CARDIAC DISEASE IN PREGNANCY – Dr.

Kudoyi • Patient without a heart lesion develops CCF

in pregnancy or post-partum
PLAN • Treat with digoxin and lasix
• Epidemiology 5. Ischaemic Heart Disease
• Pathology
• Clinical Presentation
6. Syphylitic Heart Disease
• Investigations
• Management – New York Heart Association 7. Cor pulmonale
Classification • Increased pulmonary vascular resistance
o Antepartum
• Chronic obstructive airway diseases e.g
o Intrapartum
asthma or chronic bronchitis.
o Post Natal
COMPLICATIONS OF CARDIAC DISEASE
EPIDEMIOLOGY
1. Maternal –
• Cardiac disease complicates 1% (0.3 – 3.0%) of
• CCF
pregnancies worldwide
• Pulmonary embolism
• It is the most important non-obstetric cause of maternal
mortality • Anaemia
• Worldwide MMR = 5/100,000 deliveries; K.N.H MMR = 2. Fetal
3,200/100,000 deliveries • IUGR
• 95% of cardiac disease in pregnancy are due to • Abortions
Rheumatic heart diseases (RHD) in developing countries.
• Preterm deliveries
This is due to high prevalence of untreated beta
haemolytic streptoccocal throat infections. • IUFD
• About 90% of cardiac diseases in pregnancy are due to
CLINICAL PRESENTATION
congenital heart disease in some developed countries
1. Failure to thrive – poor growth, finger clubbing
2. C.C.F
PATHOLOGY
• symptoms – shortness of breath, orthopnoea,
• In normal pregnancy hemodynamic changes occur from paroxysmal nocturnal dyspnoea, haemoptysis,
the first trimester and peak in the 3rd trimester into a wheezing.
high output cardiac status • signs – tachycardia,Increased JVP, Murmurs,
• HR increases by 10% (10-15 beats/min) Plasma volume basal creps, alae nasi flaring, tachypnoea,
increases by 40%. oedema, ascites, tender hepatomegaly
• This increase in cardiac output may cause a systolic 3. Tissue hypoxia – pallor, cyanosis, oliguria, anuria ,
murmur in women who are healthy. However diastolic confusion , coma , cold periphery .
murmurs are always indicative of heart disease. 4. Myocardial strain – angina pain , palpitations, fibrillation
• With cardiac disease in pregnancy increased cardiac 5. Murmurs
output predisposes to CCF 6. Infective endocarditis
• CCF is further predisposed to by
o Sepsis INVESTIGATIONS
o Anemia 1. ECG
o Exercises (physical activity) 2. Echo – cardiogram
• To prevent CCF prevent sepsis and anaemia and reduce 3. Urinalysis
exercises. 4. Haemogram
5. U/E
AETIOLOGY
1. Rheumatic Heart Disease (RHD) NEW YORK HEART ASSOCIATION CLASSIFICATION
Based on functional state of the heart.
• 90% involve mitral valve
• Mitral stenosis has highest risk for CCF 1. Grade 1 -Uncompromised.
• When tricuspid valve is affected all other -No Limitation of physical activity.
valves are usually involved 2. Grade 2 -Slight limitation of physical activity
-Dyspnoea on moderate exertion
2. Congenital Heart Disease (CHD) 3. Grade 3 -Marked limitation of physical activity
• VSD, ASD, PDA are commonest -Dyspnoea on mild exertion.
4. Grade 4 -Inability to perform any physical activity
3. Hypertensive Heart Disease (HHD) -Dyspnoea at rest , current or past CCF
• Age above 35yrs
• Below 35yrs common causes are MANAGEMENT
i. renal artery stenosis
ii. phaechromocytoma ANTENATAL CARE
iii. thyrotoxicosis 1. Combined team of cardiologist & obstetricians.
2. Grades 1&2 as out-patients until 36 weeks of gestation.
4. Peripartum Cardiomyopathy 3. Prevent
• Rare • excess weight gain (diet)
 • Fluid retention (frusemide)
• Anemia (haematinics)
• Sepsis (screen for UTI & isolate from URTI
patients)
4. Adequate rest – 10hrs at night , 2 hrs daytime.
5. Prop up in bed NOTES
6. Treat pre-eclampsia aggressively
7. Grades 3&4 – give digoxin 0.25mg & Frusemide 40 mg
daily
8. RHD – monthly benzathine penicillin 2.4 MU.
9. Prosthetic valves – anticoagulate.
10. Dental Procedures be done under antibiotic cover
11. Minor Heart surgery .e.g valvotomy is allowed.
12. Avoid open heart surgery

INTRAPATUM
Prepare resuscitation tray containing ; -
1. Digoxin
2. Frusemide
3. Adrenaline
4. Naloxone.
5. Hydrocortisone
6. Calcium gluconate
7. Sodium bicarbonate
8. Aminophylline
9. Oxytocin
10. Pethidine or morphine

1ST STAGE
1. Keep propped up
2. I.M morphine 15mg or I.M pethidine 100mg to allay
anxiety & minimize pain.
3. Oxygen by mask.
4. Avoid I.V. fluids and if given , add I.V. frusemide
5. If oxytocin is necessary use pump to minimize fluid
infusion.
6. Delay ARM.
7. I.V. Broad-spectrum antibiotics
8. Minimize number of pelvic exams.
9. Caesarean sections for obstetric indications only.

2nd STAGE
1. No valsava maneuver
2. Vacuum extraction.

3rd STAGE
1. I.V. frusemide 40mg stat
2. Massage uterus
3. Avoid ergometrine
4. I.M. oxytocin 10 units

PEUPERIUM
1. Keep admitted for 10 days.
2. Limit exercises
3. Continue with antibiotics.
4. Continue anticoagulation

POST-NATAL VISIT
1. Advice on limited family size , 1-2 children.
2. BTL or vasectomy
3. Progesterone only drugs – microlut , jadelle , noristerat
4. Barrier – condoms
5. Avoid oestrogens – may cause fluid retention.
6. Avoid IUCD – increases sepsis rate.