Cardiac Diseases

in Pregnancy

Nariska Cooper
 objectives
 Cardiovascular Changes in  Management of Labor and
Normal Pregnancy Delivery

 Introduction to Cardiac Disease  Ischemic Heart Disease

in Pregnancy
 Mitral Stenosis
 Preconception Counseling
 Aortic Stenosis
 Normal vs. Abnormal findings
 Marfan's Syndrome
 Risk Markers and high risk
Cardic conditions  Pulmonary Hypertension

 Antenatal Management  Peripartum Cardiomyopathy

 Treatment of Cardiac Failure in  Summary

Pregnancy
 cardiovascular CHANGES IN
normal pregnancy
 Blood Volume Increases by approximately 45%. It begins
increasing by 6-8 weeks gestational age and peaks at 32 weeks
gestation.
 Cardiac Output (CO) Increases by 30-50% above the non pregnant
state as a product of increased Stroke Volume along with increased
heart rate by 10-20beats/min. By 8weeks gestation, the CO has
already increased by least 15%-25%.
 Myocardial contractility improves, left atrial and left ventricular
chamber sizes ↑, and peripheral vascular resistance falls
 The systemic arterial pressure falls during the first trimester, remains
stable during the second trimester, and returns to pregestational
levels before term
 The ↓ in diastolic pressure is more pronounced than the ↓ in systolic
pressure, leading to a wide pulse pressure
cardiovascular CHANGES IN normal
pregnancy : Labor &DELIVERY

 Uterine contractions displace 300-500mL of blood

with each contraction, further augmenting CO

 Oxygen consumption ↑ 3-fold

 Approximately 10- 15 mins after delivery, the CO

increase by 60-80% due to, release of vena cava
compression; auto transfusion of uteroplacental blood
and rapid mobilization of the extravascular fluid.
 introduction TO cardiac disease

• Heart disease is surpassing other causes of maternal

mortality in recent years

• Cardiac disease complicates approximately 1% of all

pregnancies

• Pregnant patients with significant symptoms on exertion,

such as patients in the New York Heart Association
(NYHA) functional classes III and IV, have high event rates
and may succumb to complications of heart disease

• Patients with stenotic lesions and minimal baseline

symptoms (NYHA class I or II) may deteriorate rapidly
 NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION OF HEART DISEASE

CLASS
I No signs or symptoms (chest pain or
shortness of breath)

II No symptoms at rest, slight limitation with

mild to moderate activity (walking >2
blocks)

III No symptoms at rest, marked limitation

with less than ordinary activity (walking
<2 blocks)

IV Symptoms at rest
 introduction TO
cardiac disease
 Pregnant women with congenital heart disease now
outnumber those with rheumatic heart disease in
developing countries

 Acquired conditions such as ischemic heart disease are

also not uncommon today as women are delaying
childbearing to the third and fourth decades of life

 As the general population becomes more susceptible to

diabetes mellitus, morbid obesity, and hypertension,
more frequent encounters with ischemic heart disease
in pregnant patients are expected
 preconception counseling

 Most women with cardiac disease are fully aware of their

condition and should be adequately assessed before attempting
pregnancy.
 Patient should be jointly managed by both and Obstetrician and
Cardiologist
 Certain conditions may need treatment before attempting
pregnancy.
 Patients with cardiac conditions associated with high maternal
mortality should be advised against pregnancy and offered
termination of pregnancy at an appropriate gestational age
 Preconception counseling also allows for optimal timing of
conception if the individual wants to become pregnant.
 Issues addressed in PRECOCEPTION
COUNSELLING

 Risk of maternal death

 Possible reduction of maternal life expectancy
 Effects of pregnancy on cardiac disease
 Mortality associated with high risk conditions
 Risk of fetus developing congenital heart disease
 Risk of preterm labor and FGR
 Need for frequent hospital attendance and possible admission
 Intensive maternal and fetal monitoring during labor
 Other options - contraception, adoption, surrogacy
 Timing of pregnancy
• Before antenatal management and risk assessment is
addressed, its important to distinguish normal cardiac
and symptoms in pregnancy from those that are
pathologic
 FINDINGS IN NORMAL PREGNANCY
Symptoms Fatigue, ↓ exercise capacity, lightheadedness, syncope,
palpitations, dyspnea, orthopnea

