0733-8651/98 $8.00 + .OO SPECIAL ARTICLE

THE EARLY RECOGNITION OF CARDIAC INSUFFICIENCY IN THE

PRESENCE OF PREGNANCY

Mary H. Easby, MD

The importance of the early detection of cardiac insufficiency during pregnancy is em- phasized by the statistics of a maternal mor- tality report published by the Philadelphia County Medical Society.’ In this 3-year study there were 69 maternal deaths with heart dis- ease as a factor; in 16 cases heart disease was the primary and in 53 the secondary cause of death. This figure represents 9% of the total deaths of the series. Of the 78 maternal deaths with nonobstetric conditions as their primary cause, heart disease is second only to pneu- monia. From a study by Fraser2 comes the statement that among all causes of maternal deaths not due primarily to pregnancy, heart disease stands second only to nontuberculous lung disease. Forty of the 69 patients in the Philadelphia County Medical Society report, whose deaths were caused by or complicated by heart disease, had shown complications during previous deliveries. It seems justifiable to conclude from such figures that a substan- tial improvement in the maternal mortality rate might be effected if this group of cardiac deaths could be eliminated or markedly re- duced.

This article is reprinted from Medical Clinics of North America, volume 21, Philadelphia number, 1937; pp 1059- 1071.

The observations that are presented in this study were made in the cardiac clinics of the Presbyterian and Woman’s Hospitals of Philadelphia. The collection of data on preg- nant patients was begun at the Woman’s Hos- pital in 1931 and extended through the mid- dle of 1936. At the Presbyterian Hospital observations were made during the years 1934, 1935, and 1936. The total number of patients passing through the prenatal clinics of these two hospitals during the years under consideration was 3059; of this number, 258 were referred to the cardiac clinics for study because of the presence of abnormal cardio- vascular signs and symptoms. These patients were all examined before delivery and when- ever possible were seen after delivery. When patients failed to return for check-up after their confinements, their hospital records were studied to determine the cardiac diagno- ses at the time of their discharge. Those who were considered to have organic heart disease have, with few exceptions, been seen and re- examined at least once since their deliveries; many of them attend heart clinic regularly. Three cases without postpartum data were discarded from the series.

Of the 255 who are included, 42 were found to have organic heart disease; this is 1.37% of the total number of patients passing through

From the Woman’s Hospital, Graduate School of Medicine, Presbyterian Hospital, University of Pennsylvania, Philadel- phia, Pennsylvania

CARDIOLOGY CLINICS

VOLUME 16 NUMBER 1 * FEBRUARY 1998 115

116 EASBY

the prenatal clinics of the two hospitals. This figure is comparable with the data given by Herrick? who found that 1% of all pregnan- cies are complicated by cardiac disease, and that 6% of these die. White4 found that 2% of pregnant women have symptoms and signs of heart disease, and that 1% have organic heart disease. Lamb5 found organic heart dis- ease in 2.7% of pregnant women in a 4-year study. Sodeman6 states that, in general, the incidence of heart disease in pregnancy is about 1 %.

Of the 42 cases, 12 or 28.6% showed some degree of congestive failure during pregnancy or at the time of delivery; the number of deaths was three. A brief review of these cases follows. In making the diagnoses, the functional classification approved by the American Heart Association was used.7

Case I. Age 26 years. This patient was first seen between the first and second months of her first pregnancy. Her diagnosis was congenital heart dis- ease, pulmonary stenosis, cardiac enlargement, right ventricular preponderance, normal sinus rhythm, Class I1 B. She was hospitalized during almost her entire pregnancy, and although seen early and presenting evidence of congestive failure during the entire time she was under observation, pregnancy was not interrupted because there was a persistent gonorrheal infection, which did not clear up until almost the end of the prenatal pe- riod. At times her functional classification was Class 111, but adequate therapy restored her to Class I1 B; she was allowed to go to term and was delivered with forceps of a normal male child. Some evidence of failure was present during the puerperal period, but this gradually cleared up. This patient attends cardiac clinic regularly. Her present functional classification is I1 A.

