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HEART DISEASE IN

PREGNANCY

Cardiac output begins to rise in the first trimester and


continues as steady increase to peak at 32 weeks gestation
by 30% to 50% of pre pregnancy level.
Causes for increased cardiac output are
1. Increases in stroke volume (early pregnancy)
2. Increase in heart rate (late pregnancy)
3. Decreased peripheral resistance
4. Decreased blood viscosity

The fall in the peripheral resistance is about 20-30% at 2124 weeks & returns to normal at term. This fall is due to
1. Due to the trophoblastic erosion of endometrial vessels,
the placental bed serves as a large arteriovenous shunt
causing lowered systemic vascular resistance
2. There is physiological vasodilatation which is believed to
be secondary to endothelial prostacyclin and circulating
progesterone.

Table 1: Normal Hemodynamic Changes During Pregnancy

Hemodynamic
Parameter

Change During
Normal
Pregnancy

Blood volume

40%-50%

Heart rate

10-15 beats/min

Cardiac output

30%-50% above
baseline

Blood pressure

10mmHg

Stroke volume
Systemic vascular
resistance

Change During
Labor and
Delivery

Additional 50%

Change During
Postpartum
(auto diuresis)

First and second


trimesters;
third trimester

(300500mL/contracti
on)

The clinical features in a normal pregnancy which can


mimic a cardiac disease are
1. Dyspnea - due to hyperventilation, elevated diaphragm..
2. Pedal Edema
3. Cardiac impulse- Diffused and shifted laterally from
elevated diaphragm.
4. Jugular veins may be distended and JVP raised.
5. Systolic ejection murmurs along the left sternal border
occur in 96% of pregnant women and are believed to be
caused by increased flow across the aortic and
pulmonary valves.

Table 2: Predictors of Maternal Risk for Cardiac Complications


Criteria

Example

Points

Prior cardiac events

Heart failure, transient ischemic


attack, stroke before current
pregnancy

Prior arrhythmia

Symptomatic sustained
tachyarrhythmia or
bradyarrhythmia requiring
treatment

NYHA III or IV or
cyanosis

Valvular and outflow


tract obstruction

Aortic valve area < 1.5 cm2, mitral


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

Myocardial dysfunction

LVEF < 40%, restrictive


cardiomyopathy, or
hypertrophic cardiomyopathy

*Maternal cardiac event rates for 0, 1, and >1 points are 5%, 27%, and 75%, respectively.
LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.
Adapted from Siu SC, Sermer M, Colman JM, et al: Prospective multicenter study of pregnancy outcomes in women
with heart disease. Circulation 2001;104:515-521.

The New York Heart Association (NYHA) Grading of


functional capacity of the heart:
CLASS I

No functional limitation of
activity

Symptoms with extra


ordinary physical
work.

CLASS II

Mild limitation of physical


activity.

CLASS III

Marked limitation of
physical activity

Symptoms with
ordinary physical
work
Symptoms with less
than ordinary physical
work

CLASS IV

Severe limitation of physical


activity

Symptoms at rest

Mortality associated with specific cardiac lesions;


1. Low risk of maternal mortality (less than 1%).
(a) Septal defects.
(b) New York Heart Association classes I and II.
(c) Patent ductus arteriosus.
(d) Pulmonary / tricuspid lesions.
2. Moderate risk of maternal mortality (5-15%).
(a) NYHA classes III and IV mitral stenosis.
(b) Aortic stenosis.
(c) Marfans syndrome with normal aorta.
(d) Uncomplicated coarctation of aorta.
(e) Past history of myocardial infarction.
3. High risk of maternal mortality (25-50%).
(a) Eissenmengers syndrome.
(b) Pulmonary hypertension.
(c) Marfans syndrome with abnormal aortic root.
(d) Peripartum cardiomyopathy.

Prognosis depending on the functional status


In general, women in NYHA classes I and II lesions
usually do well during pregnancy and have a
favorable prognosis with a mortality rate of <1%.
Patients in NYHA classes III and IV may have a
mortality rate of 5% to 15%. These patients should
be advised against becoming pregnant.

