterized by dilatation of the four
chambers of the heart.  Occurs in the last months of pregnancy or
chambers of the heart.  Occurs in the last months of pregnancy or
the first 5 months  postpartum.
the first 5 months  postpartum.
Complaints are orthopnea, dyspnea, edema
Complaints are orthopnea, dyspnea, edema
ECG, Chest X-ray, echocardiogram – will show cardiomegaly
ECG, Chest X-ray, echocardiogram – will show cardiomegaly
Treat heart failure with digitals, diuretics, or vasodilators, bed
Treat heart failure with digitals, diuretics, or vasodilators, bed
rest and anti coagulation.
rest and anti coagulation.
Mortality is high if heart size does not return to normal in 6
Mortality is high if heart size does not return to normal in 6
months. Advised not to get pregnant because 50% will develop
months. Advised not to get pregnant because 50% will develop
cardiomyopathy in future pregnancies with high mortality rate.
cardiomyopathy in future pregnancies with high mortality rate.
 
Myocardial Infarction
 
The risk in a reproductive age woman is low (1 in 10,000).  Risk
The risk in a reproductive age woman is low (1 in 10,000).  Risk
factors include arteriosclerosis, thrombosis and vasospastic
factors include arteriosclerosis, thrombosis and vasospastic
disease.
disease.
Maternal mortality is higher in the 3
Maternal mortality is higher in the 3
rd
rd
 trimester.
 trimester.
MANAGEMENT:
MANAGEMENT:
Bed rest – to minimize cardiac workload
Bed rest – to minimize cardiac workload
Nitrates, aspirin, beta blockers
Nitrates, aspirin, beta blockers
Calcium channel blocks
Calcium channel blocks
Epidural anaesthesia in labour and oxygen
Epidural anaesthesia in labour and oxygen
Avoid another pregnancy for at least one year after M1 – if
Avoid another pregnancy for at least one year after M1 – if
ventricular function has returned to normal.
ventricular function has returned to normal.
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Normal pregnancy induces significant physiologic changes in the cardiovascular system, which can impact women with pre-existing cardiac diseases. Understanding the New York Heart Association classification scheme is crucial for assessing symptomatology during pregnancy. Rheumatic Heart Disease, particularly Mitral stenosis, poses specific challenges and requires careful monitoring and management to prevent serious complications. Treatment options may include beta-blockers, digoxin, heparin, and surgical interventions like balloon valvuloplasty. Proper cardiac monitoring during labor and delivery is essential to avoid complications.


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  1. CARDIAC DISEASES IN PREGNANCY DR. RAZAQ MASHA,FRCOG Assistant Professor & Consultant Department of Obstetrics & Gynaecology

  2. Normal pregnancy results in many physiologic changes that can stress the cardiovascular system By 6-8 weeks of gestation, increase in plasma volume has started and may be up to 45% greater by 30-34 weeks. Red cell volume increases but only by 25% resulting in physiologic anaemia. Cardiac output increases by 30% to 50% during the first half of pregnancy stroke volume and heart rate increase. Cardiac output increases by another 30% during active labour and by 45% during pushing. Systemic vascular resistance decreases during pregnancy (2ndtrimester) and returns to pre-pregnancy levels in the third trimester. During labour each uterine contraction results in an auto transfusion of 300-500 ml of blood At delivery, cardiac output increases as a result of auto transfusion caused by relief of caval compression by the involuting uterus.

  3. Women with cardiovascular disease may tolerate these physiologic changes poorly. The New York Heart Association (NYHA) classification scheme is used for quantifying symptomatology Class I : Patients are asymptomatic in all situations Class II: Patients are symptomatic with greater-than normal exertion Class III: Patients are symptomatic with normal activities Class IV: Patients are symptomatic at rest For most patients, any change in cardiac classification during the pregnancy, even from Class I to II, can be ominous and should prompt a thorough evaluation and aggressive management.

