Introduction:

• The occurence of cardiac lesion is below than 1% amongst all deliveries.
• The commonest cardiac lesion in pregnanacy has two types:
• Rheumatic Heart diseases.
• Congenital Heart diseases.

Rheumatic valvular lesion

• 80% of cases are Mitral stenosis.

PREDOMINANT CONGENITAL LESIONS

1. Acyanotic:

• Patent ductusarteriosus
• Atrial or ventricular septal defect
• Pulmonary stenosis
• Mitral valve prolapse
• coarctationof aorta

1. Cyanotic:

• Fallot’s tetralogy
• Eisenmengers syndrome

1. Rare causes:

• Hypertensive
• Thyrotoxic
•  syphilitic
• coronary cardiac diseases.

The cardiac failure takes placeduring pregnancy at 30 weeks, during labor andfollowing delivery.

Factors responsible for cardiac failure:

 (1) Advanced age

 (2) Cardiac arrhythmias left ventricular hypertrophy

 (3) History of previous heart failure

 (4) Appearance of “risk factors” in pregnancy are: infection, anemia, hypertension, excessive weight gain and multiple pregnancy

(5) Inadequate supervision.

Effects of heart lesion on pregnancy:

• There is a tendency of preterm delivery and prematurity.
• IUGR is quite common in cyanotic heart diseases.

Prognosis

• Maternal
• Fetal

Maternal The prognosis depends on:

(1) Nature of cardiac lesion

(2)Heart Functional capacity

(3)Management during pregnancy, labor and puerperium

(4)Existence of other risk factors  to be specified earlier

• Maternal mortality is lowest in rheumatic heart lesions and acyanotic group of heart diseases is less  than1%.
• With elevation of pulmonary vascular resistance specificwally with cyanotic heart lesions, the mortality may be incresedto 50% (Eisenmenger’s syndrome).
•  Most of the deaths occur due to cardiac failure and the maximum deaths occur following birth. The other causes of death are

(a) pulmonary edema

(b) pulmonary embolism

(c) active rheumatic carditis

(d) subacute bacterial endocarditis

(e) rupture of cerebral aneurysm in coarctation of aorta.

fetal:

• In rheumatic heart lesions, the fetal outcome is good and in no way dissimilar from the patients without any heart lesion.
• However, in cyanotic group of heart lesion, there is fetal loss (45%) due to abortion, IUGR and prematurity. Fetal congenital cardiac disease is increased by 3–10% if either of the parents have congenital lesions.

Differential Diagnosis:

Anatomical and Physiological Changes DuringPregnancy that imitate Cardiac Disease

• Hyperdynamic circulation
• Systolic ejection murmur at left sternal border

(due to increased blood flow across the aortic and

pulmonary valves)

• Dyspnea, decreased exercise tolerance, fatigue,

syncope

• Tachycardia, shift of ventricular apex
• Continuous murmur in 2nd to 4th intercostal space called mammary souffle.

Diagnosis of Heart Disease in Pregnancy

• Symptoms:Breathlessness, nocturnal cough,

syncope, chest pain

• Signs: Chest murmurs—pansystolic, late systolic, louder ejection systolic or diastolic along with a thrill.
• Cardiac expansion, arrhythmia .
• Chest radiography (using lead shield): Cardiomegaly, increased pulmonary vascular markings, enlargement of pulmonary veins.
• Electrocardiography: T wave inversion, biatrial

enlargement, dysrhythmias

• Echocardiography (color flow Doppler study):

Structural abnormalities (ASD, VSD), valve anatomy,

valve area, function, left ventricular ejection fraction,

pulmonary artery systolic pressure

• Cardiac MRI can delineate complex

Grades

Grade-I: Uncompromised and no limitation of physical activity .

Grade-II: Slightly compromised with slight limitation of physical activity. The patients are comfortable at rest but

ordinary physical activity causes discomfort

Grade-III: Markedly compromised with marked limitation of activity. The patients are comfortable at rest but discomfort occurs with less than ordinary

activity

Grade-IV: Severely compromised with discomfort even at rest .