Physiological changes during labour and puerperium.


1.First stage.
Cardiac output increases by15%. Uterine contractions
increases venous return , causing increase in cardiac
output & can cause reflex bradycardia.
2.Second stage
Increase in intra abdominal pressure (valsalvas)
causes decrease in venous return and cardiac output.
3.Third stage
Normal blood loss during delivery
(around 250-350 ml).
It leads to
a. Decrease blood volume

Criteria to diagnose cardiac disease during pregnancy:


1.Presence of diastolic murmurs.
2.Systolic murmurs of severe intensity (grade 3).
3.Unequivocal enlargement of heart (X-ray).
4.Presence of severe arrythmias, atrial fibrillation or flutter

Box 1: Maternal Cardiac Lesions and Risk of Cardiac Complications During


Pregnancy
Low Risk
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Asymptomatic AS with low mean gradient (<50 mm Hg) and normal LV
function (EF > 50%)
5. AR with normal LV function and NYHA Class I or II
6. MVP (isolated or with mild or moderate MR and normal LV function)
7. MR with normal LV function and NYHA Class I or II
8. Mild or moderate MS (MVA > 1.5 cm2, mean gradient < 5 mm Hg) without
severe pulmonary hypertension
9. Mild or moderate PS
10. Repaired acyanotic congenital heart disease without residual cardiac
dysfunction
1.
2.
3.
4.

Intermediate Risk
1.
2.
3.
4.
5.
6.

Large left to right shunt


Coarctation of the aorta
Marfan syndrome with a normal aortic root
Moderate or severe MS
Mild or moderate AS
Severe PS

High Risk
1. Eisenmenger's syndrome
2. Severe pulmonary hypertension
3. Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, tricuspid
4.
5.
6.
7.
8.

atresia)
Marfan syndrome with aortic root or valve involvement
Severe AS with or without symptoms
Aortic or mitral valve disease, or both (stenosis or regurgitation), with
moderate or severe LV dysfunction (EF < 40%)
NYHA Class III or IV symptoms associated with any valvular disease or with
cardiomyopathy of any cause
History of prior peripartum cardiomyopathy

AR, aortic regurgitation; AS, aortic stenosis; EF, ejection fraction; LV, left ventricular; MVP, mitral valve prolapse; MS, mitral stenosis; MVA, mitral
valve area; NYHA, New York Heart Association; PS, pulmonary stenosis; TOF, tetralogy of Falot; TA, truncus arteriosus; TGA, transposition of the
great arteries.

The indications for Termination of pregnancy.


Because of high maternal risks, MTP is indicated in:
1.Eisenmengers syndrome.
2.Marfans syndrome with aortic involvement
3.Pulmonary hypertension.
4.Coarctation of aorta with valvular involvement.
Termination should be done before 12 weeks of
pregnancy.

Warfarin use in first trimester can be


teratogenic and can cause fetal embryopathy
(15 to 25 % ) which includes :
Nasal cartilage hypoplasia,
Stippling of bones,
IUGR and
Brachydactyly

Risk factors for cardiac failure during pregnancy


Infection
Anemia
Obesity
Hypertension
Hyperthyroidism
Multiple pregnancy

Antibiotic prophylaxis consists of


a.
b.

2 gm ampicillin IV/plus
1.5mg per kg gentamicin /IV prior to the
procedure , followed by one more dose of
ampicillin 8 hours later.

In the event of penicillin allergy 1 gm vancomycin


IV can be substituted.

Contraception
1. OC pills are not ideal as they can cause thrombo
embolism.
2. IUCD can cause infection- endocarditis.
3. Barrier contraceptives Have high failure rates.
4. Progestin only pills or Long acting injectable
progesterone are better
PILL - Desogestrel
INJECTABLES
a. Medroxy progesterone 150mg IM every 3 months.
b. Norethisterone.200 mg every 2 months
5. Sterilization is best.

Thank You