Cardiovascular Diseases in Pregnancy

Clinical Description

Cardiovascular disease (CVD) is a class of diseases that involve the heart muscle, chambers, valves or blood vessels. These may be congenital or acquired. It is associated with increased risk of maternal morbidity and mortality.

Signs and Symptoms

• Severe progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, syncope with exertion, chest pain, palpitations, nocturnal cough, sudden reduction in ability to perform ordinary physical activity, increasing dyspnea on exertion, and hemoptysis are associated with CCF, irregular pulse.

Investigations

• CXR (shielded), ECG, echocardiogram, ABG where available.

Treatment

• All pregnant patients with cardiac disease should be referred to Central Hospital for

Treatment

• Preconception counselling for known cardiac disease in order to assess risk and optimize treatment (i.e., preconception surgery, family planning)
• Explain the cardiac anomaly to the patient and its impact on pregnancy

Antenatal management

• Antenatal care visits: regular visits with obstetrician +/- cardiologist
• Determine the patient's functional capacity (NYHA)
• For detailed antenatal management refer to O & G protocols and guidelines

Intrapartum management

• Admit for vaginal delivery (Caesarean delivery or induction for obstetric indications only).
• Consult anesthesiologist immediately so that he/she is aware of high-risk patient.
• Open partograph, monitor vital signs every 30 minutes, and record fetal surveillance.
• Semi-recumbent position with lateral tilt.
• Minimize IV fluids- strict monitoring of fluid intake and urine output.
• Treat with oxygen at 4-6 L/min as needed.
• Adequate analgesia with Pethidine 100 mg IV or epidural if available.
• Treat with X-Penicillin 2.4 MU IV 6 hourly and Gentamicin 240mg IV stat, no need for antibiotic in labour.
• Second stage of labour: assist delivery with vacuum or forceps.
• Third stage of labour: AMTSL with Oxytocin 10 IU IM (no ergometrine).

Postnatal management

• Avoid PPH, anaemia, sepsis, VTE, development of CCF
• Keep in HDU until > 24hrs after delivery if no complications
• Keep in postnatal ward at least 48 hours to monitor for complications
• For patients on anticoagulation, start heparin 6-12 hours after vaginal delivery or 12-24 hours after caesarean delivery
• Inform pediatrician of maternal history of cardiac disease so that newborn is evaluated for congenital heart disease (i.e., examination, echocardiogram)
• Contraception: consider surgical sterilization for life-threatening cardiac disease or intrauterine contraceptive devices, may need to avoid estrogen
• Review mother and infant at 6-week postnatal visit