• Most pregnant women develop fatigue , shortness of breath, exercise capacity , palpitations .

• Some times peripheral edema , jagular venous distension ,audible physiologic 3rd heart sound , audible systolic flow murmer .

• This is explained by : changes occurring during 1st 5 -8 weeks of pregnancy and reach the peak by the end of 2nd trimester . These changes include :

1. Changes in blood volume

by 40 – 50 % during pregnancy and reach the peak at 32nd week remained at high level to delivery occur .

2. Changes in cardiac output

by 30 – 50 % above normal level and reach the peak by 20th – 24th week of pregnancy after which a plateau till delivery occurs . these changes in cardiac output occurs due to :

i. preload due to blood volume

ii. afterload due to systemic vascular resistance

iii. heart rate

3. Changes in heart rate

heart rate by 10 – 15 b/min

4. Changes in blood pressure

remains normal however systolic and diastolic blood pressure may in the 2nd trimester but becomes normal again in the 3rd trimester

systolic by 5 – 10 mm/Hg

diastolic by 10 – 15 mm/Hg

Due to vasodilatation caused by :

i. Prostacyclin and hormones of pregnancy

ii. Placenta acts as arterio – venous shunt thus peripheral resistance .

5. Changes in blood chemistry

• Fibrinogen by 50 % , in factors 7 , 8 , 9 ,10 , platelets remains normal .

• RBCs , WBCs ( up to 12,000/mm3 is normal )

• in blood urea , serum creatinine , nitrogen and uric acid

6. Heart displacement

In late pregnancy , the apex is displaced upward and outward to be in the 4th intercostals space outside the mid-clavicular line .

7. Liability to varicose vein

This occurs due to :

i. Pressure of gravid uterus on pelvic veins .

ii. Relaxation of smooth muscle fibers in the blood vessel wall by progesterone .

iii. in the blood volume .

Supine hypotensive Syndrome :

In late pregnancy when woman lies in supine position fainting attack

Why ? heavy gravid uterus compresses IVC leading to :

i. Poor venous return .

ii. Poor cardiac output .

iii. Low blood pressure .

1-4 % , the most common non-obstetric cause of maternal mortality

Varies in countries :

Developing countries :

rheumatic heart diseases are the most common ( mitral stenosis is the most common )

Developed countries :

congenital heart diseases ( ASD – VSD – PDA )

• Ischemic heart disease : rare but now due to :

i. use of COCs

ii. smoking

iii. Older age of pregnancy

iv. DM

Grade I :

Asymptomatic , no limitation of activity

Grade II :

Symptoms ( Dyspnea , palpitation , anginal pain ) on ordinary work

Grade III :

Symptoms with less than ordinary work but comfortable at rest

Grade IV :

Symptoms at rest with evidence of congestive heart failure

Pregnancy deteriorates the patient one clinical grade

1. Heart failure :

i. between 28th – 32nd week maximum in blood volume , cardiac output and heamodilution (anaemic heart failure )

ii. During labour contraction load on heart ( in 2nd stage of labour more than 1st stage) , stress and anxiety

iii. 3rd stage of labour or immediately postpartum :

• after placental delivery 500 – 900 ml of blood passed to general circulation load on heart

• sudden release of pressure on IVC cardiac output is doubled

• acute pulmonary edema with maternal mortality 70 %

2. Cardiac arrhythmias threshold for arrhythmias ( atrial fibrillation especially with mitral stenosis )

3. Reactivation of rheumatic activity

4. Subacute bacterial endocarditis especially during peurperium

5. Postpartum thromboembolic complications especially with caesarian

section ( 5 – 7 day postpartum ) pelvic thromophlebitis

6. Pulmonary embolism up to 7th day postpartum

Fetal complications :

i. Abortion

ii. IUGR

iii. IUFD

iv. Preterm labour

v. CFMF

vi. Early neonatal death

Maternal complications :

i. Polyhydraminos ( part of systemic venous congestion )

ii. Preterm labour ( cervix is congested )

iii. Postpartum hemorrhage

SCREENING

Any pregnant female should be examined at least once for heart

( EVEN IF SHE IS ASYMPTOMATIC )

