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Mulia Amelia
Novi Rahmawati
Tiara Suci Amanda


A. General

Heart disease in pregnancy in Indonesia still causes a high mortality and

morbidity. Early detection and intervention in pregnancy is the efficient method of
reducing this risk. Antenatal care is screening medium that should be effective for
early detection of heart disease. Unfortunately many health workers who handle
pregnant and childbirth women is miss the golden opportunity. Early detection of
heart disease in pregnancy can be done thrugh a simple methods such a history
taking, and physical examination. Symptoms such as shorthness of breath,
orthopnea, edema of the lower extremities, fatigue, not being able to do light or
heavy activity should be sought since the first ANC. Family history if heart
disease, a history of sudden feath can also be a clue that leads to heart disease
in pregnancy.

B. purpose

Our purpose in discussing this matter is to find components, and explanation

about the Cardiac Disease in Pregnancy.

C. objectives of this write

1. To know the definition of Cardiac Disease in Pregnancy.
2. To explain the physiology and pathophysiology of Cardiac Disease in
3. To explain the condition about Cardiac Disease in Pregnancy in Indonesia
4. To explain implementation by midwifery of Cardiac Disease in Pregnancy.
5. To know about the evaluation of Cardiac Disease in Pregnancy.


A. Definition
Cardiac disease in pregnant women can presentchallenges in cardiovascular and
maternal-fetal management. It is important to understand that even in normal
patients, pregnancy imposes some dramatic phycologic changes upon the
cardiovascular system. These include an increase in plasma volume by 50%, an
increase in resting pulse by 17% and an increase in cardiac output by 50%. After
delivery, the heart rate normalizes within 10 days, by 3 month postpartum, stroke
volume, cardiac output, and system vascular resistance return to the pre-
pregnancy state. General guidelines for the management of pregnant women
with heart disease are outlined below.

B. Etiology
The etiology of cardiovascular diseases of pregnancy is variable and dependent
on the pathology involved. The following summarizes some common
cardiovascular diseases of pregnancy and their hypothesized etiologies:
1. Cardiomyopathy: There are several hypotheses regarding the etiology of this
disease process. Some of the most common theories are viral myocarditis,
autoimmune causes, hemodynamic instability, microchimerism, as well as
others. It is important to note that the risk factors which exist towards causing
cardiomyopathy in non-pregnant individuals continue to exist during
pregnancy and the weeks following pregnancy, and the heart may even be at
a higher susceptibility to these exposures. These causes include alcohol
abuse, doxorubicin use, and abuse of drugs such as cocaine and
2. Coronary artery disease: The etiology of ischemic heart disease in pregnant
women is similar to that of non-pregnant women. Risk factors which expose
these individuals to ischemic heart disease include hypertension,
hyperlipidemia and hypertriglyceridemia, diabetes mellitus, obesity, smoking,
and immobility.

3. Pregnancy-associated myocardial infarction: The same risk factors which

exist for coronary artery disease also exist for pregnancy-associated MI. It
has been hypothesized that certain conditions of pregnancy such as pre-
eclampsia and eclampsia could contribute to myocardial infarction.
4. Valvular disease: Although the hemodynamics of pregnancy can exacerbate
certain valvular diseases, it is inconclusive whether pregnancy has a specific
role in the etiology of newly diagnosed valvular disorders of pregnancy.

C. Pathophyisiology
A developing fetus will need a lot of oxygen and nutrients during the
pregnancy process. All of that must be fulfilled through the mother's blood, for
that the amount of blood circulating in the mother's body will increase, so the
heart must work harder. Therefore, in pregnancy there is always a change in the
cardiovascular system which is still within physiological limits. These changes are
mainly due to:
1. Hydrenia (Hypervolemia), starting at 10 weeks gestational age and
peak in the UK 32-36 weeks
2. Uterus gravidus which is getting bigger and bigger pushes the
diaphragm up, left, and forward so that the large blood vessels near
the heart experience curvature and rotation.

Plasma volume increases also by 22%. Large and when an increase in

plasma volume is different from an increase in the volume of red blood cells; this
results in delusional anemia (blood thawing). 12-24 hours after childbirth an
increase in plasma volume due to fluid imbibition from extra vascular into the
blood vessels, then follow the period of postpartum deuresis which results in
hemoconcentration (decreased plaque volume). 2 weeks postpartum is an
adjustment in plasma volume values like before pregnancy. A normal heart can
adjust, but a diseased heart does not. Therefore, in pregnancy the heart rate
increases and the pulse averages 88x / minute in pregnancy 34-36 weeks. In
advanced pregnancy the precordium is left shifted and systolic noise is often
heard in the apex and pulmonary valves. Heart disease will become more severe
in patients who are pregnant and giving birth, and even cord decompensation
can occur.

