WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
AND
NEWBORN
HEALTH
SECTIONWOMEN
B: GUIDELINES
RELEVANT
TO OBSTETRICS
ANDSERVICE
MIDWIFERY
King Edward Memorial Hospital

3 MEDICAL DISORDERS ASSOCIATED WITH PREGNANCY

3.2 CARDIAC DISEASE AND PREGNANCY

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Quick Reference Guide

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CARDIAC DISEASE AND PREGNANCY QRG

ANTEPARTUM
Preconception counselling, education &assessment & refer early pregnancy care to tertiary
centre
Baseline evaluation early pregnancy (risks, physical examination, electrocardiogram (ECG) &
other tests as per Obstetric Physician), with careful check-up of women from developing countries.
st
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Ultrasound (1 trimester screen; tertiary fetal anatomy scanning at 18-22 weeks & 2 trimester
fetal echocardiography if maternal structural cardiac disease).
Regular antenatal care
Visits every 2-3 weeks >20wks, fortnightly >28wks, weekly >36wks
Check blood pressure (BP) manually; check for signs/ symptoms of cardiac failure (auscultate
lungs, pulse rate/rhythm, jugular venous pressure) & monitor for atypical signs of ischaemia.
Screen for asymptomatic bacteriuria at first appointment (if not already done) &prevent anaemia
Birth planning (Multidisciplinary team approach)
Document planned intrapartum care (analgesia, labour supervision, birth mode, second stage
management, oxytocic, PPH prevention, thromboprophylaxis & antibiotic prophylaxis (where
indicated) and length of postpartum stay) in medical record on MR 004.
Vaginal birth (where appropriate) usually carries the lowest risk of complications.
Encourage rest & admit if chest infection or cardiac failure occurs.
Ask Obstetric Physician about endocarditis prophylaxis &antibiotics for dental/surgical procedures.
INTRAPARTUM
Notify Obstetric Registrar (And in major risk cases: Senior Obstetric Registrar, Obstetric
Consultant, Obstetric Physician, Anaesthetic Registrar, Labour Suite Consultant Anaesthetist).
Additional observations/care (Cardiac exam 4 hourly, strict fluid balance chart, oxygen if required,
haemodynamic monitoring & pulse oximetry if indicated; respirations, pulse & BP half hourly)
If major cardiac risk: Position in sitting or semi-Fowlers.
Continuous fetal heart rate monitoring.
Consider: Analgesia (e.g. epidural) & monitoring intravenous fluids; Antibiotic prophylaxis &
Shortened second stage when major cardiac risk present.
Prevent PPH: Use oxytocin infusion 60units in 500mL Hartmanns solution- rate to be documented
by Obstetric Physician. Do not use ergometrine routinely.
POSTPARTUM
Manage high risk cases in Adult Special Care Unit (ASCU) until maximum risk period passed.
Thromboprophylaxis: Anti-embolic stockings & early ambulation; delay warfarin (where applies).
Breastfeeding: Encourage, where not medically contraindicated. Encourage rest & educate on
signs/ symptoms of mastitis/ infection & action to take if develops.
Discuss contraception, future pregnancy guidance & regular cardiac reviews.
Follow up at 6 weeks (& 6 months if continued concerns), then return to usual cardiac care.

Note: This flowchart represents minimum care & should be read in conjunction with the following full guideline & disclaimer.
Additional care should be individualised as needed.

DPMS
Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 1 of 7

AIM

To provide information on the management of cardiac disease in pregnancy for the antenatal,
intrapartum and postnatal periods.

BACKGROUND
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Cardiovascular disease (CVD) affects approximately 0.2% to 4% of pregnant women. Maternal

mortality in pregnant women with CVD is about 1%, which is 100 times higher than women without
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CVD. In western countries CVD is increasing and is a major cause of maternal mortality in
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pregnancy. Congenital heart disease (CHD) is the predominant type of CVD in first world countries,
whilst rheumatic cardiac disease is still an important cause of morbidity and mortality in developing
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countries, groups living in poor socio economic conditions, and Indigenous Australians. Furthermore,
ischaemic heart disease in pregnancy is becoming more prominent with a higher number of older
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women giving birth, obesity, smoking, hypertension, hypercholesterolaemia and the incidence of
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diabetes increasing.
Mortality of women with cardiac disease is low except in certain conditions such as Eisenmengers
syndrome, pulmonary hypertension, severe systemic ventricular dysfunction, and Marfans syndrome
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with pathology of the aorta, where pregnancy may be contraindicated . Careful monitoring through
pregnancy is required as there are altered physiological demands on the womans body, including
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cardiovascular system, glucose, cholesterol and coagulation homeostasis.
CLASSIFICATION OF CARDIAC DISEASE

Cardiac disease is classified according to functional status:

1. Class I asymptomatic with normal activity.
2. Class II symptoms with normal activity.
3. Class III symptoms with less than normal activity.
4. Class IV symptoms with any physical activity or at rest.
KEY POINTS
1.

