CARDIAC

DISEASE IN
PREGNANCY
DR SHAMSA TARIQ
ASSISTANT
PROFESSOR
GYNE /OBST
UNIT II
HOLY FAMILY
HOSPITAL
 PHYSIOLOGIC CHANGES
DURING PREGNANY

CO increases by 40% as SV increases

HR increases by 10 beats/min - 3rd trimester
CO peaks at 18-24 wks then stabilize
CO increase grade II systolic flow murmur along
the left sternal border without radiation
 Diastolic murmur if present consider
pathologic investigate
IncreaseVR Cardiac fullness & hypertrophy
displacement of heart
Apex beat superiorly and laterally
ECG
Lt axis deviation
Flattened T wave
 CARDIAC DISEASE

1. Rheumatic 90% of HD in pregnancy

Reduces by 50% with better
treatment of RHD and decrease
pathogenisty of organism

2. Congenital 35% HD
 RHEUMATIC HEART DISEASE

Mitral stenosis
Specific valvular disease
Increase Risk of Heart failure
SABE
Thromboembolic disease
Increase of fetal wastage
 MITRAL STENOSIS

90%
During pregnancy CO increase obstruction
worsens
Asymptomatic pt. symptomatic
Symptoms of cardiac decompensitions or pulmonary
edema appear as pregnancy progresses
Pt. with severe Mitral stenosis Atrial fibrillation
CCF.
If Atrial fibrillation predates pregnancy 50% CCF.
 OTHER CARDIAC LESION

Mitral insufficency

Aortic stenosis
 CONGENITAL HEART DISEASE

1. Atrial septal defects

2. Ventricular septal defects
3. Fallot tetrology
4. Primary Pulmonary hypertension (eisenmengers
syndrome )
5. Cyanotic heart disease
1. Defects corrected in childhood with no residual
damage pregnancy progresses without
complication.

2. Atrial and ventricular septal defects + tetralogy of

fallot tolerated pregnancy after surgical correction.

3. Maternal mortality increases by 25-50% in 4th and

5th condition (pregnancy and postpartum period)
CAUSE OF DEATH

Overload

Pulmonary Congestion

Hypotension

Hypoxia

Sudden death
 CARDIAC ARRHYTHMIAS
Benign

Paroxysmal atrial tachycardia

Supraventicular tachycardia
due to the structural changes in heart
 CARDIAC ARRHYTHMIAS
Serious

Atrial fibrillation

Atrial flutter
assosiated with underlying cardiac disease

Management same in pregnant & non

pregnant
 PERIPARTUM & POSTPARTUM
CARDIOMYOPATHY
Rare

No etiological factor found

No underlying cardiac disease

Symptoms of cardiac decompensation appear during

last weeks of pregnancy or ( 2-20wks) postpartum.
Women prone to this condition gives h/o

Pre-eclampsia

Hypertension

Malnutrition
 MANAGEMENT
NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION (NYHA) OF HEART DISEASE

CLASS I No signs or symptoms of cardiac

decompensation.
CLASS II No symptoms at rest but minor
limitation of physical activity.
CLASS III No symptoms at rest but marked
limitation of physical activity.
CLASS IV Symptoms present at rest increses
discomfort with any kind of physical activity.
 With I and II Maternal and fetal small

With III and IV Increases risk in both

 PRENATAL MANAGEMENT

Management with the help of cardiologist .

Frequent antenatal visit and admissions in class III

and IV.
 GUIDELINES FOR
MANAGEMENT

1. Avoid excessive weight gain and odema

2. Avoid sternuous activity

3. Avoid anemia

4. Early detection of a problem

 AVOID EXCESSIVE WEIGHT
GAIN & ODEMA

Low sodium diet (2 gm/day)

Rest in left lateral position

Adequate sleep
 AVOID STERNUOUS ACTIVITY

Unable to increase CO to meet demand of

exercise

Extract more oxygen from arterial blood large AV

difference uteroplacental circulation suffer
 AVOID ANEMIA

Oxygen carrying capacity decreases increase CO

increase HR

Mitral stenosis worsens increase heart rate

decrease in left ventricular filling time pulmonary
congestion odema
 EARLY DETECTION OF A
PROBLEM
On each visit look for
Infection

Cardiac decompensation

Pulmonary congestion

Cardiac arrhythmias
 SYMPTOMS OF CARDIAC
DECOMPENSATION
Pulse increases more than 100 bpm
Engorged neck veins
Increase JVP
Liver, spleen enlarged and tender
Weight gain and generalized edema

Treatment
Digitalization
Diuretic
 SYMPTOMS OF PULMONARY
CONGESTION
1. Dyspnoea
2. Orthopnea
3. Pulmonary creptation
4. Decrease vital capacity

Mostly appear at
18-24 weeks
During labour
During delivery
Immediate postpartum
 MANAGEMENT OF LABOUR
CO increases 40-50% of pre-labour level
80% of pre-pregnancy
increase catecholamine release
pain and apprehension
abdominal and uterine muscle
contractions
 TO MINIMIZE INCREASE
CARDIAC OUTPUT

Assurance

Sedation

Epidural analgesia
 TO CONTROL INFECTION

Prophylactic antibiotic (penicilline gentamylin)

Early labour postpartum (1-2 weeks)

 Left lateral position decrease risk of supine
hypotension

Increase oxygen carrying capacity of blood

 IN SEVERE CARDIAC DISEASE
(III & IV)

Monitoring of CV status is essential arterial and

swan- ganzcathetors
Monitor arterial pressure and CO with right atrial
main pulmonary artery pressure
Fluid intake and urine output
Arterial blood gases
Hemoglobin %
Electrolytes
 INVOLVEMENT OF
CARDIOLOGIST IS MUST
DURING LABOUR, DELIVERY
AND POSTPARTUM PERIOD
 OBSTETRICAL MANAGEMENT
Labour and foetal monitoring by using ext. electrode

Limit number of pelvic exam

Vaginal delivery preffered unless obstetrical

indication for C section

Shorten 2nd stage outlet

vacumn
 Pushing avoided increase CO due to increase VR

No ergometrine

Delivery of placenta increase 500 ml of blood so

lower extremities should kept at lower level

No massage of uterus

Small postpartum hge is desirable.