Cardio Vascular Diseases in

Pregnancy

Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.
Department of Obstetric & Gynecological Nursing
SCPM College Of Nursing & Paramedical Sciences,
Gonda. U.P.
Introduction
• Heart Diseases & Mortality
• In western countries maternal heart disease is now the
major cause of maternal death during pregnancy [UK 2003-
2005].

• In South India, 30% H’ge, 17% sepsis, 13% hypertensive

disorders [2001-2003 Special Survey Of Deaths].
 EFFECT OF CARDIOVASCULAR
PHYSIOLOGY ON HEART LESION
• Marked hemodynamic changes in pregnancy and cardiac
output in particular, have profound effects on heart disease.
A normal heart has got enough reserve power so that the
extra load can well be tackled. While a damaged heart with
good reserve can even withstand the strain but if the reserve
is poor, cardiac failure occurs sooner or later. The cardiac
failure occurs during pregnancy around 30 weeks, during
labor and mostly soon following delivery.
FACTORS RESPONSIBLE FOR CARDIAC
FAILURE:
• Advanced age
• Cardiac arrhythmias or left ventricular hypertrophy
• History of previous heart failure
• Appearance of ‘risk factors’ in pregnancy are: infection,
anemia, hypertension, excessive weight gain and multiple
pregnancy.
• Inadequate supervision.
EFFECTS OF HEART LESION ON PREGNANCY:
• There is a tendency of preterm delivery and prematurity.
IUGR is quite common in cyanotic heart diseases.
PROGNOSIS
MATERNAL:
The prognosis depends on:
(1) Nature of lesion
(2) Functional capacity of the heart
(3) Quality of medical supervision provided during pregnancy,
labor and puerperium.
(4) Appearance of the risk factors mentioned earlier.
• Maternal mortality is lowest in rheumatic heart lesions and
acyanotic group of heart diseases—less than 1%. With
elevation of pulmonary vascular resistance specially with
cyanotic heart lesions, the mortality may be raised to even
50%. Most of the deaths occur due to cardiac failure and the
maximum deaths occur following birth.
The other causes of death are—
• Pulmonary edema
• Pulmonary embolism
• Active rheumatic carditis
• Subacute bacterial endocarditis
• Rupture of cerebral aneurysm in coarctation of aorta.
• FETAL:
• In rheumatic heart lesions, the fetal outcome is usually good
and in no way different from the patients without any heart
lesion. However, in cyanotic group of heart lesion, there is
increased fetal loss (45%) due to abortion, IUGR and
prematurity. Fetal congenital cardiac disease is increased by
3–10% if either of the parents have congenital lesions.
DIAGNOSIS:
• Anatomical and physiological changes during pregnancy that mimic cardiac
disease
• Hyperdynamic circulation
• Systolic ejection murmur at left sternal border (due to increased blood flow
across the aortic and pulmonary valves)
• Dyspnea, decreased exercise tolerance, fatigue, syncope
• Tachycardia, shift of ventricular apex
• Continuous murmur at 2nd to 4th intercostal space— mammary souffle
• Loud first sound with splitting
• Symptoms must be carefully assessed and investigations are to
• be done to confirm the diagnosis
DIAGNOSIS OF HEART DISEASE IN PREGNANCY
• Symptoms:
• Breathlessness, nocturnal cough, syncope, chest pain
• Signs:
• Chest murmurs—pansystolic, late systolic, louder ejection
systolic or diastolic associated with a thrill.
• Cardiac enlargement, arrhythmia
• Chest radiography (using lead shield):
• Cardiomegaly, increased pulmonary vascular markings, enlargement of
pulmonary veins.
• Electrocardiography: T wave inversion, biatrial enlargement, dysrrhythmias
• Echocardiography (color flow Doppler study):
• Structural abnormalities (ASD, VSD), valve anatomy, valve area, function,
left ventricular ejection fraction, pulmonary artery systolic pressure
• Cardiac MRI can delineate complex (anatomy when it is not well-evaluated
by echo cardiography)
 NEW YORK HEART ASSOCIATION (NYHA)
CLASSIFICATION OF HEART DISEASE
(DEPENDING UPON THE CARDIAC RESPONSE TO
PHYSICAL ACTIVITY)
• Grade-I: Uncompromised and no limitation of physical
activity.
