HEART DISEASES IN PREGNANCY

INTRODUCTION

An increased prevalence of cardiovascular disease (CVD) has been found in women of

childbearing age, with the presence of CVD in pregnant women posing a difficult clinical

scenario in which the responsibility of the treating physician extends to the unborn fetus.

Profound changes occur in the maternal circulation that have the potential to adversely affect

maternal and fetal health, especially in the presence of underlying heart conditions. Up to 4% of

pregnancies may have cardiovascular complications despite no known prior disease ( Regitz-

Zagrosek V., Gohlke-Barwolf C., Iung B., Pieper P.G., 2014)

In a woman with valvular disease, a short, pain-free labor and delivery helps to minimize

hemodynamic changes. Hemodynamic monitoring, including continuous monitoring of oxygen

saturation, ECG, and arterial pressure should be under surveillance. Rarely, pulmonary artery

wedge pressures, and cardiac output, may be indicated in severe disease. Fetal monitoring is

another means of assessing the adequacy of cardiac treatment because fetal distress is an

indicator of impaired cardiac output.

Women with valvular disease should undergo a vaginal delivery with adequate pain control as

cesarean delivery results in greater hemodynamic changes and blood loss and should be reserved

for obstetric indications. In certain patients, especially those with mitral or aortic stenosis,

delivery should be aided by forceps or vacuum-assisted techniques to avoid the sudden rise in
systemic vascular resistance and drop in systemic venous return that occurs with maternal

pushing.

Risk classification in pregnancy and heart disease

The following conditions are considered high maternal and fetal risk:

 Severe aortic stenosis with or without symptoms

 Aortic regurgitation with NYHA class III or IV symptoms

 Mitral stenosis with NYHA class II, III, or IV symptoms

 Mitral regurgitation with NYHA class III or IV symptoms

 Aortic valve disease, mitral valve disease, or both resulting in pulmonary hypertension with

a pulmonary pressure greater than 75% of systemic pressures

 Aortic valve disease, mitral valve disease, or both with left ventricular ejection fraction less

than 40%

 Maternal cyanosis

 Any valve disease with NYHA class III or IV symptoms

The following conditions are considered low maternal and fetal risk:

 Asymptomatic aortic stenosis with a mean transvalvular gradient of less than 50 mm Hg

and normal left ventricular systolic function

 Aortic regurgitation with NYHA class I or II symptoms and normal left ventricular systolic

function

 Mitral regurgitation with NYHA class I or II symptoms and normal left ventricular systolic

function
  Mitral valve prolapse with no regurgitation or with mild-to-moderate regurgitation and

normal left ventricular systolic function

 Mild-to-moderate mitral stenosis (mitral valve area >1.5 cm 2, gradient < 5 mm Hg) without

severe pulmonary hypertension

 Mild-to-moderate pulmonary valve stenosis

Cardiovascular Evaluation During Pregnancy

The patient's history is an essential part of the initial risk assessment and should include

information on the baseline functional status and previous cardiac events because these are

strong predictors of peripartum cardiac events. The strongest predictors include the following:

 Any prior cardiac event

 Cyanosis or poor functional class

 Left-sided heart obstruction

 Ventricular dysfunction

Left-sided heart obstruction includes valve disease or hypertrophic cardiomyopathy (aortic valve

area < 1.5 cm2, mitral valve area < 2 cm2, or left ventricular outflow tract peak gradient >30 mm

Hg). Impaired ventricular function is significant when the ejection fraction is below 40% (Subtil

D., Goeusse P., Puech F., 2013). Prior events of interest also include treatment for heart

failure, TIA or stroke, or arrhythmia.

Many of the normal symptoms of pregnancy, such as dyspnea on exertion, orthopnea, ankle

edema, and palpitations, are also symptoms of cardiac decompensation. However, angina, resting

dyspnea, paroxysmal nocturnal dyspnea, or a sustained arrhythmia are not expected with

pregnancy and warrant a further diagnostic workup ( Stout K.K., Otto C.M., 2007). Almost all

pregnant women develop physiologic murmurs, which are usually soft, midsystolic murmurs
heard along the left sternal border usually caused by functional pulmonary stenosis due to

increased transvalvular flow.

