Heart Disease in Pregnancy

Heart Disease with Pregnancy

• Presented by Dr. Hend Salah Abdelmenam, Assistant Professor of Obstetrics and Gynecology.

Physiologic Changes During Pregnancy

• Cardiac output (CO) increases by 40% as stroke volume (SV) increases.
• Heart rate (HR) increases by 10 beats per minute during the third trimester.
• CO peaks at 18-24 weeks and then stabilizes.
• An increase in CO results in a grade II systolic flow murmur along the left sternal border, without radiation.
• Diastolic murmur warrants investigation for potential pathology.
• Increased right ventricular size (VR) leads to cardiac fullness and hypertrophy, displacing the heart.
• Apex beat shifts superiorly and laterally.
• ECG shows left axis deviation and a flattened T-wave.

Cardiac Disease

• Rheumatic heart disease (HD) is the most prevalent type (90%) during pregnancy; its prevalence reduces by 50% with improved treatment.
• Congenital heart disease (CHD) occurs in approximately 35% of cases.

Rheumatic Heart Disease (Specific - Mitral Stenosis)

• Mitral stenosis is a specific valvular disease.
• Risk factors during pregnancy include heart failure, thromboembolic disease, and increased fetal wastage.

Mitral Stenosis

• Pregnancy can worsen mitral stenosis by increasing cardiac output (CO) leading to obstruction.
• Asymptomatic patients may become symptomatic during pregnancy.
• Symptoms like cardiac decompensation and pulmonary edema manifest as pregnancy progresses.
• Severe mitral stenosis often results in atrial fibrillation.
• Atrial fibrillation, if present pre-pregnancy, is associated with a 50% chance of congestive heart failure (CCF).

Other Cardiac Lesions

• Mitral insufficiency
• Aortic stenosis

Congenital Heart Disease

• Atrial septal defects
• Ventricular septal defects
• Tetralogy of Fallot
• Primary pulmonary hypertension (Eisenmenger's syndrome)
• Cyanotic heart disease

Specific Congenital Heart Conditions Management

• Defects corrected in childhood without residual damage create no complications during pregnancy progression.
• Atrial and ventricular septal defects and Tetralogy of Fallot, following surgical correction, offer tolerable pregnancy outcomes.
• Maternal mortality increases by 25-50% during the fourth and fifth months (pregnancy and postpartum period) in complicated cases.

Cause of Death

• Overload → Pulmonary Congestion → Hypotension → Hypoxia → Sudden death

Cardiac Arrhythmias

Benign

• Paroxysmal atrial tachycardia
• Supraventricular tachycardia (related to structural heart changes)

Serious

• Atrial fibrillation
• Atrial flutter (associated with underlying cardiac disease)
• Management remains unchanged in pregnant and non-pregnant patients.

Peripartum and Postpartum Cardiomyopathy

• Rare condition.
• No identifiable cause or underlying heart disease.
• Symptoms of cardiac decompensation emerge during the last weeks of pregnancy or (2-20 weeks) postpartum.
• Women prone to this condition typically report a history of pre-eclampsia, hypertension, or malnutrition.

Management

• The New York Heart Association (NYHA) Functional Classification guides management:
  • Class I: No signs or symptoms of cardiac decompensation.
  • Class II: No symptoms at rest, but minor limitations during physical activity.
  • Class III: No symptoms at rest, but marked limitations during physical activity.
  • Class IV: Symptoms present at rest, worsened by any physical activity.
• Lower NYHA classes (I and II) present a lower risk to both mother and fetus.
• Higher NYHA classes (III and IV) elevate both maternal and fetal risks.

Prenatal Management

• Cardiologist involvement is vital.
• Class III and IV patients need frequent antenatal visits and admissions.

Guidelines for Management

1. Avoid excessive weight gain and edema.
2. Avoid strenuous activity.
3. Avoid anemia.
4. Implement early problem detection.

Specifics on Avoiding Excessive Weight Gain and Edema

• Low sodium diet (2 grams per day).
• Rest in the left lateral position.
• Ensure adequate sleep.

Specifics on Avoiding Strenuous Activity

• Inability to increase cardiac output (CO) to meet exercise demands.
• Reduced oxygen extraction from arterial blood, impacting uteroplacental circulation.

Specifics on Avoiding Anemia

• Reduced oxygen-carrying capacity lowers CO and increases HR.
• Mitral stenosis can worsen, inducing an increased heart rate.
• Reduced left ventricular filling time leads to pulmonary congestion and edema.

Early Detection of a Problem

• Regular checks for infections.
• Recognition of cardiac decompensation.
• Identification of pulmonary congestion.
• Monitoring of cardiac arrhythmias.

Symptoms of Cardiac Decompensation

• Pulse >100 bpm.
• Engorged neck veins.
• Increased jugular venous pressure (JVP).
• Enlarged and tender liver and spleen.
• Weight gain and generalized edema.
• Treatment: digitalization and diuretics.

Symptoms of Pulmonary Congestion

• Dyspnea
• Orthopnea
• Pulmonary crepitations
• Decreased vital capacity
• Symptoms are common during weeks 18-24, labor, delivery, and the immediate postpartum period.

Management of Labor

• Cardiac output (CO) increases to 40-50% of pre-labor levels and 80% of pre-pregnancy levels.
• Catecholamine release increases due to pain and apprehension, inducing abdominal and uterine contractions.

Minimizing Increased Cardiac Output During Labor

• Patient reassurance.
• Sedation.
• Epidural analgesia.

Controlling Infection

• Prophylactic antibiotics (penicillin – gentamycin).
• Treatment is administered from early labor through the first 1-2 weeks postpartum.

Additional Care

• Left lateral positioning decreases supine hypotension risk.
• Improved blood oxygen-carrying capacity.

Severe Cardiac Disease (Classes III & IV) Monitoring

• Continuous cardiac and vascular status monitoring (e.g., swan-ganz catheter).
• Essential monitoring of:
  • Arterial pressure.
  • Cardiac output (CO).
  • Right atrial pressure.
  • Main pulmonary artery pressure.
  • Fluid intake and urine output.
  • Arterial blood gases.
  • Hemoglobin percentage.
  • Electrolytes.

Cardiology Involvement

• Ongoing cardiology involvement is crucial during labor, delivery, and the postpartum period.

Obstetric Management

• Labor and fetal monitoring using external electrodes.
• Limiting pelvic exams.
• Preferring vaginal delivery unless obstetrical reasons indicate a C-section.
• Expediting second-stage labor, if necessary, with techniques like vacuum extraction.

Postpartum Care

• Avoid pushing to minimize increased VR and resultant CO.
• Avoid ergometrine.
• After placental delivery, maintain lower extremities at a lower level to manage blood flow changes.
• Minimal postpartum hemorrhage is favorable.

General Summary

• The presentation discusses heart disease and pregnancy, encompassing physiological adaptations, disease classifications, management strategies, and potential complications throughout pregnancy, labor, and the postpartum period.