• Grade-II: Slightly compromised with slight limitation of
physical activity. The patients are comfortable at rest but
ordinary physical activity causes discomfort
• Grade-III: Markedly compromised with marked limitation of
activity. The patients are comfortable
• at rest but discomfort occurs with less than ordinary activity
• Grade-IV: Severely compromised with discomfort even at
rest
• Limitation: This classification has considered the symptoms
only but not the anatomical type and severity of pathology. It
does not predict pregnancy outcome
RISKS OF MATERNAL MORTALITY WITH
HEART DISEASE (NYHA, 1992)
Mortality (%) Mortality (%)
Group 1 (minimal risk): ASD, VSD, PDA, Fallot tetralogy 0 - 1
(corrected), Mitral stenosis (NYHA– Grade I and II),
biopresthotic Valve
Group 2 (moderate risk): MS (NYHA – III and IV) AS, 5 - 15
Marfan syndrome (Normal aorta), Fallot tetralogy
(uncorrected), M S with atrial fibrillation, artificial valve

Group 3 (major risk): Pulmonary hypertension, Marfan 25 - 50

syndrome (aortic involvement), aortic coarctation with
valvular involvement
PRINCIPLES
• Early diagnosis and evaluation of anatomical type and
functional grade of the case
• To detect the high risk factors and to prevent cardiac failure
• Combined (obstetrician and cardiologist) care and
mandatory hospital delivery
ANTENATAL CARE
• Injection penidure LA 12 (benzathine penicillin) is given at
intervals of 4 weeks throughout pregnancy and puerperium
to prevent recurrence of rheumatic fever. Counseling is to
be done regarding prognosis and risks.
• Special care in each antenatal visit is to detect and to treat
the risk factors that precipitate cardiac failure in pregnancy.
RISK FACTORS FOR CARDIAC FAILURE
• Infections—Urinary tract, dental and respiratory tract.
• Anemia
• Obesity
• Hypertension
• Arrhythmias
• Hyperthyroidism
• Drugs—Betamimetics.
• Excess intake of caffeine, alcohol, high calorie diet.
ROLE OF ANTICOAGULANTS:
• Anticoagulants are necessary in cases of congenital heart
disease who have pulmonary hypertension, artificial valve
replacements or atrial fibrillation. The patient taking warfarin
should discontinue it as soon as pregnancy is diagnosed and
replace by heparin 5000 units twice daily subcutaneously up
to 12th week. This is then replaced by warfarin tablet 3 mg.
daily to be taken at the same time each day and continued
up to 36 weeks. Thereafter it is replaced by heparin upto 7
days postpartum. Warfarin is then to be continued.
ADMISSION: ELECTIVE:
• Grade–I : At least two weeks prior to the expected date of
delivery
• Grade–II : At 28th week specially in case of unfavorable
social surroundings
• Grade III and IV : As soon as pregnancy is diagnosed.
MANAGEMENT DURING LABOR
• PLACE OF INDUCTION: Most patients with cardiac disease go
into spontaneous labor and deliver without any difficulty.
However, induction (vaginal PGE2) may be employed in very
selected cases for obstetric indications. One should guard
against infection and pulmonary edema due to fluid
overload.
LABOUR
• FIRST STAGE:
• Position: The patient should be in lateral recumbent position
to minimize aortocaval compression
• Oxygen is to be administered (5–6L/min) if required
• Analgesia in the majority, is best given by epidural
• Fluids should not be infused more than 75 mL/hour to
prevent pulmonary edema.
• Careful watch of the pulse and respiration rate. If the pulse
rate exceeds 110 per minute in between uterine
contractions, rapid digitalization is done by intravenous
digoxin 0.5 mg.
• Cardiac monitoring and pulse oxymetry can detect
arrhythmias and hypoxemia early.
• Central venous pressure monitoring may be needed in
selected cases.