General management

place of therapeutic termination:

Considering high maternal deaths, absolute indications are

(a) primary pulmonary hypertension

(b) Eisenmenger’s syndrome

(c) pulmonaryveno-occlusive disease.

Relative indications are

(a) Parous woman with grade III and IV cardiac lesions

(b) Grade I or II with previous history of cardiac failure in early months or in between pregnancy.

The termination should be done within 12 weeks by manual suction  orvaccumevacuation (MVA) or by conventional D & E.

Risk factors for cardiac failure :

• Infections—Urinary tract, dental and respiratory tract.
• Anemia
•  Obesity
•  Hypertension
•  Arrhythmias
•  Hyperthyroidism

Role of anticoagulants:

Anticoagulants are indicated in cases with:

(a) Congenital heart disease

(b) pulmonary hypertension,

(c) mechanical heart valve,

(d) atrial fibrillation. The patient taking warfarin should discontinue it as soon as pregnancy is diagnosed and to replace it by heparin 5,000 units two times daily subcutaneously up to 12th week. Low molecular weight heparin (LMWH) can also be used. This is then replaced by warfarin tablet 3 mg daily to be taken at the same time each day and continued up to 36 weeks. Thereafter it is replaced by heparin up to 7 days postpartum. Warfarin is then to be continued.

UFH, LMWH and Warfarin therapy do not contraindicate breast-feeding.

Indications for cardiac surgery in pregnancy:

Failure of medical treatment for:

 (i) Intolerable symptoms

(ii) Intractable cardiac failure

• Grade–I : At least 2 weeks prior to the expected date of delivery
• Grade–II : At 28th week especially in case of unfavorable social surroundings
• Grade III and IV : As soon as pregnancy is diagnosed. The patient should be kept in the hospital throughout pregnancy.

Emergency:

(1) Deterioration of the functional grading

 (2) Appearance of dyspnea or cough or basal crepitations or tachyarrhythmias

 (3)Appearance of any pregnancy complication like anemia,

preeclampsia.

Management during labor

place of induction: Most patients with cardiac disease go into spontaneous labor and deliver without any difficulty. However, induction (vaginal PGE2 ) may be employed in very selected cases for obstetric indications. Patient should be monitored against infection and pulmonary edema due to fluid overload.

Labor:

First stage:

— Position: To keeppatient should be in lateral recumbent position to minimize aortocaval compression

— Oxygen is to be administered (5–6 L/min) if required

— Analgesia in the majority, is best given by epidural

— Prophylactic antibiotics against bacterial endocarditis

— Fluids should not be infused more than 75 mL/hour to prevent pulmonary edema.

— Monitor  pulse and respiration rate. In case the pulse rate exceeds 110 per minute in between uterine contractions, rapid digitalization is done by intravenous digoxin 0.5 mg.

— Cardiac monitoring and pulse oximetry can detect arrhythmias and hypoxemia early.

— Central venous pressure monitoring will be needed in selected cases.

Prophylactic antibiotics for bacterial endocarditis: Antibiotic prophylaxis during labor and 48 hours after delivery is considered appropriate. This is to prevent bacterial endocarditis. The recommended management include intravenous ampicillin 2 g and gentamicin 1.5 mg/kg (not to exceed

80 mg), at the onset or induction of labor followed by repeat doses 8 hours interval.

High risk patients :

(a) Structural heart disease

(b) Rheumatic heart disease

(c) Cyanotic congenital heart disease

(d) Presence of dental and respiratory tract infections

(e) Hypertrophic cardiac myopathy

(f) Prosthetic heart valves

(g) Prior history of infective endocarditis

 (h) Cardiac transplant.

Second stage:

• There should not be maternal pushing and the tendency to delay in the second stage of labor which to be followed  by forceps or ventouse under pudendal and/or perineal block anesthesia.
• Ventouse is preferable to forceps as it can be applied without putting the patient in lithotomy position.
•  Intravenous ergometrine with the delivery of the anterior shoulder should be withheld to prevent sudden overloading of the heart by the additional blood squeezed out from the uterus.

