Cardiac Diseases In Pregnancy

Hasan Arafat
Abdullah Matar
Badran

Subjects
Pre-pregnancy counselling
Antenatal Management
Management of labour and

Delivery
Treatment of Heart Failure in
Pregnancy
Specific Conditions : Ischemic Heart
Disease , Mitral and aortic stenosis , Marfan
syndrome and Pulmonary Hypertension

Normal Cardiac Changes During

Pregnancy
Cardiac Output Increases up to 50% by

20 weeks ( i.e. Heart Rate , Stroke

Volume are both Increased )
CO is the lowest in supine position
CO is the highest in the left lateral
position
CO increases progressively through the
three stages of labour
Systolic Ejection Murmur is present due
to increased CO passing through the
aortic and pulmonary valves .

Pre-pregnancy Counselling
Women with heart disease should be aware

of their condition prior to pregnancy and

they should be also assessed by
Cardiologist managed or treated
according to situation
Issues related to that :
- Risk of maternal death
-

Possible reduction of maternal life expectancy

Effects of pregnancy on cardiac diseases
Risk of fetus developing Congenital Heart Disease
Risk of preterm labour & Fetal Growth Restriction
Intensive Maternal and Fetal monitoring during labour

Antenatal Management (1)

Pregnant with significant Heart Disease should be managed in a

joint obstetrician/cardiac Clinic .

Physicians have to distinguish Between Normal Pregnancy
changes and impending heart failure . This gained by asking the
pregnant woman about breathlessness - esp at night - ,
changes in heart rate or rythym , tiredness or in
exercise tolerance .
Routine Physical examination Pulse rate and pressure , BP , JVP , and
sacral and ankle oedema , presence of basal crackles

As these women should be advised to reduce their normal

physical activities
Echocardiography is good to assess Fxn and valves ,
Echocardiogram is usual around 28 week - at the booking visit -.
Hospital Admission for bed rest will reduce workload of the
heart.

Antenatal Management (2)

The use of anticoagulants during

pregnancy is a complicated issue .

This because Warfarin is teratogenic 1 st
trimester and linked with fetal intracranial
hemorrhage 3rd trimester
LMWH may be insufficient at preventing
thrombosis in women w/ prosthetic heart
valves ( risk >10% )
Anticoagulation is essential in patients w/
congenital heart disease who have
pulmonary hypertension or artificial valve
replacement , or for those at risk of atrial
fibrillation

Stages of Heart Failure

NYHA

classification
Class I ( Mild ) : no signs or symptoms of heart

decompensation with ordinary physical activity

no fatigue , no dyspnea , no palpitations
Class II ( Mild ) : no symptoms at rest , slight
limitations with activity fatigue , dyspnea ,
palpitations
Class III ( Moderate ) : no symptoms at rest ,
marked limitations with ordinary activity
fatigue , palpitations , dyspnea
Class IV ( Severe ) : symptoms and discomfort
at rest , increased with any physical activity

High Risk Cardiac conditions

Systemic venricular Dysfunction ( ejection

fraction <30 % , NYHA class III-IV )

Pulmonary Hypertension
Cyanotic congenital heart disease
Aortic pathology ( dilated aortic root > 4cm ,
Marfan syndrome )
Ischemic heart disease
Left heart obstructive lesions ( mitral , aortic
stenosis )
Prosthetic heart valves (metal)
Previous peripartum cardiomyopathy

Fetal Risks of Maternal Cardiac

Diseases
Recurrence ( congenital Heart Disease )
Maternal cyanosis Fetal Hypoxia
Iatrogenic Prematurity
FGR
Effects of Maternal Drugs ( Teratogenesis ,

Growth Restrictions , Fetal Loss )

Management of Labour and

Delivery
The aim of management is to await the

onset of spontaneous Labour

Induction of labour should be considered
for the usual obstetrician Indications and in
high risk women
Epidural Anesthesia is often recommended
This regional Anesthesia has some risk in
some cardiac conditions as it causes
Hypotension
Anesthetist should document an anesthetic
management plan .

Management of Labour and

Delivery
Prophylactic Antibiotics should be given to

any woman with cardiac defects to reduce

risk of endocarditis
Monitoring of Oxygen Saturation and
Arterial Blood Pressure is appropriate
during labour
In normal labour 2nd stage , we may
intentionally make it short w/ elective
foreceps or vacuum delivery .
CS should be done for normal obstetrician
indications
CS increases the risk of hemorrhage ,

Management of Labour and

Delivery
Postpartum Hemorrhage in particular can

lead to major Cardiovascular Instability

3rd stage of labour is managed actively by
Oxytocin ONLY
not w/
ergometrine
As Oxytocin is a vasodilator , it should be
administrated SLOWLY to patients w/
significant heart disease
( w/ low-dose infusions preferable )
High-level maternal surveillance is
required until the main hemodynamic
changes following delivery have passed

Management of Labour and

Delivery (SUMMERY)
Avoid induction of labour if possible
Use prophylactic Antibiotics
Ensure Fluid Balance
Avoid the supine position
Discuss the type of anesthesia w/ senior

anesthetist
Keep the 2nd stage SHORT
Use Oxytocin Judiciously