• Prophylactic antibiotics: Antibiotic prophylaxis during labor
and 48 hours after delivery is considered appropriate. This is
to prevent puerperal endocarditis. The recommended
regimens include intravenous ampicillin 2 g and gentamicin
1.5 mg/kg (not to exceed 80 mg), at the onset or induction of
labor followed by repeat doses 8 hours interval. All high risk
patients with structural heart disease, complex cyanotic
congenital heart disease, prosthetic valves need
endocarditis prophylaxis.
SECOND STAGE:
• No maternal pushing and the tendency to delay in the
second stage of labor is to be curtailed
• by forceps or ventouse under pudendal and/or perineal
block anesthesia. Ventouse is preferable to forceps as it can
be applied without putting the patient in lithotomy position
(raising the legs increases the cardiac load). Intravenous
ergometrine with the delivery of the anterior shoulder
should be withheld to prevent sudden overloading of the
heart by the additional blood squeezed out from the uterus.
THIRD STAGE
• Conventional management is to be followed. Slight
blood loss is not detrimental but if it is in excess,
oxytocin can be given by infusion. This may be
accompanied by intravenous frusemide. It is better to
administer oxytocin in preference to ergometrine in all
cases of heart disease in third stage.
PLACE OF CESAREAN SECTION
• CARDIAC INDICATIONS OF CESAREAN DELIVERY:
• Coarctation of aorta
• Aortic dissection or aneurysm
• Aortopathy with aortic root > 4 cm
• Warfarin treatment within 2 weeks
• In coarctation of aorta, elective cesarean section is indicated to
prevent rupture of the aorta or mycotic cerebral aneurysm. The
anesthesia should be given by expert anesthetist using either epidural
(preferred) or general anesthesia.
PUERPERIUM
• The patient is to be observed closely for the first 24 hours.
Oxygen is administered. Hourly pulse, BP and respiration are
recorded. Diuretic may be used if there is volume overload.
• Breastfeeding is not contraindicated unless there is failure.
Anticoagulant therapy is not a contraindication of
breastfeeding.
CONTRACEPTION
• Steroidal contraception is contraindicated as it may
precipitate thrombo-embolic phenomenon.
• Intrauterine device is avoided for fear of infection.
• Progestin only pills or parenteral progestins are safe and
effective. They may cause irregular bleeding specially if the
patient is anticoagulated.
• Barrier method of contraceptives (condom) is the best.
• Sterilization should be considered with the completion of the family
at the end of first week in the puerperium under local anesthesia
through abdominal route by minilap technique. If the heart is not well
compensated, the husband is advised for vasectomy.
MANAGEMENT OF CARDIAC FAILURE
IN PREGNANCY
• Propped up position
• O2 administration
• Monitoring with ECG and pulse oxymetry
• Diuretic: Frusemide (Loop) (40–80 mg) IV
• Mechanical ventilation • Injection morphine 15 mg IM
• Digoxin 0.5 mg IM followed by tab digoxin 0.25 mg P.O. (Digoxin
crosses the placenta and is excreted in breast milk)
• Dysrhythmias—quinidine or electrical cardioversion
• Tachyarrhythmias—Adenosine (3–12 mg) IV or DC conversion
SPECIFIC HEART DISEASE DURING PREGNANCY
AND THE MANAGEMENT
RHEUMATIC HEART DISEASE

• MITRAL STENOSIS: Mitral stenosis is the commonest heart lesion met

during pregnancy. Normal mitral valve area ranges between 4 and 6
cm2. Symptoms usually appear when stenosis narrows this to less
than 2.5 cm2. In asymptomatic cases, the mortality is < 1% but once it
is significantly symptomatic, mortality ranges between 5 and 15%.
During labor continuous epidural analgesia is ideal and intravenous
fluid overload is to be avoided.
PLACE OF VALVOTOMY:
• It is better to withheld elective cardiac surgery during
pregnancy. Surgery should be considered in cases of
unresponsive failure with pregnancy beyond 12 weeks. Best
time of surgery is between 14–18 weeks. Valve replacement,
commissurotomy, balloon-valvotomy can be carried out in
early second trimester.