D. Subjective data
These data in the form of the phrase complaint from the client directly and
can be obtained from other people who know the state of the client directly.
Data-data collected covering :
1. Biodata or the identity of a mother and husband
2. The reason visit
3. A central complaint : is the main reason to come to the hospital and nothing
just feel clients. As for the possibility that found in a pregnancy with heart
disease, example :
- Mother said it was difficult breathing
- Mother feel the pain great on the part of the left chest
4. Menstrual hystory
5. A history of obstetric ago
6. A history of the pregnancy now
7. Medical history ago and now
8. A history of socio, economi and culture
9. A history of psychological
10. A basic need

E. Objective data
Sign and symptoms that can be found during physica examination can be in the
form of abnormal heart sounds, be it systolic or diastolic, cyanosis, jugular
venous distention, enlarged heart cousing tenderness, enlarged heart, too fast
heartbeat, heart rate is not usual either too fast or too slow and peripheral edema
in parts of the body, especially in the extremities of the body.
At the time of physical examination carried out on pregnant women who have
heart disease. With general differences that are difficult to breatg=hing, pale face,
irregulae chest movements and legs are edema.
Diagnosis test that can be done to find out about heart disease during pregnancy
according to (Manuaba,, 2004) are as follows:
1. Chest cardiograph is useful for viewing cardiac features such as
enlarged heart and pulmonary edema.
2. Electrocardiography (EGC) can detect disorder such as heart rythym,
heart conduction system, and so forth
3. Echocardiography to see the structure and function of blood vessels,
as well as record heart rate
4. Ultrasound to monitor fetal well-being in ther womb
5. Serum electrolutes to assess potassium as a guide to fluid and
electrolyte theraphy.

F. Midwifery diagnose
Examination modality that can be done to establish the diagnosisheart disease
in pregnancy are: electrocardiography, echocardiography, tests exercise (chest
exercise), chest radiograph (chest radiograph), MRI and CT scan. And also inspection
invasive cardiac catheterization if very necessary. Most pregnant women have normal
ECG, left heart rotation during pregnancy can give rise to a picture ECG axis deviation
to the left 15-20 degrees. Other general findings include ST segment images transients
and T wave changes, the presence of Q waves and T waves reversed at the leads III,
an increase in Q waves in AVF leads, and T waves reversed in leads V1, V2, and V3.
While echocardiography examination is recommended if there are signs of
dyspnea or a pathological murmur is found. Because this examination does not use
radiation beams, then it is proven to be quite safe for the fetus and can be repeated as
needed. On condition certain trans esophageal echocardiography examinations need to
be done, which can be display images more clearly. Usually indicated in cases of
complex congenital heart defects. This examination has a risk of stimulating vomiting
accompanied by risk of aspiration, and increased intra-abdominal pressure. If using
sedation, fetal well-being needs to be evaluated rigorously. While the exercise test is
done to assess capacity cardiac functional, chronotropic, blood pressure response, and
also induced arrhythmias practice. MRI examination may be useful for diagnosing
complex cardiac abnormalities or aortic pathology. This check is only carried out if
another inspection method (transthoracal or trans oesophageal echocardiography)
cannot make the diagnosis MRI is safe during pregnancy, especially after the first
trimester. CT scan no recommended to do a cardiac examination, because of the
radiation effect on the fetus. The only exception is to enforce or get rid of the diagnosis
of pulmonary embolism. But this check still has to do with lowest possible radiation
In addition to the detection of disease in pregnancy, determine the risk of
current complications pregnancy also needs to be done. There are many scorings that
can be used: capacity assessments functional heart (NYHA, 1979), CARPREG I (Siu et
al, 2001), ZAHARA I (Drenthen, 2010),CARPREG II (Silverside CK et al, 2018), and
WHO stratification. All can be used to assess pregnancy prognosis and the most
optimal pregnancy management for mother and fetus.
CARPREG I is a scoring system created to assess the risk of disease
heart in pregnancy. There are 5 parameters assessed:
1. History of heart failure, TIA, arrhythmias, or stroke
2. NYHA grade 3 or 4, or cyanosis
3. Left heart obstruction (mitral valve area <2 cm2, or aortic valve area <1.5 cm2)
4. Ejection Fraction <40%
5. Absence of previous cardiac intervention / treatment

G. Midwifery careplan
Care plans for heart disease in pregnancy:

Planning a Comprehensive Care

A care plan must be agreed by both the midwife and the client so that planning can be
done effectively. All decisions must be rational and valid based on theories and
applicable assumptions about what will and will not be done. Planning possible actions,
among others

1. Notify mother about the results of the examination / condition of the mother :
Communication interpersonal with mother, so as to create a comfortable
atmosphere and to foster a good and trusting relationship between mother and

2. Explain to the mother about the pregnancy being experienced : Inform the
mother of the results of examinations that have been carried out that the
condition of the mother and fetus is not good.

3. Explain to the mother that her pregnancy has heart disease complications and if
not treated immediately it will interfere the health of his mother and fetus. The
history of heart disease that you have is very influential on your current
pregnancy, increasing the fetus's need for oxygen and nutrients causes changes
that commonly occur in the circulatory system during pregnancy such as blood
thinning, increased blood volume, causing the heart to work harder, this can
worsen the condition heart disease that the mother suffered before pregnancy.