Physical Examination distended neck veins, ↑ intensity of S1, exaggerated splitting,

exaggerated splitting of S2, mid-systolic, soft, ejection-type
murmurs (lower left sternal border or over the pulmonary area),
third heart sound, continuous murmurs, brisk, diffused,
displaced left ventricular impulse, palpable right ventricular
impulse

Electrocardiogram QRS axis deviation, small Q and inverted P in lead III

(abolished by inspiration), sinus tachycardia, higher incidence of
arrhythmias

Chest Radiograph Horizontal position of heart, ↑ lung markings

EchoCardiography slightly ↑ systolic and diastolic left ventricular dimensions,

moderate ↑ in side of right atrium, right ventricle, and left
atrium, functional pulmonary, tricuspid, and mitral regurgitation
 SIGNS AND SYMPTOMS INDICATIVE OF
CARDIAC DISEASE

Symptoms progressively worsening SOB, cough with frothy pink sputum,

paroxysmal nocturnal dyspnea, chest pain with exertion,
syncope preceded by palpitations or exertion, hemoptysis

Physical Examination abnormal venous pulsations, rarely audible S1, single S2 or

paradoxically split S2, loud systolic murmurs, any diastolic
murmur, ejection clicks, late systolic clicks, opening snaps,
friction rub, sustained right or left ventricular heave, cyanosis or
clubbing

Electrocardiogram significant arrhythmias, heart blocks

Chest Radiograph cardiomegaly, pulmonary edema

 FUNCTIONAL CAPACITY OF THE HEART:
nEW YORK HEART ASSOCIATION
CLASSIFICATION

CLASS SYMPTOMS
I No limitation of physical activity. Ordinary physical activity
does not precipitate fatigue, palpitations, dyspnea, angina.

II light limitation of physical activity. Comfortable at rest, but

ordinary physical activity results in fatigue, palpitation or
dyspnea.

III Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity causes fatigue, palpitation or
dyspnea.

IV Unable to carry out any physical activity without discomfort.

Symptoms of cardiac insufficiency at rest. If any physical
activity is undertaken, discomfort is increased.
• The NYHA classification is the best means of
assessing cardio-pulmonary status and is a good
indictor of whether or not the patient is incapacitated
by her symptoms and to what extent .

 It is important to note that patient with functional

Class I or II can easily progress to class III/IV. Thus
functional capacity should be assessed on each visit.

 Some advocate for the termination of pregnancy( in

early stages) for Class III/IV
 Toronto risk Markers for Maternal
CARDIAC EVENTS

Prior cardiac event (heart failure, arrhythmia

1 or stroke)

2 NYHA functional class > II or cyanosis

3 Outlet obstruction of the left heart

4 Reduced left ventricular function (ejection

fraction <40%)

0 predictors: risk of cardiac event is 5 per cent; 1 predictor: risk of cardiac

event is 37 per cent; 1 predictors: risk of cardiac event is 75 per cent.
 high-risk cardiac CONDITIONS

ETIOLOGY DISEASE

Pump failure severe cardiomyopathy

Symptomatic Valve Narrowing mitral stenosis, aortic stenosis, pulmonary stenosis

Cyanotic heart disease tetralogy of fallot, transposition of great arteries

Aortic Rupture Marfan’s syndrome with dilated aorta

Artificial Prosthesis Mechanical heart valves

Elevated pulmonary artery Eisenmenger’s syndrome, 1° pulmonary

pressure hypertension, pulmonary vascular disease
 Fetal Risk for
maternal Cardiac
disease
 Recurrence (congenital
heart disease)
 Maternal cyanosis (fetal
hypoxia)
 Iatrogenic prematurity
FGR
 Effects of maternal drugs
(teratogens, growth
restriction, fetal loss)
 Antenatal Management

 Routine physical examination should include:

 pulse rate

 blood pressure

 jugular venous pressure ankle and sacral edema

 presence of basal crepitations

 Physical Examination

 Focus on facial, digital, or skeletal abnormalities that

suggest the presence of congenital anomalies .(
Marfan’s syndrome: extremely tall, slender limbs
finger and toes; disproportionally long arms)