An electrocardiogram (ECG) is required by all women who have chest pain in pregnancy.
Additionally, if the pain is severe, a computed tomography (CT) or magnetic resonance imaging
(MRI) scan of the chest (if dissection is suspected) and serum troponin levels may be ordered, as
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decided by the Obstetric Medical team.
If the woman has congenital heart disease the risk of fetal congenital heart disease varies
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between 6 to 50%.
Pregnant women with cardiac disease are at risk of serious morbidity such as heart failure,
arrhythmias and stroke.

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ACUTE CARDIAC FAILURE

If acute cardiac failure develops:

Sit the woman up and lower her legs

Administer oxygen

Intravenous frusemide 40mg (diuretics ) and/or intravenous morphine 5mg to 10mg

administered slowly

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Consult the physician.

Except in an emergency, digoxin is to be commenced by the obstetric physician and is rarely utilised.
Postpartum: Angiotensin Converting Enzyme (ACE) Inhibitors including enalapril and ramipril may be
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used, and are safe to use in breastfeeding mothers.

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 2 of 7

ANTENATAL
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1. Pre-conception counselling, education and assessment.

Ideally women with known cardiac
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disease will have been assessed in the preconception period.
Significant pulmonary
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hypertension in pregnancy is a high risk situation. Preconception counselling should be
undertaken with multidisciplinary specialists as to the risks posed by the pregnancy, including risk
of maternal death. In the event of an unplanned pregnancy, early consultation is essential for
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assessment of maternal risk if the pregnancy continues and discussion of all options.
2. Referral of high risk women to a tertiary maternity service (dependent on CVD complexity, risks
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and services available) and early pregnancy management.
Referral sent to Obstetric Physician for women with:

A past history of cardiac disease

Symptoms or signs of cardiac disease

3. Baseline evaluation early pregnancy with physical examination.

An ECG shall be done on referral; other investigations should be left to the obstetric physician.

Risk stratification assists in determining appropriate level and timing of antenatal care.

Careful screening with a physical examination should be performed on women who come from
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developing countries as the incidence of rheumatic heart disease is high in these areas.
4. Ultrasound:

First trimester ultrasounds, particularly around 13 weeks, have been shown to detect major
congenital heart disease with 85% sensitivity and 99% specificity, thus providing earlier
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detection, consideration of options and management. In the case of congenital heart disease
of the mother, increased nuchal thickness of the fetus at the 12 week gestation scan is
associated with fetal congenital cardiac disease (some studies suggest it may have a
sensitivity of up to 90% for cardiac lesions).

Fetal echocardiography by a fully trained fetal cardiologist should be offered in the second
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trimester to women with structural cardiac disease.

Careful tertiary fetal anatomy scanning at 18-22 weeks should be performed looking for
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cardiac abnormality.
5. Antenatal care:

Prevent anaemia.

A woman with significant cardiac disease will require more frequent antenatal assessments.
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The suggested frequency is every 2-3 weeks after 20weeks , fortnightly after 28 weeks
gestation and weekly after 36 weeks gestation.

At each assessment check blood pressure manually and check for signs and symptoms of
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cardiac failure (e.g. auscultate lungs, check jugular venous pressure, pulse rate and rhythm).

Monitor for any atypical signs of ischaemia such as shortness of breath, dizziness or vomiting,
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with a low threshold for cardiac investigations (e.g. ECG, troponin levels, stress testing).

Screen women with CHD for asymptomatic bacteriuria at the first antenatal appointment if not
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done previously in the pregnancy, due to the risk of pyelonephritis.
6. Planning for birth should be undertaken by the Obstetric Medical team in consultation with the
woman and other members of the multidisciplinary team which may include cardiologists, maternal
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fetal medicine specialists, anaesthetists and midwives.