  4. Rheumatic Heart Disease Results from rheumatic fever, caused by Group A, haemolytic streptococcus. Even though the prevalence of rheumatic heart disease rheumatic valvular disorders still account for a substantial proportion of heart disease in reproductive age women. has decreased significantly, a. Mitral stenosis This is the most common form of rheumatic heart disease in women. Even though rheumatic fever may occur at age 6- 15 years, symptoms may not begin until the early 30 s. Initial symptoms include fatigue and dyspnoea exertion at rest, and haemoptysis. dyspnoea

  5. The stenosis impairs left ventricular filling reducing cardiac output. Left atrial volume and pressure increase, pulmonary venous pressure increases and eventually pulmonary hypertension,right ventricular hypertrophy and failure. Other serious complications are atrial fibrillation and pulmonary oedema-which can lead to death. Treatment: Beta blockers for tachycardia Digoxin and heparin if there is atrial fibrillation Some may require surgery balloon valvuloplasty During labour, cardiac monitoring is essential avoiding overloading. Pain must be managed effectively Epidural can be useful if you avoid overload Antibiotic prophylaxis for SBE ampicillin and gentamycin 30 minutes before delivery.

  6. b. Mitral insufficiency This results in regurgitation of blood from the left ventricle3 back into the left atrium, with resulting left atrial enlargement. If pulmonary oedema, embolism, atrial tachycardia and infective endocarditis occur during pregnancy, then such patients can develop complications . Avoid overload, atrial fibrillation, hypertension. Manage pain of labour with epidural. Antibiotic prophylaxis for SBE.

  7. Aortic Insufficiency This causes a chronic increase in left ventricular volume, leading to increased end-diastolic pressure and pulmonary congestion and oedema. Most pregnant women with AI are relatively asymptomatic because of a. Decreased systemic vascular resistance b. Increased heart rate of pregnancy During labour, the changes may lead to decomposition if systemic vascular resistance is increased by pain. Pain relief by epidural. No overload of fluid. Antibiotic prophylaxis for SBE.

  8. Aortic Stenosis This tends to occur in women over 40 years. If it however occurs in the reproductive age, the symptoms include angina, syncope and shortness of breath. Can result in left ventricular failure and infective endocarditis. Maintain adequate fluid volume. Pain relief by narcotics, epidural may cause decreased systemic resistance which is poorly tolerated.

  9. Congenital Heart Disease Women who have undergone surgical correction have normal hemodynamics and tolerate pregnancy well. Women with uncorrected lesions require special management. The most uncontrolled lesions are: Atrial Septal Defects (ASD) Patent Ductus Arteriosus (PDA) Ventricular Septal defect (VSD) Pulmonary Stenosis Coarctation of the aorta Tetralogy of Fallot Both maternal and fetal outcomes depend on the nature of the cardiac lesion. In the presence of cyanosis, there is an increased risk of functional deterioration, congestive heart failure, maternal mortality, IUGR, preterm birth, miscarriage and still-births.

  10. Left to Right Intra Cardiac Shunts These shunts can result from ASDs, VSDs, or PDAs. If there is no pulmonary hypertension and the patient is asymptomatic, pregnancy does not impose significant increased risk. If however, the shunt is substantial resulting in many years of increased pulmonary blood flow, pulmonary hypertension and right heart failure can develop and the shunt reverses. The combination of pulmonary hypertension and right-to-left shunt through any communication between the systemic and pulmonary circulation is know as Eisenmenger syndrome. - Maternal mortality rate of 40% to 60% - Perinatal mortality rate of 28% to 55% -Should be discouraged to get pregnant - Delivery : Excellent pain management - Shorten 2nd stage of labour - Antibiotic prophylaxis for SBE

  11. Peripartum Cardiomyopathy Congestive heart failure characterized by dilatation of the four chambers of the heart. Occurs in the last months of pregnancy or the first 5 months postpartum. Complaints are orthopnea, dyspnea, edema ECG, Chest X-ray, echocardiogram will show cardiomegaly Treat heart failure with digitals, diuretics, or vasodilators, bed rest and anti coagulation. Mortality is high if heart size does not return to normal in 6 months. Advised not to get pregnant because 50% will develop cardiomyopathy in future pregnancies with high mortality rate.

  12. Myocardial Infarction The risk in a reproductive age woman is low (1 in 10,000). Risk factors include arteriosclerosis, thrombosis and vasospastic disease. Maternal mortality is higher in the 3rd trimester. MANAGEMENT: Bed rest to minimize cardiac workload Nitrates, aspirin, beta blockers Calcium channel blocks Epidural anaesthesia in labour and oxygen Avoid another pregnancy for at least one year after M1 if ventricular function has returned to normal.

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