About 1% of the pregnancies complicated by heart diseases

Leading cause of maternal mortality Mortality rate 50% in case of pulmonary

hypertension Two main types of heart diseases seen

pregnancy are rheumatic and congenital

Oxygen consumption at rest increase to meet the needs of the fetus and to support increased metabolic rate of mother

Supply of oxygen to tissues is increased by means of increasing the cardiac output by 40%

Increase is due to followingincrease in pulse rate,partial increase in stroke

volume,fall in peripheral vascular resistance,increase in contractility

Increase in cardiac output does not increase blood pressure due to massive fall in peripheral resistance

Diastolic blood pressure falls in second trimester

Increase in cardiac output by 40% Increase in stroke volume by 10% Increase in heart rate by 10% or 15 bpm Increase in blood volume by 40% Decrease in peripheral resistance and

diastolic blood pressure

“A diseased heart may not be able to cope with these haemodynamic changes in

pregnancy”

symptoms Progressive dyspnoea Orthopnea Paroxysmal nocturnal

dyspnoea Hemoptysis Palpitations Syncope Nocturnal cough Chest pain

signs Cyanosis Clubbing Persistent distension of

neckveins Thrill,persistent split s2 Parasternal heave A Diastolic murmur A grade3 systolic

murmur Atrial fibrillation Loud p2,cardiomegly

Echocardiography :shows cardiac structure and function.Does not involve radiation and hence safeElectrocardiographyChest Xray :

may show cardiac enlargement,pulmonarycongestion or pleural effusion

What are the clinical features in a normal pregnancy which can mimic a heart disease???

Collapsing pressure due to wide pulse pressure

Increase in HR and ectopic beats JVP waves are more prominent Heart size increases Apex beat is displaced upwards and laterally

due to pressure from the distended abdomen S1 may be loud and there can be a third heart

sound

Ejection systolic murmurs may be heard over the precordium in 90% of women

Venous hums in the neck and mammary souffle over the breast

Peripheral edema is very common ECG shows left axis deviation and mild ST

changes

Class 1Uncompromised or no limitation of physical activity

Slight limitation of physical activity;dyspnoea on severe exertion

Class 3

Marked limitation of physical activity;dyspnoea on mild exertion

Class4

Severity compromised ;dyspnoeaat rest

Myocardial dysfunction(ejection fraction less than 40% or cardiomyopathy)

Prior heart failure,arrhythmia or stroke Previous arrhythmia needing treatment Baseline NYHA class3 or class 4 or cyanosis Left sided obstruction

“risk of pulmonary oedema or even death is substantially increased with even one of

these factors”

high risk Prosthetic valves Prev endocarditis Complex cyanotic

heart diseases Surgically corrected

shunts

moderate risk Most other congenital

cardiac malformations Rheumatic valvular

heart diseases Hypertrophic

cardiomyopathy Mitral valve prolapse

with regurgitation

American heart association recommends prophylaxis based on risk stratification

Prophylaxis be given intrapartum to women at high risk only in presence of suspected bacteraemia or active infection

Current recommendations are that prophylaxis be given 30-60 minutes before the procedure

Isolated secundum atrial septal defect Surgical repair of atrial and ventriular septal

defect and patent ductus arteriosus Previous coronary bypass graft surgery Mitral valve prolapse without regurgitation Previous rheumatic fever without valvular

dysfunction Cardiac pacemaker Previous kawasaki disease without valvualar

dysfunction

Preconceptional councellingAntepartum management Intrapartum management Puerperium contraception

Should be planned pregnancy after complete evaluation of cardiac status and need for cardiac surgery before pregnancy

Most of the congenital lesions and mitral stenosis should be surgically corrected before pregnancy

Women may be adviced to have their family as early as possible in cases of early diseases like mild mitral stenosis

Eisenmenger syndrome Primary pulmonary hypertension Uncorrected severe coarctation Murfans with aorta dilated >45mm Severe mitral stenosis with complications Severe symptomatic aortic stenosis Previous peripartum cardiomyopathy with

residual impairment of left ventricular function

Nature and severity of the disease are assessed.In the first trimester main two issues are need for termination of pregnancy or need for surgery.

NYHA class 1&2:most women go through pregnancy uneventfully.adequate rest and followup.nocturnal cough,persistent basal crepitations,increasing dyspnoea on exertion are symptoms of heart failure

Anaemia Tachycardia and arrhythmia Hyperthyroidism Hypertension Multiple pregnancy Respiratory infections stress

NYHA class 3&4 :these women are at high risk should become pregnant after surgical correctionIf seen in first trimester such patients are candidates for MTP

Period of maximum risk as pain and apprehension increases cardiac output

Vaginal delivery is preferred unless there is an obstetric indication for caesarean section

1. analgesia:best given epidurallyexcept in intracardiac shunt

2. Position:semirecumbent position to avoid supine caval symdrome

3. Fluid management:not more than 75ml/hris to be given.if iv fluids are given injudiciously,pulmonary edema can be precipitated

4) monitoring:maternal heart rate and bpcontinous ECG monitoring to detect arrhythmiacontinous fetal heart rate is monitored

5)second stage:shortened with outlet forceps to avoid strain on heart.

6)third stage:oxytocin should be used to reduce amt of bleeding.ergometrine and methergin are contraindicated in women with heart disease

Patient is observed in the labour ward for atleast 24 hours

Postpartum haemorrhage,infection and thromboembolism are serious complications to be prevented.

Early ambulation and lactation are encouraged.fluid balance should be monitored

Barriers,IUDs,LNG-IUS or Mirena are preferred

Combined oestrogen- progesterone pills are not used in cons=ditions prone for thrombosis

If a permanent method of sterilisation is preferred vasectomy of male partner is better option.if tubectomy is desired best done as an interval procedure under general anaesthesia and not in post partum period