Cardiac Diseases In Pregnancy

Clinical description

Women with cardiac disease (1% prevalence) are at increased risk of maternalmorbidity and mortality. However, satisfactory outcome can be expected with careful antenatal, intrapartum and postpartum care.

In our setting, mostly we see acquired lesions seen for the first time in pregnancy due to physiologic stresses of pregnancy.

Maternal complications in pregnancy Fetal complications Congestive heart failure IUGR Arrhythmias Prematurity Stroke Risk of congenital heart defect History Severe progressive dyspnea, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, syncope with exertion, chest pain, palpitations, nocturnal cough, sudden reduction in ability to perform ordinary physical activity, increasingdyspnoea on exertion, and haemoptysis are associated with CCF.

ExamCyanosis, finger clubbing, systolic murmur > grade 3 of 6, diastolic murmur,cardiomegaly, sustained arrhythmias, loud P2; CCF: persistent basilar rales,oedema, tachycardia, increase in RR to > 24 breaths per minute InvestigationsCXR (shielded) with minimal cardiomegaly, ECG, echocardiogram for accurate diagnosis, ABG for cyanosis if available.

Treatment

• All pregnant patients with cardiac disease should be referred to Central Hospital for management.
• Preconception counseling for known cardiac disease in order to assess riskand optimize treatment (i.e.

preconception surgery, family planning)

• Explain the cardiac anomaly to the patient and its impact on pregnancy,including up to 4% risk of infant

with congenital heart disease Antenatal management

• Antenatal care visits: regular visits with obstetrician and with cardiologist
• Use the New York Heart Association (NYHA) Classification to determine the patient's functional capacity
• Class I: no limit to physical activity
• Class II: comfortable at rest, ordinary physical activity leads to discomfort
• Class III: comfortable at rest, less than ordinary activity causes discomfort
• Class IV: unable to perform any physical activity without discomfort
• Assess risk of CHF, arrhythmia, stroke, cardiac arrest, death by evaluating for these 4 risk factors
• NYHA III, IV, or cyanosis
• Left heart valvular or outflow tract obstruction:

 AVA <1.5 cm2, MVA <2 cm2  or  Peak LVOTO gradient >30mm Hg

• Previous history of arrhythmia, TIA, stroke, or CHF
• Ejection fraction<40%

 5% risk if 0 factors  27% risk if 1 factor  75% if 2 or more factors

• Offer termination of pregnancy if high-risk or with other high-risk condition (pulmonary hypertension,

Marfan’s syndrome, NYHA III/IV, previous peripartum cardiomyopathy with residual ventricular dysfunction, coarctation of aorta with hypertension)

Clinical description

• Assess functional capacity at each visit
• Screen for and prevent anaemia
• Exclude complications (i.e. CCF, thrombosis)
• Admit to antenatal ward for any complications
• Behavioural modifications: adequate rest, no smoking
• US for fetal anatomy (congenital heart disease) at 18-20 wks gestation
• Document clear labour plan in medical records
• Treat respiratory infections promptly
• Treat with antibiotics for any dental procedures
• AHA 2007 indications for antibiotic use:
• Prosthetic valve,
• Previous IE,
• Transplanted heart with valvulopathy,
• CHD- unrepaired cyanotic CHD or with palliative shunt, repair in past 6 months, repaired but with

defect of no epithelial tissue

• Treat with warfarin and/or heparin if already on anticoagulation
• Treat with anticoagulation if valve replacement
• Switch to heparin in the first trimester due to teratogenicity of warfarin
• Treat with warfarin at 16-36 wks gestation
• Switch to heparin at > 36 wks gestation
• Treat with warfarin during puerperium period

Intrapartum management

• Admit for vaginal delivery (Caesarean delivery for obstetricindications only)
• Consult anaesthesiologist immediately so that he/she is aware of high-riskpatient
• Induce labour with misoprostol for obstetric indications only
• First stage of labour
• Evaluation by doctor every ≤ 2 hours
• Open partograph, monitor vitals every 30 min, and record fetalsurveillance
• 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 every 6 hrs and gentamicin 240mg IV stat, no need for

antibiotic in labor

• 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 hrs to monitor for complications
• For patients on anticoagulation, start heparin 6-12 hrs after vaginal deliveryor 12-24hrs after caesarean

delivery

• Inform paediatrician of maternal history of cardiac disease so that newbornis evaluated for congenital heart

disease (i.e. examination, echocardiogram)

• Contraception: consider surgical sterilization for life-threatening cardiacdisease or intrauterine

contraceptive devices, may need to avoid oestrogen

• Review mother and infant at 6-week postnatal visit