4. Tell the mother about the risks that will occur in pregnancy with heart disease
such as: abortion can occur, prematurity occurs, low presmaturitis and apgar
UPD. this risk will occur due to impaired blood circulation from mother to fetus

5. Collaborating with a cardiologist so that the mother gets treatment according to

the criteria for the class of heart diseaseand proper management so that it does
not endanger the situation of the mother and fetus.

H. Implementation
Treatment and management of heart disease in pregnancy depends on the degree
and function:
1. Class I: no additional treatment needed, treatment can be converted. The patient
must rest several times a day to reduce the work of the heart
2. Class II: usually does not require additional therapy, reduce physical work,
especially between 28-36 weeks of pregnancy
3. Class III: requires digitization or other drugs, should be treated in hospital since
28-30 weeks of pregnancy
4. Class IV: must be treated in hospital, and given Management must involve the
obstetrician, cardiologist, anesthesiologist, and cardiac surgeon. Pulmonary
hypertension and marfan syndrome are contraindications for pregnancy. Most
cardiovascular muscles can be used in pregnancy taking into account the
potential risks to the mother and baby. The indications for surgery are the same
as for women who are not pregnant. If there is an indication for cardiopulmonary
bypass support surgery it should be with high flow.

Heart failure must be treated intensively with bed rest, oxygen, tourniquets, digoxin (0.5
mg intravenously for 10 minutes followed by 0.25 mg intravenously every 2-4 hours to 2 mg if
needed), and morphine ( 10-15 mg intravenously every 2-4 hours). Obvious maternal
tachycardia should be treated immediately with proponolol (0.2-0.5 mg intravenously every 3
minutes until the heart rate drops to 110 beats per minute), digoxin or cardioversion (25-100

The American Heart Association recommends giving antibiotics to pregnant patients with
heart valve disease before a cesarean section or urethral catheterization, or in a complicated
vaginal delivery. The use of beta agonists to treat premature labor is contraindicated in those
with clear cardiac disease. Sulfas magnesikus can be used with caution, because with high
doses heart poisoning may occur (Raybura, William F, 2001)

I. Evaluation
Evaluation of cardiac disease in pregnant females will often require
advanced workup. Initial basic workup with labs such as CBC, CMP, and
urinalysis can give necessary clues to underlying processes that may be
occurring. Elevated white blood cell count can help test for inflammatory
conditions of the heart such as myocarditis or myocardial infarction. Routine
serum creatinine measurement can help the provider test if the patient has had
periods of hypo-perfusion in recent history. Liver enzymes could help identify
congestive hepatopathy as they would in non-pregnant individuals. Urinalysis
could reveal protein to help identify a state of pre-eclampsia. Labs such as brain
natriuretic peptide (BNP) may have utility as some note to double during
pregnancy. Still, those who have overt peripartum cardiomyopathy have been
found to have higher levels of BNP than those who do not.

An electrocardiogram may be done and reveal various findings as well similar to those
who have cardiovascular disease outside of pregnancy. Normal heart changes in
pregnancy will cause rotation of heart to the left and a resultant mild left axis deviation.
As previously mentioned, dilation of all chambers of the heart occur in pregnancy, and
thus this predisposes these individuals to develop dysrhythmias. Some of the most
common dysrhythmias seen in pregnancy include atrial premature beats,
supraventricular tachycardias, and ventricular premature beats. Ventricular
tachyarrhythmias may also form but are much rarer. If an individual is undergoing
ischemic changes, one would expect to find ECG changes consistent with an ischemic
burden, including ST-elevations or depressions, T-wave inversion, or formation of Q-
waves. Non-specific changes to ST segment or T-waves present in up to 14% of

An echocardiogram is essential towards evaluating those undergoing cardiac insults of

pregnancy. Physiologic findings may reveal chamber enlargement, physiologic aortic,
mitral, and tricuspid regurgitation, and valvular dilatation. Clinical manifestations of
these processes along with the degree of echocardiographic findings will require
evaluation by a clinician to evaluate their significance. No strict cutoff for each of these
has been deemed “normal” or “abnormal” in pregnancy. Findings of cardiomyopathy
may reveal exaggerated septal thickening, end-diastolic posterior wall thickening, and
resultant eccentric hypertrophy. Echocardiography can diagnose peripartum
cardiomyopathy if ejection fraction reveals to be less than 45% and/or M-mode
shortening below 30%, and end-diastolic dimension is greater than 2.7cm/m2. Localized
wall motion abnormalities may present in myocardial ischemia or infarction. Pericardial
effusion may also be evident in pregnancy, and in small amounts can be physiologic,
however, if the patient is exhibiting signs of hypotension, JVD, or pulsusparadoxus, then
evaluation of tamponade should be undertaken with echocardiography