1. Heart disease with pregnancy

2. Incidence of heart disease
Varies between 0.1 – 4.0 %, average 1%
Mortality due to heart disease has decreased
Developed countries – maternal mortality due to heart disease has increased
Pregnancy with heart disease has increased
Developed countries – rheumatic is decreasing
Congenital heart disease with pregnancy is also increasing

3. Hemodynamic changes in normal pregnancy
PARAMETER
CHANGE (PERCENT)
Plasma volume
+40
Cardiac output
+43
Heart rate
+17
Mean arterial pressure +4
Stroke volume
+27
Systemic vascular resistance
-21
Pulmonary vascular resistance
-34

4. Critical periods Changes start from as – 6weeks
Max changes around –30 weeks
Intra partum period
Just after delivery
Second week of puerperium

5. Pregnancy changes mimic cardiac disease
Symptoms – breathlessness, weakness, oedema, syncope
Tachycardia
Splitting of 1st hear sound
Murmur – systolic , breast bruit
Displacement of apex beat – upwards to left

6. Symptoms of heart disease
Progressive dyspnea or orthopnea
Nocturnal cough
Syncope
Chest pain
Hemoptysis

7. Clinical findings of heart disease
Cyanosis
Clubbing of fingers
Persistent neck vein distention
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrythmia
Persistent split second sound
Pulmonary hypertension

8. Investigations ECG – cardiac arrhythmias, hypertrophy
Echocardiography – cardiac status and structural anomalies
X-ray chest – cardiomegaly, vascular prominence
Cardiac catheterization - rarely

9. NYHA (New York Heart Association) Functional grading of heart disease
Grade I: No limitation of physical activity- asymptomatic with normal activity
Grade II: Mild limitation of physical activity -Symptoms with normal physical activity
Grade III: Marked limitation of physical activity -Symptoms with less than normal activity, comfortable at rest
Grade IV: Severe limitation of physical activity- symptoms at rest

10. Classification of Heart Disease according to etiology
Congenital – non cyanotic ( ASD, VSD, Pulm stenosis, coarctation of aorta), cyanotic (Fallots tetralogy, Eisenmenger’s syndrome)
Rheumatic heart disease – MS, MR, AS, AR
Cardiomyopathy
Ischaemic heart disease
Others – conduction defects, syphilitic, thyrotoxic, hypertensive,

11. Classification of Heart Disease during pregnancy according to risk
Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-1,2, corrected FT
Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT
High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement

12. Poor prognostic indicators
h/o heart failure, ischaemic attack, stroke
Arrhythmias,
Base line NYHA class 3 and 4
MV area below 2cm sq, AV area below 1.5
Ejection fraction less than 40%

13. Additional risk factors
Anaemia
Infections
Hypertension
Physical labour
Weight gain
Multiple pregnancy
Caffein , alcohol intake
Pain
Drugs – tocolytic

14. Effect of pregnancy on heart disease
Worsening of cardiac status
CCF, bacterial endocarditis, pulmonary edema, pulmonary embolism, rupture of aneurism
No long term effect on basic defect

15. Effect of heart disease on pregnancy
Abortion
Preterm labour
IUGR
Congenital heart disease in baby – 5%
Intrauterine fetal demise

16. Management Requires- High index of suspicion Timely diagnosis
Effective management
Team Approach-
Obstetrician
Cardiologist
Anesthetist
Neonatologist
CTV surgeon
Nursing Staff

17. Preconceptional Counseling
No pregnancy unless must esp in high risk types
Maternal mortality varies directly with functional classification at pregnancy onset
Optimal Medical/Surgical treatment pre-pregnancy
Counselling-
Maternal & Fetal risks
Prognosis
Social and cost considerations
Hospital delivery- Preferable at tertiary care centre

18. Medical termination of pregnancy
Termination advised in early pregnancy in high risk group only – ( Primary pulmonary Ht, Eisenmenger syndrome, Coarctation of aorta, Marfan syndrome with dilated aortic root)
Only in 1st trim, better before 8 weeks
Suction evacuation preferred
MTP also carries risk for life

19. Antenatal care Clear counseling of risk and prognosis
ANC every 2 weeks upto 30 weeks then weekly
On each visit-note-pulse rate, BP, cough dyspnea, weight, anaemia, auscultate lung bases, re-evaluate functional grade
Ensure treatment compliance
Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease
Fetal monitoring

20. Special Advice Rest, Avoid undue excitement/strain
Diet/ Iron and vitamins
Hygiene, dental care to prevent any infection
Dietary salt restriction (4-6g/d)
Avoid smoking, drugs – betamimetics
Early diag and tmt of PIH, infections
Therapeutic/prophylactic cardiac interventions as applicable-
Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of rheumatic fever
Diuretics, Beta Blockers, Digitalis, Anticoagulants
Surgical treatment as applicable - balloon mitral valvotomy