Case 11. Age 39 years. This patient showed fail- ure when seen in the seventh month of her ninth pregnancy. She gave no history of failure pre- viously during her long period of childbearing. Her etiology was undetermined; the anatomic di- agnosis was cardiac enlargement with mitral insuf- ficiency, left ventricle preponderance; she had a normal sinus rhythm throughout, her functional classification was Class I1 B. She was hospitalized and given appropriate medication for congestive failure; there was sufficient improvement for the patient to go home until she was at term. She returned to the hospital and was delivered sponta- neously. At the time of delivery and during the puerperium she had some decompensation; she has been classed as I1 B since the time of delivery.

Case 111. Age 21 years. When first seen she was in her seventh month of her first pregnancy. Her

diagnosis was rheumatic heart disease with car- diac enlargement, mitral insufficiency, mitral ste- nosis, right ventricle preponderance, and auricular fibrillation; she was classed as I1 B. She was hospi- talized a few days after her first examination and remained in the ward until 3 weeks after delivery, a total of 10 weeks. She was given appropriate therapy and at term had reestablished compensa- tion. A cesarean section was done, and the patient left the hospital in fair condition. She attends car- diac clinic regularly and still has sufficient cardiac disability to be classed as I1 B.

Case IV. Age 23 years. This patient was 3 months pregnant when first seen in clinic. The pregnancy under consideration was her second, and she gave no history of failure with the first. She was diagnosed as follows: rheumatic heart disease, cardiac enlargement, mitral insufficiency, mitral stenosis, right ventricle preponderance, nor- mal sinus rhythm; functional classification Class I1 A. She showed increasing cardiac disability, and the classification was changed to I1 B within a month after her initial examination. She was hospi- talized several days before delivery and showed improvement with digitalization; a cesarean sec- tion was done and the patient was sterilized. Three days after operation she had an acute right-sided heart failure with auricular fibrillation; she recov- ered from this, and after 7 weeks’ hospitalization, went home in fair condition. She attends cardiac clinic and is classified as I1 B.

Case V. Age 25 years. She was first seen in the third month of her second pregnancy; no failure had occurred with the first. She was found to have rheumatic heart disease with mitral insufficiency and stenosis and gallop rhythm, and was placed in Class I1 B. Because of cardiac insufficiency, she was hospitalized 10 days before delivery and given appropriate therapy. After compensation was restored, a cesarean section and sterilization were done. She showed some signs of failure dur- ing the puerperium, but improved and was sent home in good condition. She attends cardiac clinic, and has remained in Class I1 A since her discharge from the hospital.

Case VI. Age 21 years. This patient, who was first seen in the second month of her second preg- nancy, gave no history of previous failure. She was found to have rheumatic heart disease with cardiac enlargement, mitral insufficiency, mitral stenosis, normal sinus rhythm, and she was classified as I1 B. In addition to signs of congestive heart failure, she had persistent vomiting, weight loss, tempera- ture rise, and nosebleeds. Pregnancy was termi- nated because of rheumatic activity after the pa- tient had been hospitalized long enough for compensation to be restored; she was subsequently sterilized. Her recovery was uneventful. She at- tends cardiac clinic regularly, and has remained in Class I1 A since leaving the hospital.

Case VII. Age 21 years. This was the patient’s first pregnancy, and she was in her sixth month

SPECIAL ARTICLE 117

when first seen. She was found to have rheumatic heart disease with cardiac enlargement, mitral in- sufficiency, mitral stenosis, with normal sinus rhythm. She was in marked failure, Class 111, and was hospitalized. She improved on appropriate medication and was permitted to go home on a strict regimen of rest and digitalis. Later in her pregnancy it was necessary to hospitalize her again for 7 days; she again improved, went to term, and was delivered by a cesarean section. Sterilization was done, and subsequently the pa- tient left the hospital with compensation reestab- lished. No follow-up examination has been possi- ble.