 Observe for clubbing cyanosis ,or pallor

 The first heart sound usually is widely split

 A loud first heart sound suggest mitral stenosis

whereas low-intensity first heart sound indicates first-
degree heart block

 A widely split second heart sound goes along with

atrial septal defect where as a paradoxically split
sound occurs in severe left ventricular hypertrophy or
left bundle branch block
 physical examination

 A third heart sound is normal in pregnancy

 A fourth heart sound, ejection click, opening snap, or mid-to-
late systolic click suggests heart disease
 Functional systolic murmurs can be heard in most pregnant
women and can result from the hyperkinetic circulation of
pregnancy
 Continuous benign murmurs, such as the cervical venous hum
and mammary soufflé, also result from ↑ flow 2° to the
hemodynamic changes of pregnancy.
 Diastolic murmurs heard during pregnancy require further
investigation by echocardiography and Doppler ultrasound.
 Investigations

 Electrocardiography

 Chest Radiograph

 Echocardiography

 Exercice Stress Test

 Cardiac Catheterization
 Management of Cardic disease in
preganacy

• Bed rest and limitation of strenuous physical activity

• Mild exercise is encouraged to improve physical fitness and
to reduce the risks of venous thromboembolism
• Careful diet and weight control Prevention and early
treatment of anemia
• Prevention and treatment of infection especially urinary and
respiratory infections
• Prompt treatment of hypertension
• Avoid supine position, the semi-recumbent position is
preferable
 Indication for Hospitilization

 Patients with Class III/IV of heart disease for the

entire duration of pregnancy.

 Hypertensive disorders of pregnancy

 Infections such as pyelonephritis

 Anemia

 Routine admission for 28-32 weeks gestation and again

at 38-39 weeks in preparation for delivery.
 Treatment of Cardiac failure in
Pregnancy

 The principals of treatment are similar to that of a non

pregnant patient.
 The woman should be admitted and the diagnosis
confirmed by clinical examination for signs of heart
failure, and by echocardiography
 Drug therapy may include:
diuretics, vasodilators digoxin
 Oxygen and morphine may also be required
 Arrhythmias require urgent correction and drug therapy
including adenosine for supraventricular tachycardia, and
selective beta-adrenergic blockade may be required
Treatment of Cardiac failure in
Pregnancy

 Assessment of fetal well being is essential and should

include fetal ultrasound to assess fetal growth and regular
cardiotocography

 Premature delivery may be considered if there is evidence

of fetal compromise

 In cases of intractable cardiac failure, the risks to the

mother of continuing the pregnancy and the risks to the
fetus of premature delivery must be carefully balanced

 Cardiac surgery is not performed in pregnancy unless it is

absolutely necessary .
 Obstetric Management

 Ideally, regional/epidural, anesthesia/analgesia should be

discussed with senior anesthetist .
 Patient should be allowed to undergo spontaneous labor.
Cardic disease alone is not and indication for IOL.
 Syntocinon (Oxytocin) infusion should not be used due to
the risk of Circulatory overload. Artificial rupture of
membrane may lead to chorioamnionitis and Bacterial
endocarditis.
 Caesarian section is also not indicated in Cardiac Disease,
however it can be done due to an obstetric complication.
 Vaginal delivery is the preferred route of delivery!!
 First stage of labor
 The patient is placed on bed rest in a semi- recumbent position

 Avoid the supine position

 Intravenous infusions should be restricted as to avoid fluid overload

 Ensure a recent hemoglobin value and 2 units of cross-matched

blood should be available

 Intermittent oxygenation via face mask or nasal cannula

 Administer broad-spectrum antibiotics every 8 hours as soon as labor

starts or when the membranes rupture to reduce the incidence of
bacterial endocarditis

 Close monitoring of pulse, temperature, blood pressure, respiratory

rate, and for the development of cyanosis

 Adequate pain relief with narcotic analgesics

 Early amniotomy is best avoided and vaginal examinations should

be restricted
 Second stage of labor

 When the cervix is fully dilated, the patient

is encouraged to bear down with each
contraction
 If there is maternal distress, the second stage
is shortened with the aid of forceps and a
generous episiotomy ought to be performed
 With the birth of the anterior shoulder,
Syntometrine (ergometrine and oxytocin) is
withheld . Syntometrine is Contraindicated
because it cause intense uterine contraction
and thus increased venous return which
aggravates the work on the heart.
Syntometrine may also lead to transient
hypertension.
 All oxytocin agents may be reserved for
those with significant bleeding after the end
of the third stage of labor
 THIRD STAGE OR labor

 The placenta is removed using the

Brandt Andrews method. Upward
pressure is applied to the uterus
through the abdominal wall while
holding the umbilical cord taut. When
the uterus is elevated in this way, the
placenta will be in the cervix or upper
vagina and is then expelled by applying
pressure below the base of the uterus.