Physical signs commonly seen with pregnancy are jugular venous distension, an apical S 3, basal

crackles, prominent left and right ventricular apical impulses, exaggerated heart sounds, and

peripheral edema. Diastolic murmurs are rare with pregnancy despite the increased blood flow

through the atrioventricular valves, their presence should prompt further diagnostic

evaluation. Systolic murmurs more than 2/6 in intensity, continuous murmurs, and murmurs that

are associated with symptoms or electrocardiographic changes should also prompt further

investigation such as echocardiography

Electrocardiography offers low-cost screening that may identify the need for further study if

findings otherwise appear benign

Antenatal assessment during pregnancy

The midwives' role includes obtaining pertinent medical and cardiac history in the antepartum

period. Specific risk factors such as hypertension, pre‐eclampsia, smoking, obesity, diabetes,

elevated saturated fats and cholesterol that require referrals and ongoing self‐management need

to be identified ( Knight, M. , Nair, M. , Tuffnell, D. , Kenyon, S. , Shakespeare, J. ,

Brocklehurst, P., Kurinczuk, J. J., 2016). For example, a woman with a pre‐existent cardiac state

may have received preconception counselling and, thus, be well informed; however, this is not

always the case. Midwives need to be appraised of the “at‐risk” populations such as Indigenous

people and immigrants, particularly those who are newly arrived or from African nations.

The potential problems with new or undiagnosed cardiac dysfunction in pregnancy could be

mitigated by midwives who are able to distinguish between normal and abnormal cardiovascular
symptoms and initiate early referral and investigations (Roberts & Ketchell, 2012). This requires

knowledge of pre‐existent cardiac conditions or conditions unmasked by the physiological

changes in pregnancy (Knight et al., 2016). A recent UK‐based report emphasized that women

presenting repeatedly with cardiac symptoms and objective signs such as raised respiratory rate,

persistent tachycardia and orthopnoea should be fully investigated (Knight et al., 2016).

Examples of the cardiovascular symptoms observed in pregnancy are summarized in Table

Table2.2. The current track and trigger systems in clinical practice for midwives can improve

recognition and response to clinical deterioration during pregnancy.

Labour and delivery

Midwives need to be cognizant that the haemodynamic changes during labour and delivery

present potential challenges for women with heart disease; therefore, they need to anticipate and

be prepared for sudden clinical deterioration. Repositioning mothers to a left lateral position to

avoid compression of the inferior vena cava by the gravid uterus for women who experience

supine syndrome is recommended for labour. However, this may be inappropriate for women

with some specific cardiac conditions (Canobbio, M. M. , Warnes, C. A. , Aboulhosn, J. ,

Connolly, H. M. , Khanna, A. , Koos, B. J. Stout, K., 2017).

During each uterine contraction, a bolus of fluid is expelled into the intravascular space.

Although it is transient and repetitive, for some at‐risk women, these changes may exacerbate

underlying cardiac conditions. During labour, the CO increases by 15%–20% and SBP by 10%.

Concurrently, anxiety and pain stimulate the systemic nervous system to further elevate the SBP

and heart rate (Canobbio et al., 2017). Physiological changes during labour affect various cardiac

conditions differently, notably aortic diseases, obstructive valve disease and cardiomyopathy.
During the second stage of labour when women use the prolonged “Valsalva” manoeuvre,

increasing blood pressure and afterload can complicate aortic disease. Judicious management of

fluid therapy and epidural anaesthesia may mitigate the risk of marked fluctuations in blood

pressure that are detrimental to women with obstructive valve disease or cardiomyopathy.

Midwives recognize that delivery and management are tailored to a mother's specific cardiac

state following a multidisciplinary team review. This team includes an obstetric high‐risk

physician, a cardiologist, an anaesthetist, an obstetrician and midwives. The proposed birth plan

is also clearly documented, with vaginal delivery being the preferred mode and lower (uterine)

segment caesarean section remaining limited to obstetric indications (Canobbio et al., 2017). In

instances of maternal collapse, both resuscitation and obstetric guidelines recommend that a

perimortem caesarean delivery should be carried out within four minutes, but only if there is no

return of spontaneous circulation with delivery of the foetus within five minutes beyond

20 weeks' gestation (McGregor, A. J. , Barron, R. , & Rosene‐Montella, K., 2015).