The obstetric management plan is to be discussed with the woman and documented in the
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medical record on the MR 004: Obstetric Special Instruction Sheet. This should occur early in
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pregnancy and again at 32-34 weeks. Plans include analgesia , who should supervise the
labour, planned birth mode, second stage management, postpartum haemorrhage (PPH)
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prevention, oxytocic, thromboprophylaxis, and length of postpartum stay.

Vaginal birth usually carries the lowest risk of complications, although ideally long and difficult
labours should be avoided.

Induction of labour may be appropriate for optimising anticoagulation, specialist medical staff
presence, or deteriorating maternal cardiac function as decided by the Obstetric Medical
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team. Induction may increase the chance of caesarean birth.

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 3 of 7

 Document specific instructions for intrapartum antibiotic prophylaxis (where applicable).

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7. Encourage rest in the third trimester (symptomatic women may need to finish work earlier ) and
admit to hospital if there is a major risk of cardiac failure. Admit if chest infection or cardiac failure
occurs. Women with significant cardiac disease require thromboprophylaxis when admitted to
hospital for bed rest in pregnancy, and may require it in the postpartum period.
For venous thromboembolism (VTE) information and prophylaxis see also:
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Clinical Guideline Section B 2.12.4 Women with cardiac conditions.

Clinical Guideline Section B 2.12.1 Venous thrombosis occurring in the present pregnancy.
8. Ask the Obstetric Physician's opinion on:

Endocarditis prophylaxis in women with a history of rheumatic carditis or any valve abnormality

Appropriate antibiotic cover for dental (penicillin) and surgical (amoxycillin and gentamicin)
procedures.

INTRAPARTUM
Labour is potentially the most dangerous period for many women as this is the period with the greatest
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increase in cardiac output.
Consider two groups:

Major Risk - those women with increased risk of cardiac failure - such as women with Grade
III and IV cardiac disease, mitral stenosis and atrial fibrillation.

Minor Risk - those women with relatively minimal disease - such as women with Barlow's
Syndrome or a small atrial septal defect.

MANAGEMENT IN LABOUR
1. Notify:
In all cases - Obstetric Registrar.
In all major risk cases - Senior Obstetric Registrar, Obstetric Consultant, Obstetric Physician,
Anaesthetic Registrar, Labour and Birth Suite Consultant Anaesthetist (the Obstetric Physician
will indicate if he/she is to be notified).
2. In addition to routine labour observations:
Respirations half-hourly. Women with a major cardiac risk must have half-hourly observations
(pulse, respirations and blood pressure) and be nursed in a sitting or semi Fowler's position.
Relevant cardiac examination at least 4 hourly.
Strict fluid balance chart.
Oxygen, invasive haemodynamic monitoring and pulse oximetry if indicated.
3. Antibiotic cover: (see next page for dosage)
Start when labour commences or at induction (including cervical ripening). Use in all women with:
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congenital heart disease (cyanotic and non-cyanotic),

hypertrophic cardiomyopathy,

prosthetic valve(s) of any type,

previous infective endocarditis,

presence of surgically constructed systemic-pulmonary shunts or conduits,

Note: Routine labour antibiotic prophylaxis is not indicated for women with cardiac disease of low
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risk. Additionally, continuation of antibiotic prophylaxis for 24 to 48 hours postnatally is not
currently recommended although this may be indicated in certain clinical circumstances (e.g.
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women with prosthetic valves or history of infective endocarditis ).

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 4 of 7

Prophylactic antibiotics
For women NOT allergic to penicillins, betalactams or cephalosporin antibiotics:

Amoxycillin

Initial: 2 grams intravenously (IV).

Thereafter: 1 gram IV 8 hourly.
Postnatal: An additional IV dose 6 hours after birth.
PLUS

Gentamicin

Initial: 5mg/kg IV once a day.

Thereafter: If the birth is 24 hours or more after commencing antibiotics, a
repeat dose of gentamicin 5mg/kg should be given.
Postnatal: If the birth is within 24 hours of commencing gentamicin no
additional postnatal dose is required.

NOTE

Amoxycillin based regimens may need alteration if a woman has required

a course of antibiotic therapy in the preceding month or is on long term
prophylactic penicillin therapy for rheumatic fever.

For women allergic to Penicillins, Betalactams or Cephalosporin antibiotics:

Vancomycin

Initial & thereafter: 25mg/kg up to 1.5 grams IV over 2 hours twice a day.
Dilution: 500mg vancomycin/100mL 0.9% sodium chloride.