Symptoms suggesting heart disease with pregnancy :

i. Dyspnea

ii. Palpitation

iii. Warm extremities

iv. Lower limb edema

v. Intolerance to exertion

vi. Syncopal attack

vii. Plethoric face

viii. Sinus tachycardia

ANY PATIENT WITH DYSPNEA AS A COMPLAINT MUST BE TAKEN SERIOUSLY

ONCE THESE SYMPTOMS DISCOVERED

Sure signs of heart disease with pregnancy ( by a cardiologist ) :

i. Diastolic murmer and opening snap

ii. Systolic murmer and if > grade III palpable thrill

iii. Accentuated 1st heart sound , fixed paradoxic split of 2nd heart sound

iv. Diastolic gallop

v. Pericardial rub

vi. cardiomegally

Investigations :

i. Electrocardiogram ECG

ii. Chest radiography

iii. Echocardiography

Before conception : ( pre-conception counseling )

Reassurance of the patient about maternal and fetal risk during pregnancy, suitable method for contraception , maternal morbidity and mortality

Women with NYHA class III , class IV are liable to :

i. Maternal mortality up to 7 %

ii. Maternal morbidity up to 30 %

So they should be strongly cautioned against pregnancy

After conception : ( management of pregnant woman with a cardiac disease )

Antenatal care ANC : should be in a special clinic under supervision of both obstetrician and cardiologist . medical treatment depend on the NYHA class of the patient .

NYHA class I , class II ( compensated patient ) :

1. ANC : every 2 weeks and hospitalized between 28th , 32nd weeks

2. Rest : more time of rest mental and physical – more time of sleep 2 hours in the afternoon and 8 hours at night

3. Diet : as any normal pregnancy proteins , carbohydrates , fat , salt free diet and avoid weight gain

4. Drugs :

guard against

i. heart failure by treatment of anaemia if present ( patient Hb must be not less than 11 gm/dL ) iron + folic acid + calcium

ii. infections long acting penicillin , dental care prophylaxis of SABE

iii. arrhythmia proper sedation

iv. thromboembolic disorders give anti-coagulant when needed

NYHA class III , class VI ( decompensated patient ) :

A) if < 12 weeks

1. Termination of pregnancy

HOW ?

Before 12 weeks and never after 12 weeks because the risk of termination > risk of continuation by Suction under heavy sedation

2. Cardiac surgery

Open cardiac surgery Closed cardiac surgery

Mitral or aortic valve replacement

1) Heterograft

2) Metallic valve

3) Human graft

Mitral valvotomy can be done

between 20 – 24 weeks

Great fetal risk not preferred Little risk on mother

Slight risk on fetus

OTHER INDICATIONS OF TERMINATION OF PREGNANCY : ( < 12 weeks when cardiac surgery is not possible )

i. Esinmenger's syndrome 40 % mortality rate and pulmonary hypertension due to any cause .

ii. Heart failure in previous pregnancy or before this pregnancy .

iii. History of rheumatic activity or subacute bacterial endocarditic in the last 2 years .

iv. History of atrial fibrillation .

b) if > 12 weeks Hospitalization

1. Hospitalization through the whole time of pregnancy +

bed rest in semi-sitting position

2. Diet : as any normal pregnancy proteins ,

carbohydrates , fat , salt free diet and avoid

weight gain

3. Drugs : the same as grade I , II + maintained anti-failure treatment ( digitalis + diuretics + potassium + aminophylline + O2 inhalation )

Route of Delivery :

1. Vaginal delivery : usually easy and rapid due to :

i. Small baby

ii. Cervical congestion

2. Caesarean section :

i. obstetric indications

ii. in patients with severe mitral stenosis , aortic stenosis , pulmonary hypertension and Esinmenger's some advice elective caesarean section to avoid contraction and straining ( controverse )

Intra partum management :

Managed by ( Obstetrician + Cardiologist + ICU specialist )

A) During 1st stage of labour :

i. Rest in semi-sitting position to aid respiration

ii. Oxygen inhalation

iii. Analgesia : the best epidural anesthesia or pethidine to avoid tachycardia resulting from labour pain

iv. Concentrated glucose as a nutrient

v. Start antibiotic therapy combination of ampicillin 2 gm + gentamycin 1.5 mg / kg IV or IM and repeated after 8 hours ( vancomycin in case of ampicillin sensitivity )