Third stage:

• Excess blood loss is present, oxytocin can be given by infusion. This may be accompanied by aggressive diuresis by IV frusemidein third stage.

cardiac indications of cesarean delivery:

• Coarctation of aorta
• Aortic dissection or aneurysm
•  Aortopathy with aortic root > 4 cm
•  Warfarin treatment within 2 weeks
• In coarctation of aorta, elective cesarean section is indicated to prevent rupture of the aorta or mycotic cerebral aneurysm.

puerperium:

• Patient is to be observed closely for the frst 24 hours.
• Oxygen is administered. Hourly pulse, BP and respiration are recorded.
• Diuretic may be used if there is volume overload.
• Breastfeeding is not contraindicated unless there is failure.
• Anticoagulant therapy is not a contraindication of breastfeeding.

contraception:

• Steroidal contraception is avoided as it can cause thromboembolic phenomenon.
• Intrauterine device (copper IUCD or LNG-IUS) is mostly avoided for it can cause  infection. Progestin only pills or parenteral progestins are safe and effective. They may cause irregular bleeding especially if the patient is anticoagulated.
• Barrier method of contraceptives is the best.
• Sterilization should be considered with the completion of the family at the end of first week in the puerperium under local anesthesia through abdominal route by minilap technique. If the heart is not well compensated, the husband is advised for vasectomy.

specific heart disease during pregnancy and the management

• Rheumatic heart disease

Mitral stenosis: Mitral stenosis is the most common heart lesion in pregnancy. Normal mitral valve is  between 4 and 6 cm . Symptoms appears when stenosis narrows this to less than 2.5 cm . Women with mitral valve area ≤1 cm , have the high rate of pulmonary edema  and arrhythmia .During labor continuous epidural analgesia is ideal and intravenous fluid overload is to be avoided.

place of valvotomy: It is better to withheld elective cardiac surgery during pregnancy. Ideal time of surgery is between 14 weeks and 18 weeks. Valve replacement, commissurotomy, balloon valvotomy can be carried out in early second trimester. Atrial fibrillation is a complication. Digoxin, β blockers and anticoagulation (heparin) should be used.

Aortic stenosis: Most cases of aortic stenosis are congenital, some are rheumatic in origin. Normal aortic valve area is 3–4 cm . When it is reduced to less than or equal to 1 cm , stenosis is present. Epidural anesthesia is contraindicated. During labor, fluid therapy should not be restricted. Left ventricular after load is high and the pregnant patient is sensitive to hemorrhage. Medical management is not helpful in a symptomatic patient. Valve replacement is the definitive treatment. Open heart surgery is preferably avoided in pregnancy. Aortic balloon valvuloplasty may be done as a palliative procedure.

• congenital heart disease: Pregnancy occurs in uncorrected congenital lesions, specially in a cyanotic group. Risk to the offspring of congenital heart disease is high .Major maternal risks in pregnancy are:

(i) Cyanosis

(ii) Left ventricular dysfunction

(iii) Pulmonary hypertension.

The common maternal complications are:

(i) Congestive cardiac failure

 (ii) Pulmonary edema

(iii) Arrhythmia

(iv) Hypertension.

A. Acyanotic (L to R shunt)

Atrial Septal Defect (ASD):ASD (ostiumsecundum type) ,Even uncorrected ASD tolerates pregnancy and labor well. Congestive cardiac failure unresponsive to medical therapy requires surgical correction.Shunt reversal is the major risk which may develop in hypovolemia. Such cases may occur in hemorrhagic conditions and following  administration of epidural anesthesia is not advised.

Patent DuctusArteriosus (PDA):

(Continuous murmur at the upper left sternal border )Pulmonary hypertension cause maternal death. Surgical correction during pregnancy can be performed provided there is no pulmonary hypertension. Epidural analgesia is better avoided to minimize shunt reversal due to systemic hypotension.