Case VIII. Age 27 years. This patient was first seen in the seventh month of her second preg- nancy. Her diagnosis was rheumatic heart disease, cardiac enlargement, mitral insufficiency, a slight degree of coronary sclerosis, normal sinus rhythm, Class I1 B. She gave a history of having had suffi- cient cardiac disability with the first pregnancy to have needed bed rest for a period of several weeks and delivery by cesarean section. In the pregnancy under consideration, she was carried along to term and was delivered by forceps of a stillborn child. Later she came in near the end of her third preg- nancy and was hospitalized and delivered by ce- sarean section because of evidence of congestive failure and small measurements. Her recovery was uneventful and she left the hospital with compen- sation restored. Unfortunately this patient has been lost sight of, and no follow-up examination was possible after discharge from the hospital.

Case IX. Age 32 years. This patient was first seen between the seventh and eighth months of pregnancy. She had rheumatic heart disease with cardiac enlargement and mitral stenosis and showed definite evidence of myocardial fibrosis by electrocardiogram; she had normal sinus rhythm and was classed as I1 B. She had had four previous pregnancies, but gave no history of previous fail- ure with any of them. She improved with rest and digitalization, and about 1 month after her first cardiac examination, labor was induced. Her re- covery was uneventful. About 10 days later she was sterilized; she recovered and left the hospital in good condition and has shown no evidence of failure since.

Case X. Age 28 years. This patient was first seen between the fourth and fifth months of her fifth pregnancy. She had rheumatic heart disease with cardiac enlargement, mitral insufficiency, mitral stenosis, sinoauricular tachycardia; she was in ad- vanced failure (Class 111), with a marked degree of pulmonary edema. She was immediately hospital- ized and digitalization begun. Later on the same day of her admission to the hospital she had a premature separation of the placenta followed by death.

Case XI. Age 19 years. This was the patient’s first pregnancy. She was first examined at 6 months and found to have rheumatic heart disease

with cardiac enlargement, mitral insufficiency, mi- tral stenosis, early aortic insufficiency, and a possi- ble adherent pericardium. The electrocardiogram showed normal sinus rhythm interrupted by auric- ular premature contractions and right axis devia- tion; she was classed as I1 B. She was put on a strict regimen of rest and digitalis with frequent reexaminations in clinic; no definite failure oc- curred during this period. At 8.5 months she was admitted to the hospital for observation, and after about 2 weeks of complete rest, a cesarean section was performed. The patient had a cardiac arrest on the operating table but recovered. Following this she developed auricular fibrillation, and for 3 days her progress seemed fairly satisfactory under digitalis therapy. She then developed a Stuphylococ- cus uureus bloodstream infection and died 10 days after operation.

Case XII. Age 25 years. When this patient first came under observation she was 5.5 months preg- nant; she had had no previous pregnancies. She was found to have rheumatic heart disease, cardiac enlargement, mitral insufficiency, mitral stenosis, right ventricular preponderance, normal sinus rhythm, and she was put into Class I1 B. She was followed for 6 weeks in clinic during which time she presented no definite evidence of failure. At 7 months she went abruptly into failure with an attack of nocturnal dyspnea; unfortunately she did not report to the hospital until 4 days later at which time she was in advanced failure (Class 111). She was then admitted to the ward, and an effort was made to digitalize her. Her condition was too serious to permit interruption of pregnancy. Digitalis and bed rest failed to restore compensa- tion in any degree and 4 days after admission she delivered spontaneously and the following day died in failure.

In this group of 12 patients presenting with cardiac failure, one was first seen between the first and second months of pregnancy, two were seen at 3 months, one at 4 months, one at 4.5 months, one at 5.5 months, two at 6 months, and four at 7 months; five were pri- miparae, four were gravida 11, two were grav- ida V, and one was gravida IX. Only 1 of the multiparae had any history of failure with previous pregnancy; 11 were considered to have sufficient cardiac disability to be classed as I1 B at the time of their initial examination. The one who was in Class I1 A at the begin- ning of the observation period (3 months) had gone into Class I1 B a month later. All but two had definite rheumatic histories; of these two, one had a congenital lesion and the other gave no history of disease predisposing to organic cardiac change.