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PLUS

Gentamicin

Initial: 5mg/kg IV once a day

Thereafter: If the birth is 24 hours or more after commencing antibiotics, a
repeat dose of gentamicin 5mg/kg should be given.
Postnatal: If the birth is within 24 hours of commencing gentamicin no
additional postnatal dose is required.

Women having an Elective/Non-elective Caesarean Birth

Initial: Antibiotic prophylaxis at the time of caesarean in accordance with Clinical Guidelines,
Section P 3.2 Antibiotic prophylaxis for Caesarean Section (see link).
Postnatal: An additional dose of cefazolin intravenously 6 hours post Caesarean section.
PLUS
Gentamicin

NOTE

Initial: 5mg/kg IV
Thereafter: No additional dose of gentamicin is usually required.
For women allergic to penicillins, betalactams or cephalosporin antibiotics
replace cefazolin with vancomycin as per above recommendations. No
additional dose of vancomycin post Caesarean section should be required

Therapeutic antibiotics:

Treat any suspected infection aggressively with parenteral antibiotics after blood and other
appropriate cultures are taken.

Contact the on-call Clinical Microbiologist for specific advice.

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 5 of 7

4. Epidural analgesia may be used for obstetric indications. For high-risk women managing their
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pain well will decrease their cardiac workload during labour.
The Anaesthetic Registrar must
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first discuss major risk cases with the Anaesthetic Consultant.
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5. Continuous electronic fetal heart rate monitoring. See also Clinical Guideline Section B: 5.6
Intrapartum fetal heart rate monitoring.
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6. Vaginal birth is preferred unless obstetric or specific cardiac condition requires caesarean birth.
7. Shorten the second stage if there is major risk of cardiac failure or hypertension.

Intervention carries a risk of infection.

Avoid routine mid cavity forceps birth.

Assisting vaginal birth and limiting active maternal pushing may be necessary dependent on
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the womans clinical situation to reduce additional load on the cardiovascular system.
Pushing in the left lateral position, rather than supine, lessens cardiovascular changes.
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8. Prevent PPH (particularly if surgical intervention) which may lead to cardiovascular instability.
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Do not use ergometrine routinely (can cause acute hypertension).

Use oxytocin by intravenous infusion in preference to oxytocin 10 units intramuscular or

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intravenous bolus (as bolus doses may cause hypotension).
For patients at risk of fluid overload i.e. those with mitral stenosis, outflow tract obstruction or
cardiac failure, dilute 30iu oxytocins in 25mL Compound Sodium Lactate and administer at
2.5mL / hour.
In caesarean, uterine compression sutures may be beneficial to control PPH from uterine
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atony.
POSTPARTUM
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Manage high-risk cases in Adult Special Care Unit (ASCU) postpartum. Haemodynamics do not
return to normal for several days. Monitoring in ASCU should be continued until the maximum
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risk period has passed. This will depend on the nature of the cardiac disease.
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For VTE prevention: Encourage anti-embolic stockings and early ambulation after birth.
Resumption of warfarin anticoagulation (where applicable) should be delayed by 2 days
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postpartum due to the increased risk of PPH, and close monitoring is required. See also Clinical
Guideline, Section B: 2.12.4 Women with Cardiac Conditions.
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The womans choice to breastfeed should be promoted, where not medically contraindicated.
There is a small risk of mastitis related bacteraemia, and bottle feeding may be medically
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indicated in women with high cardiac risks. Educate the woman on breast care, adequate rest,
the signs/ symptoms of mastitis and what to do if she develops these.
Discuss safe and effective contraception options, future pregnancy guidance and importance of
women with significant heart disease having regular cardiac reviews prior to any future
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pregnancy.
Postnatal multidisciplinary follow up assessment at 6 weeks (and at 6 months if there are
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continued concerns), with the woman then returning to her routine cardiac outpatient care.

PERIPARTUM CARDIOMYOPATHY
Peripartum cardiomyopathy is a cardiac condition that develops in the absence of pre-existing heart
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disease or identifiable cause. It can cause serious complications and maternal mortality, and should
be considered in women who present with shortness of breath/dyspnoea/orthopnoea (particularly when
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supine or at night) usually in the third trimester or up to 6 months after birth.
Other symptoms
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include tachypnoea, tachycardia , palpitations, peripheral oedema (pitting), excessive third trimester
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weight gain, chest pain, cough, and frequent night urination. Risks include multiparity, ethnicity,
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smoking, diabetes, hypertension or pre-eclampsia, and advanced or teen maternal age. A chest x3, 6
ray, echocardiogram and ECG should be considered by the obstetric medical team.