B) During 2nd stage of labour :

i. Put the patient in semi-sitting position

ii. Oxygen inhalation in between contractions

iii. Analgesia maintain epidural anesthesia

iv. No bearing down , no straining to avoid rising in blood pressure

v. If 2nd stage is prolonged more than 20 minutes ( forceps – ventose )

C) During 3rd stage of labour :

There should be no hurry , Time should be allowed for post partum circulatory adjustment .

i. Oxytocin is given to all patient unless there is a heart failure

ii. Ergometrine is avoided unless there is severe bleeding ( The risks of atonic postpartum haemorrhage must be balanced against the risk ergometrine )

iii. Misopristol in case of severe bleeding ( relative contra-indication )

iv. Lactation is allowed in NYHA class I , II and suppressed in NYHA class III , VI

v. Close observation for at least two hours

vi. Continue antibiotic therapy

Puerperium :

i. Hospitalization one week for NYHA class I , II and 3 weeks for NYHA III , IV

ii. Prophylaxis against subacute bacterial endocarditis by ampicilline + gentamycin

iii. Sedation in the 1st few days after labour to reduce tachycardia

If the patient developed a heart failure , she is not allowed to get pregnant

Management of post-partum acute pulmonary edema :

If the patient quickly developed

• Dyspnea

• Frothy sputum

• Haemoptysis

We should quickly do the following

1. Proppe the patient up

2. if possible, the legs allowed to hang over the edge of the bed

3. Morphine (5-15 mg) may be given intra-muscularly

4. frusemide (20-40 mg) given intravenously

5. Venous return can be reduced by applying inflatable cuffs to the limbs

6. Quickly call ICU specialist for further management

Safe During Breast-feeding

Safety in Pregnancy Side Effects Use Drug

Yes No

Oligohydramnios, IUGR, PDA,

prematurity, neonatal

hypotension, renal failure, anemia, musculoskeletal abnormalities

Hypertension ACE inhibitors

Yes

Yes

Fetal bradycardia, low birth weight,

hypoglycemia, respiratory depression

Hypertension, arrhythmias, MI, hyperthyroidism, cardiomyopathy

Beta-blockers

Yes Yes Low birth weight,

prematurity Arrhythmia, CHF Digoxin

No data

Yes

Fetal distress with maternal

hypotension

Hypertension

Nitrates

Safe During Breast-feeding

Safety in Pregnancy Side Effects Use Drug

Yes Unknown

Reduced uteroplacental

perfusion

Hypertension, CHF

Diuretics

Yes Yes Neonatal CNS

depression Arrhythmia, anesthesia

Lidocaine

Limited data

Limited

Hemorrhage, bone density

Hypercoagulable states, DVT, mechanical valves,

atrial fibrillation

LMWH

Yes

No

Warfarin embryopathy,

fetal CNS abnormalities, hemorrhage

Hypercoagulable states, DVT,

mechanical valves, atrial fibrillation

Warfarin

Yes

Yes

Maternal osteoporosis, hemorrhage,

thrombocytopenia, thrombosis

Hypercoagulable states, DVT,

mechanical valves, atrial fibrillation

Unfractionated heparin

No data No Fetal thiocyanate

toxicity Hypertension, aortic

dissection Sodium

nitroprusside

1. Preterm labour in a cardiac patient ( very common )

B-mimetic are contra-indicated

2. Pregnancy-induced hypertension in a cardiac patient

Never use magnesium sulphate and depend only on diazepam

2. Anesthesia in a cardiac patient

• For all vaginal delivery the best is epidural anesthesia , pudendal nerve block and sedation

• For C.S epidural anesthesia , careful

general anesthesia and local infiltration

anesthesia

Overall maternal mortality rate :

• NYHA class I , II 0.4 %

• NYHA class III , IV 7 %

Factors affecting prognosis :

i. Nature of cardiac disease : very high risk with mitral or aortic stenosis

ii. Clinical Class of the patient , her age and parity

iii. Social factors , degree of antenatal care , socio-economic conditions and ability of the patient to get bed rest

iv. Presence of other bad signs ; cardiomegally . SABE and rheumatic activity