118 EASBY

There were three deaths in the groups. Two of these, the one associated with the S. aweus septicemia, and the one with the premature separation of the placenta, cannot be attrib- uted to congestive heart failure alone, inas- much as the associated conditions themselves carry a high mortality rate; the third case was one of uncomplicated congestive heart failure. We find, therefore, in this group that the percentage of patients dying of congestive failure alone is 8.33% of all who were in fail- ure, and 2.38% of the entire organic group of 42 cases. This figure seems low, inasmuch as Herrick3 states that 6% of pregnant women with heart disease die, and Eastman8 gives a mortality rate of 5% to 8% after a widespread study in hospitals with and without special cardiac clinics. The explanation for this appar- ent low figure in my series is that cardiac death may occur during pregnancy or deliv- ery without failure being present, and would therefore not be included in this study. Such cases would be death from emboli or from subacute bacterial endocarditis. Also in the group of 42 organic cases studied, all except 6 were under close observation of both prenatal and cardiac clinics during that part of preg- nancy in which failure is most apt to occur-the last two months. Whenever indi- cated, these patients were hospitalized for rest and observation or put to bed at home under a regimen of rest and medication. One death occurred in the organic group, which was not mentioned previously because no failure was present; this patient had rheu- matic heart disease with mitral stenosis whose death occurred 4 days postpartum from an S. aweus bloodstream infection, but whose functional classification remained I1 A throughout the period of observation. This case added to the three already discussed gives us a total of four deaths associated with cardiac disease, but in three of which death could not be attributed to heart disease alone.

It would be justifiable to conclude that close observation in cardiac clinic as well as in prenatal clinic of the cardiogravid patient during pregnancy is a factor in reducing mor- tality from congestive failure. It enables the early signs and symptoms of failure to be detected and evaluated, and adequate treat- ment instituted. The detection of early failure

in these patients is not without difficulty; Gammeltoft9 states that 16.3% of 239 normal pregnant women studied had signs and symptoms of heart disease, all of which cleared up soon after delivery, and did not improve on rest and digitalis. Hamilton and KellogglO state that 7.5% of all pregnant pa- tients in a group they studied required a deci- sion on the heart. The signs and symptoms presented by the noncardiac pregnant patient depend on the fact that new demands are made in pregnancy on circulation, and conse- quently on the heart. Stander and Cadden," using the acetylene method of computing car- diac output, found an increase in cardiac out- put of more than 50% in the latter half of pregnancy. Grollman12 points out that there is a large increase in the area of the circulatory bed in pregnancy. To maintain a constant blood pressure without depriving other parts of the body of a normal blood flow, there must be an increased cardiac output. This suggests that the heart must enlarge during pregnancy and brings up the disputed point of whether the enlargement seen in the latter months is actual or whether the organ seems enlarged because of a pushing upward by the gravid uterus with outward displacement of the apex impulse and frequently with a marked degree of left axis deviation in the electrocardiogram. In any event, it is to be expected that a heart that has sustained dam- age from infection, and which has conse- quently a diminished reserve, will manifest evidence of disability more readily under the strain of pregnancy than an undamaged heart. Consequently the earlier in pregnancy failure appears, the more serious is the out- look. It is therefore essential that patients with definite organic damage be seen as early as possible for cardiac study, that they report for reexamination at regular intervals during pregnancy, that they be seen during their hos- pitalization by a cardiologist when possible, and that they be referred back to cardiac clinic for postnatalcheck-up. This requires the clos- est cooperation between the obstetric and car- diac departments of the hospital.