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 6 of 7

REFERENCES (STANDARDS)
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2.

Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart J-M, et al. ESC Guidelines on the
management of cardiovascular diseases during pregnancy: The Task Force on the Management of Cardiovascular
Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal.
2011;32(24):3147-97.
Roos-Hesselink JW, Ruys TP, Stein JI, Thiln U, Webb GD, Niwa K, et al. Outcome of pregnancy in patients with
structural or ischaemic heart disease: Results of a registry of the European Society of Cardiology. European Heart
Journal. 2013;34:657-65.

3.

Johns J. Cardiac disease. O&G Magazine. 2013;15(1):30-2.

4.

Lupton M, Oteng-Ntim E, Ayida G, Steer P. Cardiac disease in pregnancy. Current Opinion in Obstetrics and
Gynecology. 2002;14:137-43.
National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure
Guidelines Expert Writing Panel). Guidelines for the prevention, detection and management of chronic heart
failure in Australia. 2011. Available from: http://www.heartfoundation.org.au

5.

6.
7.

Royal College of Obstetricians and Gynaecologists. Good practice No.13: Cardiac disease and pregnancy: RCOG.
2011. Available from: http://www.rcog.org.uk/files/rcog-corp/GoodPractice13CardiacDiseaseandPregnancy.pdf
van Mook W, Peeters L. Severe cardiac disease in pregnancy, part 1: Hemodynamic changes and complaints during
pregnancy, and general management of cardiac disease in pregnancy. Current Opinion in Critical Care.
2005;11(5):430-4.

8.

Royal College of Obstetricians and Gynaecologists. Heart disease and pregnancy: Study group statement: RCOG;
2006. Available from: http://www.rcog.org.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancystudy-group-statement

9.

Carapetis J, Brown A, Maguire G, Walsh W, Noonan S, Thompson D. The Australian guideline for prevention,
diagnosis and management of acute rheumatic fever and rheumatic heart disease. 2nd ed. RHD Australia,
National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand; 2012.

10.

Curry R, Swan L, Steer PJ. Cardiac disease in pregnancy. Current Opinion in Obstetrics and Gynecology.
2009;21:508-13.

11.

Australian Health Ministers' Advisory Council. Clinical practice guidelines: Antenatal care- Module 1. Canberra:
Australian Government Department of Health and Ageing; 2012. Available from: http://www.health.gov.au/antenatal

12.

de Swiet M. Heart disease in pregnancy. In: de Sweit M, editor. Medical Disorders in Obstetric Practice. London:
Blackwell; 2002. p. 125-58.

13.

Klein LL, Galan HL. Cardiac disease in pregnancy. Obstetrics and Gynecology Clinics of North America.
2004;31:429-59.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis:
Guidelines from the American Heart Association. Circulation. 2007;116:1736-54.

14.
15.

eTG Complete. Therapeutic guidelines: Prevention of endocarditis: Genitourinary and gastrointestinal tract
procedures 2008. Available from: http://online.tg.org.au

16.

Department of Health Western Australia. Baby friendly hospital initiative: Hospital breastfeeding policy. Perth: Health
Networks Branch, Department of Health WA. 2009. Available from:
http://www.health.wa.gov.au/CircularsNew/attachments/411.pdf
Carlin A, Alfirevic Z, Gyte G. Interventions for treating peripartum cardiomyopathy to improve outcomes for women and
babies (Review). Cochrane Database of Systematic Reviews. 2010 (9).

17.

National Standards 1- Clinical Care is Guided by Current Best Practice

3- Preventing and Controlling Healthcare Associated Infection
4- Medication Safety
Legislation - Poisons Act 1964
Related Guidelines / Policies Other related documents KEMH Clinical Guidelines, Section:
B: 2.12.4 Women with Cardiac Conditions; B 2.12.1 Venous thrombosis occurring in the present pregnancy
P: 3.10 Gentamicin Dosing and Monitoring; P: Gentamicin; P: Vancomycin; P: Amoxycillin
RESPONSIBILITY
Policy Sponsor
Medical Director Obstetrics
August 2001
Initial Endorsement
August 2014
Last Reviewed
October 2014
Last Amended
August 2017
Review date
Do not keep printed versions of guidelines as currency of information cannot be guaranteed.
Access the current version from the WNHS website.

DPMS Ref: 3383

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 7 of 7