 Immediately after the third stage, the

episiotomy must be repaired

 The patient must be closely monitored

for cardiac failure
 peurperium
 Patient is encouraged to breast- feed
 Advised to have bed rest
 Patients with Class III or IV disease, sterilization should be
recommended; if not acceptable, then barrier contraception is
advisable.
 The intra-uterine contraceptive device is relatively contraindicated
because it can cause Endometritis and bacteremia which can
cause sub acute bacterial endocarditis.
 The oral contraceptive pill should be used with caution because
those containing estrogen may predispose patient to a
thromboembolic phenomena. The new low dose contraceptive
pill may be used carefully. Microgynon30 ( ethinyl-estradiol &
leveonorgestrel??
 Follow up with cardiologist before release
 Ischemic Heart
disease
 Risk of myocardial infarction during pregnancy is estimated as 1 in 10,000 with
peak incidence in the third trimester, in parous women older than 35

 Coronary atherosclerosis is the 1° cause of MI in the antepartum period

 Coronary artery dissection 1° cause of MI in the postpartum period

 Treatment options include thrombolysis, percutaneous coronary intervention or

coronary artery bypass grafting

 In the general population percutaneous trans luminal coronary angioplasty is first-

line therapy
 Ischemic heart
disease
 In pregnancy PTCA implies exposure of the fetus to radiation

 High doses of radiation place the fetus at risk of:

 spontaneous abortion , organ deformation

mental retardation,
childhood cancer

 Percutaneous trans luminal coronary angioplasty is used only

when absolutely necessary and avoid the time when the fetus is
most susceptible to radiation (8-15 weeks)

 There is little experience with thrombolytic therapy in pregnancy

and although not apparently teratogenic, there are risks of fetal
and maternal hemorrhage
 Mitral Stenosis
 Characterized by narrowing of the opening within the mitral valve. It Maybe congenital or due to
rheumatic heart disease

 RHD develops after a group A β-hemolytic streptococcal infection of the upper airway
Characteristic findings include:

• right ventricular lift ,

• loud first heart sound

• accentuated pulmonic component of the second heart sound

• opening snap

• low-frequency diastolic rumble at the apex with pre-systolic accentuation

 Murmur is best heard with the bell of the stethoscope in the left lateral decubitus position

 Echocardiogram is diagnostic
➤ The↑left atrial pressure may predispose the patient to atrial arrhythmias
➤ The pregnant cardiac patient is also at risk for developing thromboembolic complications
 Mitral Stenosis
 Goals of treatment:

prevent/treat tachycardia and atrial fibrillation

prevent fluid overload

Alleviate pain and anxiety

 Beta blockers, diuretics, and occasionally digitalis and anticoagulation maybe necessary
to treat congestive failure and atrial arrhythmias. Medical management remains the first-
line therapy

 Patients with severe MS, mitral valvotomy maybe performed for symptomatic relief
before pregnancy

 Balloon valvuloplasty has become the preferred, less invasive procedure

 Mitral valve replacement is considered as a last resort

 Narrowing of the area within the aortic valve

 Most common cause :bicuspid aortic valve followed by RHD

 Common symptoms: chest pain, syncope, and CHF

 Physical examination: diminished and delayed carotid pulse

 ECG: LFH & left atrial enlargement

 symptomatic patients should be advised to restrict their physical activity and can be
managed expectantly during pregnancy

 Patient should strongly be considered for mechanical relief of their obstruction

 Aortic balloon valvuloplasty can be performed before pregnancy or after 20weeks

gestation if the valve anatomy is favorable

 Aortic valve replacement is considered a last resort and is associated with significant
fetal loss and maternal morbidity

 surgical intervention of patient’s condition deteriorates before delivery.