21. Indications for admission
Elective admission-
NYHA 1 – 2 weeks before EDD
NYHA 2 – 28 to 30 weeks
NYHA-III/IV- Irrespective of POG as soon as patient comes
To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant
Emergency admission-
Deterioration of functional grade
Symptoms and signs of complications- Fever/ persistent cough/ basal crepts/ tachyarrhythias (P/R >100 min)/ JVP>2cm/Anaemia/ Infections/ PET/Abnormal weight gain /other medical disorders

22. Labor and Management Institutional delivery Induction of Labor
Only for obstetric indications
Oxytocin preferred- Higher concentration with restricted fluid
Intracervical foley instillation esp in congenital heart
disease
PGE2 Gel may be employed- Vasodilatation - use with caution

23. Management in first stage of labor
Confined to bed- propped up or semi recumbent
Intermittent oxygen inhalation 5-6 l/min
Sedation and analgesia- (Epidural, pethidine, tramadol)
Cautious use of I.V. fluids (not >75ml/hr except in aortic stenosis and VSD)
Stop anticoagulants
Digitalise if in CHF,P.R.>110/ min, R/R >24/min

24. Management in first stage of labor
Diuretics in pulmonary congestion
Deriphyllin if bronchospasm
Prevention of infective endocarditis
Cardiac monitoring and pulse oximetry ±pulmonary artery catheterisation- continuous haemodynamic monitoring
Evaluation by Anaesthetist and cardiologist

25. SABE Prophylaxis Prophylaxis Not recommended for all
At risk for infection
Severe lesions
Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg (max120) hours later- Ampicillin-1G I.V./IM or 1G P.O.
If Allergic to Penicillin Vancomycin-1G I.V or Clindamycin – 600mg IV
+ Gentamicin-1.5mg/kg

26. Management of second stage of labor
Delivery in propped up position
Avoid forceful bearing down
Adequate pain relief-epidural/pudendal block avoid spinal/Saddle block
Cut short second stage of labor- episiotomy, vacuum, forceps – not always must
Strict Cardiovascular monitoring

27. Third stage of labor- AMTSL-10 U oxytocin IMI
Avoid bolus syntocinon/Ergometrine
Propped Up, oxygen inhalation
Furosemide I.V. 40 mg
Pethidine/morphine (15mg)
Watch for signs of CHF & Pul. Edema
Treat PPH energetically

28. First Hour After Delivery
Propped up/sitting position, oxygen
Watch for signs of pulm edema
Sedation
Antibiotics

29. Indications for C/S- Mainly obstetrical Coarctation of aorta
Marfan syndrome with dilated root of aorta
Prefer epidural anaesthesia
Narcotic conduction analgesia/GA in Pulmonary hypertension and pts having intracardiac shunts

30. Advice at time of discharge:
Continue medical treatment
Avoid infection
Reassesment after 6 weeks or earlier if some complication occurs
Iron supplementation
Cardiological consultation for definitive management of heart disease

31. Contraceptive advice at time of discharge:
Contraception- Barrier,
Progesterone – good option- DMPA, Norplant
IUCD-Less preferred
COC - contraindicated
Sterilization- vasectomy-best
Tubal ligation-Interval, puerperial can be done

32. MCQs

33. 1. Pregnancy is contraindicated with
Mitral stenosis
Aortic stenosis
Fallots tetralogy
Eisenmengers syndrome

34. 2. Pregnancy is contraindicated with
Mitral stenosis
Aortic stenosis
Fallots tetralogy
Eisenmengers syndrome

35. 2. Third stage of labour in a case of heart disease should be managed by
Ergometrine
Oxytocin
Misoprostol
Carboprost

36. Third stage of labour in a case of heart disease should be managed by
Ergometrine
Oxytocin
Misoprostol
Carboprost

37. 3. In pregnancy with heart disease risk of cardiac failure increases at
10-12 weeks
20-22 weeks
30-32 weeks
40-42 weeks

38. 3. In pregnancy with heart disease risk of cardiac failure increases at
10-12 weeks
20-22 weeks
30-32 weeks
40-42 weeks

39. 4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is
NYHA Class 1
NYHA Class 2
NYHA Class3
NYHA Class 4

40. 4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is
NYHA Class 1
NYHA Class 2
NYHA Class3
NYHA Class 4

41. 5. Which of the following contraceptive is contraindicated in a woman with heart disease?
OCP
POP
Lng IUS
Diaphragm

42. 5. Which of the following contraceptive is contraindicated in a woman with heart disease?
OCP
POP
Lng IUS
Diaphragm

43. 6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

44. 6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

45. 7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4

46. 7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4