Ventricular Septal Defect (VSD): Pregnancy is well tolerated with small to moderate left to right shunt or with moderate pulmonary hypertension. The major risk is shunt reversal leading to circulatory collapse and cyanosis. Hypotension is to be avoided. Fetal loss may be up to 20%.

Mitral Valve Prolapse (MVP):Is the commonest congenital valvular lesion. Most of them are asymptomatic.

Women tolerate pregnancy and labor well. Endocarditis prophylaxis is given.

B. Cyanotic (R to L shunt)

Fallot’s tetralogy: It is the most common form of cyanotic heart lesion. It is a combination of

 (a) ventricular septal defect,

(b) pulmonary valve stenosis,

(c) right ventricular hypertrophy

 (d) an overriding aorta.

Complications like bacterial endocarditis, brain abscess and cerebral embolism are more common.

Maternal mortality is 5–10% and the perinatal mortality is 30–40%.

IUGR is common. Systemic hypotension is dangerous which may lead even

to death. Epidural or spinal anesthesia is avoided. Pregnancy is discouraged in women with uncorrected tetralogy.

Eisenmenger’s syndrome: Patients with Eisenmenger’s syndrome have pulmonary hypertension with shunt (right to left) through an open ductus, an atrial or ventricular septal defect. Termination of pregnancy should be seriously considered. Heparin should be used throughout pregnancy as there is risk of systemic and pulmonary thromboembolism. Epidural anesthesia

is contraindicated. Inhaled nitric oxide or I.V. prostacyclin is used as a pulmonary vasodilator. To maintain hemodynamic stability, pulmonary artery catheter and a peripheral artery catheter are used.

C. Other congenital heart lesions

Coarctation of aorta:The maternal risks due to ruptured intracranial aneurysms. Surgical correction should be done prior to pregnancy. Termination of pregnancy should be seriously considered. Elective cesarean section is preferred to minimize dissection associated with labor.

Medical and Surgical Illness Complicating Pregnancy

Primary pulmonary hypertension is characterized by increased thickening of muscular layer of pulmonary arterioles. Termination of pregnancy is indicated. Sildenafil is used as a vasodilator as it increases endogenous nitric oxide. Oral nifedipine or I.V. prostacyclin helps pulmonary vasodilatation. Epidural morphine gives effective analgesia without any hemodynamic change.

Marfan’s syndrome:Marfan’s syndrome is an autosomal dominant condition. There is 50% chance of transmission to the offspring. Dilatation of aorta more than 40 mm in echocardiography is a contraindication of pregnancy. Beta blocking drugs should be used to maintain resting heart rate around 70 bpm. Hypertension should be avoided to prevent aortic dissection. Vaginal delivery is desirable with minimizing second stage of labour. Women with aortic diameter more than 5.5 cm should have graft and valve replacement before pregnancy. Prosthetic valves are used for significant valvular disease. Mechanical valves are durable but require anticoagulation. The risk of thromboembolism is high with low molecular weight heparin rather than warfarin. Bioprosthetic valves (Porcine) are superior to mechanical valves.

D. Cardiomyopathies

Peripartum cardiomyopathy:

Pregnancy is not well tolerated in women with dilated cardiomyopathy.

The treatment is bed rest, digoxin, diuretics (preload reduction), hydralazine or ACE inhibitors (postpartum) (afterload reduction), β blocker and anticoagulant therapy. Vaginal delivery is adviced. Epidural anesthesia

is ideal. There is no contraindication of breastfeeding.

Myocardial infarction

 Treatment is mostly as in nonpregnant state. Coronary angioplasty, stenting and thrombolytic therapy have been done in pregnancy when indicated. Supine position and hypotension should be avoided.

Labor:

Elective delivery within two weeks of infarction should not be. Regional analgesia for pain in labor and β blockers for tachycardia is indicated. Maternal pushing should not be done and second stage is minimized by forceps or vacuum. Syntocinon should be used in the third stage as ergometrine may cause coronary artery spasm. Diuretics to be used postpartum. Percutaneous transluminal coronary angioplasty can be done successfully around 36 weeks of pregnancy if needed.