CONGENITAL CARDIAC CONDITIONS IN PREGNANCY

The congenital defects that are likely to be problematic in pregnancy are complicated by

pulmonary hypertension, cyanosis and severe left ventricular outflow tract obstruction, with

cyanotic CHD posing the most significant risk to both mother and foetus .Cyanosis worsens

during pregnancy due to the increased cardiac workload, while polycythaemia, hypoxaemia and

cyanosis increase the risk of thromboembolic complications.

1. Congenital valvular heart disease

Mitral valve stenosis is the most common RHD valvular lesion observed in pregnancy to require

invasive intervention such as open mitral valve commissurotomy or balloon valvuloplasty prior

to or during gestation

2. Pulmonary hypertension or Eisenmenger syndrome

The increasing cardiac pressure loads in pregnancy lead to right ventricular failure during the

peri‐ and postpartum period and increase the maternal mortality rate to 30%–50%. These women

require a detailed delivery plan that considers the optimal timing and mode of delivery,

postpartum intensive care and mechanical support and individualized support for many months

postdelivery. Further, primary pulmonary artery hypertension secondary to CHD is a

contraindication for pregnancy due to the poor prognosis for mother and baby, so termination is

recommended (Canobbio et al., 2017).

ACQUIRED CARDIAC CONDITIONS IN PREGNANCY

Acquired cardiac conditions are undetected or latent conditions where the stress of pregnancy

precipitates clinical deterioration of a woman's cardiac state.

1. Acute coronary syndrome in pregnancy

ACS is an umbrella term that describes the spectrum of conditions resulting from a reduced

coronary blood flow to the heart and range from acute myocardial ischaemia (unstable angina) to

injury and necrosism, as seen in acute myocardial infarction (AMI).

2. Cardiomyopathies and heart failure

Cardiomyopathies in pregnancy include acquired and inherited diseases such as PPCM and toxic,

hypertrophic, dilated, restrictive and idiopathic cardiomyopathies (Knight et al., 2016).

Takotsubo syndrome, also known as “stress cardiomyopathy,” previously reported in

postmenopausal women, is a now potential cause for acute heart failure (AHF) in birthing

3. Peripartum cardiomyopathy

Women with AHF symptoms in the last month of pregnancy or up to six months' postpartum,

with the diagnosis of PPCM by exclusion, will arrive with breathlessness, orthopnoea and

peripheral oedema ( Knight et al., 2016). The multifactorial risk factors for PPCM are increased

haemodynamic stress, advanced maternal age, multiparous pregnancies and/or multiple or

teenage pregnancies, African ethnicity, smoking, diabetes, hypertension and pre‐eclampsia.

4. Mitral and aortic valve stenosis

Valvular disease in pregnancy is the result of RHD and the most common lesion mitral stenosis.

If severe, the maternal mortality increases up to 5%, with clinical deterioration evident in the

third trimester or during labour and delivery. Rheumatic mitral stenosis has an asymptomatic

phase extending 10 to 20 years, so a woman's initial diagnosis may occur during pregnancy due

to the cumulative effect of tachycardia, increased blood volume and cardiac output, leading to

cardiac decompensation. This results in tachyarrhythmia (rapid atrial fibrillation) or acute

pulmonary oedema (Yu‐Ling Tan, 2010)

5. Arrhythmias

Benign and problematic arrhythmias are observed increasingly in women with heart disease

during pregnancy (Knight et al., 2016). Bradyarrhythmias are well tolerated, but some women

will require insertion of a pacemaker. The risk of arrhythmias peaks during labour and delivery
when tachyarrhythmia (which is the most prevalent) requires prompt treatment using non‐

teratogenic drug therapy or electrical therapy (Canobbio et al., 2017

CONCLUSION

Pregnancy has been regarded as the ultimate cardiac stress test that a woman may experience in

her life (Yu‐Ling Tan, 2010). The physiological changes increase the likelihood of a complicated

pregnancy and birth in women with latent cardiac dysfunction (asymptomatic cardiac

dysfunction) or a pre‐existent cardiac dysfunctional state. Thus, it is important to highlight the

cardiovascular adaptations that exacerbate acquired cardiac conditions.

Improving the detection of women with newly acquired cardiac conditions, and improving

surveillance and maintaining the continuum of cardiac care for women with CHD will together

improve the outcome for both mother and baby. As shown, the role of midwives in childbirth

facilitates ongoing surveillance, risk assessment, parental health education, maternal awareness

and self‐management to optimize outcomes.