AORTIC STENOSIS:
• Normal aortic valve area is 3–4 cm. When it is reduced to < 1
cm, stenosis is significant. Maternal mortality of significant
aortic stenosis is about 15–20% with perinatal loss of about
30%. Epidural anesthesia is contraindicated. During labor,
fluid therapy (125-150 mL/h) should not be restricted. Left
ventricular after load is high and the pregnant patient is
sensitive to haemorrhage.
• Common symptoms are angina, syncope and left ventricular failure.
• Medical management is not helpful in a symptomatic patient. Valve
replacement is the definitive treatment. Mechanical valves need
anticoagulation. Open heart surgery is preferably avoided in
pregnancy. Aortic balloon valvoplasty may be done as a palliative
procedure.
CONGENITAL HEART DISEASE:
• With increasing number of surgical correction of the
congenital heart lesions from infancy to adulthood, more
and more pregnancies with congenital lesions are met in
day-to-day practice. These patients pose little problem in
obstetrics. But when pregnancy occurs in uncorrected
congenital lesions, problems are very much there specially in
a cyanotic group. Risk to the offspring of congenital heart
disease is high (3–13%).
• Major maternal risks in pregnancy are:
• Cyanosis
• Left ventricular dysfunction and
• Pulmonary hypertension.
• The common maternal complications are:
• Congestive cardiac failure
• Pulmonary edema
• Arrhythmia and
• Hypertension. All women should have fetal echocardiography
examination at mid pregnancy.
ACYANOTIC (L TO R SHUNT)
• Atrial Septal Defect (ASD):
• ASD (ostium secundum type) is the most common congenital
heart lesion during pregnancy.
• Even uncorrected ASD tolerates pregnancy and labor well.
Congestive cardiac failure unresponsive to medical therapy
requires surgical correction. Shunt reversal is the major risk
which may develop in hypovolemia. Such cases may occur in
hemorrhagic conditions and following injudicious
administration of epidural anesthesia. In the absence of
arrhythmias, and pulmonary hypertension, ASD does not
usually complicate pregnancy.
Patent Ductus Arteriosus (PDA):
• Presence of continuous murmur at the upper left sternal
border is suggestive of diagnosis. Most patients with PDA
tolerate pregnancy well. Pulmonary hypertension may cause
maternal death. Surgical correction during pregnancy can be
performed provided there is no pulmonary hypertension.
Epidural analgesia is better avoided to minimize shunt
reversal due to systemic hypotension. Fetal loss may be up to
7% and there is 4% chance that the child of this parent will
suffer from the same abnormality. Endocarditic prophylaxis
should be given.
Ventricular Septal Defect (VSD):
• In general, if the defect is less than 1.25 cm,
pulmonary hypertension and heart failure do not
develop. Pregnancy is well tolerated with small to
moderate left to right shunt or with moderate
pulmonary hypertension. The major risk is shunt
reversal leading to circulatory collapse and cyanosis.
Hypotension is to be avoided. Fetal loss may be up to
20%.
Mitral Valve Prolapse (MVP)
• Is the commonest congenital valvular lesion. Most of them are
asymptomatic. Women tolerate pregnancy and labor well.
Endocarditis prophylaxis is given.
CYANOTIC (R TO L SHUNT)
• It is the most common form of cyanotic heart lesion. It is a
combination of ventricular septal defect,
• pulmonary valve stenosis, right ventricular hypertrophy and
an overriding aorta. After surgical correction, patients
tolerate pregnancy well. Surgically uncorrected patients are
at increased risk. Complications like bacterial endocarditis,
brain abscess and cerebral embolism are more common.
Maternal mortality is 5–10% and the perinatal mortality is
30–40%. IUGR is common. Epidural or spinal anesthesia is
avoided. Pregnancy is discouraged in women with
uncorrected tetralogy.
Eisenmenger’s syndrome:
• Patients with Eisenmenger’s syndrome have pulmonary
hypertension with shunt (right to left) through an open
ductus, an atrial or ventricular septal defect. Maternal
mortality is about 50% and so also the perinatal loss (50%).
Termination of pregnancy should be seriously considered.