 Marfan Syndrome
 Autosomal dominant connective tissue abnormality that causes cystic
medial necrosis of the aorta and may lead to dissecting aneurysm in
pregnancy
 ↑risk of rupture, dissection, and cardiovascular complications if
aortic root diameter Is more than 4cm.
 Patients with root dilatation ≥4cm should be advised against
pregnancy and offered termination if pregnant.
 Prophylactic beta-blockers should be considered to retard the
progression of aortic root dilatation in pregnancy
 Echocardiography is the principal investigation as it is able to
determine the size of the aortic root, and should be performed
serially throughout pregnancy especially in women who enter
pregnancy with an aortic root that is already dilated (≥4)
 Women with an aortic root <4cm
should be reassured that their risks are
lower and the risk of an adverse
cardiac event is around 1%

 In addition to the more ominous

cardiovascular complications,
obstetric complications include:

 early pregnancy loss

 Preterm labor

 cervical weakness

 uterine inversion

 postpartum hemorrhage

 recto-vaginal perforation
 Pulmonary
Hypertension
 Characterized by an ↑ in the pulmonary vascular resistance resulting in
an ↑ workload placed on the right side of the heart

 Symptoms include: fatigue, breathlessness, syncope

 Clinical signs are those of right heart failure

 Treatment includes:

• endothelial blockers such as Bosentan

• phosphodiesterase inhibitors such as sildenafil

 More complex therapies include:

nebulized, subcutaneous, and intravenous prostaglandins

 Disease progress can be assessed with
echocardiography
 Close monitoring by a multidisciplinary
team is crucial
 Recommended that women with
pulmonary hypertension should be
strongly advised against pregnancy and
given clear contraceptive advice with
early termination advised in the event of
pregnancy
 When women who are fully informed
of the risks choose to continue their
pregnancy, target pulmonary vascular
therapy is an option, with timely
admission to hospital and delivery
according to the progress of the woman
and condition of the fetus
 Peripartium
Cardiomyopathy
 Dilated cardiomyopathy of unknown cause.

 Usually diagnosed during late pregnancy or in the 4-5months after delivery

 Diagnosed with the finding of left ventricular systolic dysfunction in a woman

with no history of cardiac disease

 Etiology is unclear, however, a number of pathophysiologic mechanisms have

been proposed:

 inflammation, Myocarditis, and abnormal maternal immunologic response to

fetal antigens .

 Patient usually presents with dyspnea, cough, chest discomfort, or fatigue

 Diagnosis is based on the following criteria:

• Presentation with heart failure during the last month of pregnancy

or within 5months postpartum
• Absence of underlying cause for the heart failure
• No history of heart disease before presentation
• Evidence of left ventricular systolic dysfunction by an ejection
fraction 45%or reduced shortening fraction.
 Echocardiogram typically reveals a reduction in cardiac
contractility and dilation of the left ventricle without hypertrophy
 Serial B-type natriuretic peptide levels maybe a useful marker to
follow through the pregnancy
 Patients with ejection fraction of <35% are at risk of thromboembolism;
therefore, prophylactic anticoagulation during pregnancy and full
anticoagulation for 7-10 days after delivery should be considered.

 After stabilization of the mother, the fetus should be delivered

 Principles of therapy include supportive care-bed rest and fluid and salt
restriction and medical therapy

 Medical therapy includes:

• Diuretics

• Vasodilators

• Digitalis with or without beta-blockers

 The use of angiotensin-converting enzyme inhibitors is contraindicated

during pregnancy .
 SUMMARY!!
 Most pregnant patients with
cardiac disease have successful
outcomes with careful follow- up

 Extremely high-risk patients

should be advised against
pregnancy and be offered
termination if they become
pregnant

 A team of high-risk obstetrician,

cardiologist, and anesthesiologist
is recommended to optimize
maternal and fetal outcome
 rEFERENCES
 Kenny, L. C., & Bakers, P. (2011). Obstetrics by Ten Teachers. London:
Hodder Arnold.

 Roopnarinesingh, A., Roopnarinesingh, R., Roopnarinesingh, S.,

Sirjusingh, A., & Bassaw, B. (2008). Textbook of obstetrics. Port of Spain,
Trinidad & Tobago: Lexicon.

 https://emedicine.medscape.com/article/162004-overview#a4

 Ling, Frank W., et al. Step-up to obstetrics and gynecology. Wolters

Kluwer Health, 2015.