As has been pointed out, symptoms of early cardiac insufficiency may appear in pregnant patients who have no organic car- diac disease. Of the group of patients studied

SPECIAL ARTICLE 119

by me, the 213 who were not included in the organic group showed the following signs and symptoms: 139 had systolic murmurs at the apex or pulmonic areas, 114 had dyspnea, 7 had orthopnea, 67 had palpitation, and 12 had definite edema.

The early detection of congestive failure in pregnancy depends, therefore, on the finding of those same classic manifestations of cardiac insufficiency as would be seen in a nongravid cardiac patient: dyspnea, orthopnea, easy fati- gability, palpitation, edema, appearance of a systolic murmur, cardiac enlargement, prema- ture beats, and engorgement of the neck ves- sels. In addition, each symptom and sign must be evaluated in the light of the gravid state, and the degree to which it is intensified as pregnancy advances be taken as a criterion of its prognostic value. The appearance of pulmonary edema, gallop rhythm, auricular fibrillation, paroxysmal nocturnal dyspnea, severe precordial or substernal pain, or rheu- matic activity is always an indication of seri- ous trouble. History in these cases is of the utmost importance. Because the etiologic fac- tor in the great majority of these cases is rheumatic, a painstaking search for the his- tory of past infections must be made. If found, such a positive history increases the likelihood that the abnormal cardiac findings are on an organic basis, and both treatment and prognosis must be modified accordingly. When the patient gives a history of one or more breaks in compensation, the expectation of failure during pregnancy is greatly in- creased.

In considering treatment of heart failure in pregnancy, it must be kept in mind that pregnancy is a strain on the circulation, and when heart disease is present, pregnancy may precipitate failure where failure would not occur were pregnancy not in the picture. The first consideration under treatment, therefore, is prevention. Patients who are in failure or have had previous failures, either with or without pregnancy, must be prevented from becoming pregnant. The same is true of pa- tients with rheumatic activity, subacute bacte- rial endocarditis, or fixed hypertension. One cannot state that failure may be anticipated in the presence of certain valvular lesions and not in the presence of others. In my group

of 29 organic patients in whom no failure occurred, 11 had well-established mitral ste- nosis, and 1 had an aortic insufficiency associ- ated with mitral stenosis. I believe that where mitral stenosis has been of such long-standing that the cardiac reserve is definitely impaired, it should contraindicate pregnancy. If it is accompanied by auricular fibrillation, preg- nancy should certainly be forbidden even where there is no definite failure because there is always danger of fatal emboli. Aortic insufficiency is considered by some as a con- traindication. In my series, two patients had this lesion, both associated with mitral steno- sis; one did not go into failure, and the other died in failure, but had also a positive blood- stream infection.

I believe that prevention should extend to this length that any pregnant patient with definite organic heart disease should be re- garded as a potential case of failure because of the added burden that the gravid state places on an already impaired circulation, and because there is no known formula that will tell us which cases will go to term safely and which will not. In addition, there are many women with organic cardiac disease who may go through pregnancy safely, but who sustain greater impairment to their al- ready damaged hearts as a result of it. Lamb5 reports from a study of 50 cases of organic heart disease, over a 4-year period, that 43% of them were made worse by the ordeal of pregnancy. Where there is organic cardiac dis- ease of such a nature as is known to impair cardiac reserve, the patient should be warned before becoming pregnant that her pregnancy and delivery will be fraught with risk. If she has passed through previous pregnancies safely, she should be advised strongly against undertaking another one, and if she has passed through previous ones with cardiac difficulty, further pregnancies must be forbid- den.