Heparin should be used throughout pregnancy as there is
risk of systemic and pulmonary thromboembolism. Epidural
anesthesia is contraindicated. Inhaled nitric oxide or I.V.
prostacyclin is used as a pulmonary vasodilator.
Complications are: CCF, hemoptysis, arrhythmia,
cerebrovascular accident and hypoxemia; hyperviscosity
syndrome and sudden death.
OTHER CONGENITAL HEART LESIONS
COARCTATION OF AORTA:
• The maternal risks are hypertension, aortic dissection,
bacterial endocarditis and cerebral hemorrhage due to
ruptured intracranial aneurysms. Maternal mortality is high
3–9%. Fetal loss is also increased to 25%. Surgical correction
should be done prior to pregnancy. Termination of
pregnancy should be seriously considered. Elective cesarean
section is preferred to minimise dissection associated with
labor.
PRIMARY PULMONARY HYPERTENSION
• IT is characterized by increased thickening of muscular layer
of pulmonary arterioles. The cause remains unknown.
Maternal mortality is about 50% and the fetal outlook is also
gloomy. Termination of pregnancy is indicated. Bed rest
should be imposed from 20 weeks of pregnancy.
Anticoagulant (heparin) is administered. Oral nifedipine or
I.V. prostacyclin helps pulmonary vasodilatation. Epidural
morphine gives effective analgesia without any
hemodynamic change. Women with pulmonary
hypertension and right ventricular dysfunction are strongly
discouraged to become pregnant.
MARFAN’S SYNDROME
• Marfan’s syndrome is an autosomal dominant condition.
There is 50% chance of transmission to the offspring.
Dilatation of aorta more than 40 mm as evidenced from
echocardiography is a contraindication of pregnancy. Beta
blocking drugs should be used. Hypertension should be
avoided to prevent aortic dissection. Vaginal delivery is
desirable with shortening of second stage. When the aortic
root diameter measures > 4 cm, mortality increases to 25%.
• Prosthetic valves are used for significant valvular disease.
Mechanical valves are durable but require anticoagulation.
The risk of thromboembolism is high with low molecular
weight heparin rather than warfarin. Bioprosthetic valves
(Porcine) are superior to mechanical valves.
CARDIOMYOPATHIES
• Peripartum cardiomyopathy:
• Important diagnostic criteria are:
• Cardiac failure within last month of pregnancy or within 5 months
postpartum.
• No determinable cause for failure.
• Absence of previous heart disease.
• Left ventricular dysfunction as evidenced on echocardiography—
• Ejection fraction < 45%
• (b) Left ventricular end diastolic dimension > 2.7 cm/m2. Peripartum
cardiomyopathy is a diagnosis of exclusion. The patients are usually
multiparous and young (20-35 years). They complain of weakness,
shortness of breath, cough, nocturnal dyspnea and palpitation.
• Examination reveals—tachycardia, arrhythmia, peripheral edema and
pulmonary rales. Pregnancy is poorly tolerated in women with dilated
cardiomyopathy. The treatment is bed rest, digitalis, diuretics (preload
reduction), hydralazine or ACE inhibitors (postpartum) (afterload
reduction), β blocker and anticoagulant therapy. Vaginal delivery is
preferred. Epidural anesthesia is ideal. There is no contraindication of
breastfeeding. Mortality is high (20-50%)—due to pulmonary
embolism and cerebral thrombosis. It may recur in subsequent
pregnancies.
• Myocardial infarction is rare in pregnancy.
• Management is mostly as in non pregnant state. Coronary
angioplasty, stenting and thrombolytic therapy has been done in
pregnancy when indicated. Supine position and hypotension should
be avoided.
• Labor: managed as with standard cardiac care. Elective
delivery within two weeks of infarction should be avoided.
Regional analgesia for pain in labor and β blockers for
tachycardia may be used. Maternal pushing is avoided and
second stage is shortened by forceps or vacuum. Syntocinon
should be used in the third stage management as
ergometrine may cause coronary artery spasm.
Percutaneous transluminant coronary angioplasty can be
done successfully around 36 weeks of pregnancy if needed.