The treatment of early failure in pregnancy is the same as in the nongravid state. Rest is the first therapeutic measure to be enforced. Rest in the hospital is preferable to rest at home in the majority of cases. Hamilton and KellogglO state that "if a patient with heart disease develops decompensation during pregnancy, she belongs in a hospital until

120 EASBY

pregnancy is terminated.” Digitalis therapy should be employed, the dosage being ade- quate to control the heart rate at 80 or below. If the patient improves on rest and digitalis, she may gradually be worked up to mild activity. If allowed to go home, she must be on a regimen of rest and a maintenance dose of digitalis; such patients should return for hospitalization 10 to 14 days before term. If there is no favorable response to these mea- sures and failure progresses, further treat- ment depends on the stage of pregnancy. Each case must be studied as an individual problem in determining whether or not, and when, pregnancy should be terminated. Pardee,13 writing on conditions indicating therapeutic abortion, states that patients seen before the fourth month in Class I1 B or I11 should be considered for therapeutic abor- tion. He says: ”It should never be performed, however, until after a proper course of treat- ment by rest and digitalis. Such patients are always improved by this to some extent at least, and after improvement has progressed as far as it will, and there has been no further improvement for two weeks, it is time to decide on further management.” Should abortion be decided upon, the method of choice must next be considered. During the first 3 months vaginal procedures apparently do not greatly disturb circulation, but from 5 to 7 months the heart is probably less dis- turbed by abdominal operation. The choice of anesthesia presents another problem. Local anesthesia is the safest procedure if the pa- tient is cooperative; cardiac patients also stand ether well.

If the patient’s failure can be controlled and she is carried on to term, cesarean section seems to be the method of delivery most ad- vantageous because it permits of sterilization, avoids physical strain and also because it can be performed at a time which is optimum from the cardiac standpoint. The recovery stage from a nonoperative delivery is shorter. Hamilton and Kellogglo do not believe it is justifiable to do a cesarean section for the sake of sterilization on account of the greater risks of this method. They state that the majority of multiparous cardiacs are safest delivered

by forceps at full term with sterilization some months later if desirable. Should the patient be delivered by the usual method, and should some cardiac insufficiency be present, it is important that her head be kept elevated throughout delivery, and that the second stage of labor be shortened and eased in ev- ery way possible.

The success of the treatment of congestive failure depends not only on early detection, but upon such other factors as the economic status of the patient, her intelligence and abil- ity to cooperate, her religious affiliations, the avoidance of intercurrent infections, the will- ingness of the hospital to keep a patient with poor home conditions in the ward for weeks or even months of rest if necessary, and the absolute cooperation between the obstetric and cardiac departments. Each case requires individual study and care. All the above-men- tioned factors must be considered of the greatest importance if efforts to reduce the mortality from cardiac disease in general and most particularly from congestive heart fail- ure are to meet with success.

References

1. Maternal Mortality Report: Result of a Three-year Study by the Committee on Maternal Welfare of the Philadelphia County Medical Society, 1934.

2. Fraser, John R.: Maternal Mortality and Morbidity, Jour. Amer. Med. Assoc., 105 Nov. 9, 1935.

3. Herrick, W. W.: Heart Disease in Pregnancy, Fetal, Newborn and Maternal Morbidity and Mortality, 1933.

4. White, Paul D.: Heart Disease, 1931. 5. Lamb, A. E.: Heart Disease in Pregnancy, Amer. Jour.

Med. Sci., 187: 177, 1934. 6. Sodeman, W. A.: Heart Disease in Pregnancy, Amer.

Jour. Med. Sci., 193: No. 1, 121, Jan., 1937. 7. Criteria for the Classification and Diagnosis of Heart

Disease (arranged in conformity with the nomencla- ture for cardiac diagnosis approved by the American Heart Association), 1932.

8. Eastman, Nicholas J.: International Clinics, 43d series, 11: 238, 1933.

9. Gammeltoft, S. A.: Surg., Gynec. and Obstet., 46: 382, 1928.

10. Hamilton, B. E., and Kellogg, F. S.: Amer. Jour. Obs- tet. and Gynec., 13: 535, 1927.

11. Stander, H. J., and Cadden, J. F.: Amer. Jour. Obstet. and Gynec., 27: 528, 1934.

12. Grollman, Arthur: The Cardiac Output in Man in Health and Disease, 1932.

13. Pardee, H. E. B.: Jour. Amer. Med. Assoc., 103: No. 25, 1934.