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PREGNANCY-HEART
DISEASE AND THYROID
HEART DISEASE IN PREGNANCY
• Class I and II low risk while class III and IV are at high
risk
Management
• Antenatal
– Managed jointly by the obstetrician and cardiologist
– Vital sign
– Evaluate sign and symptoms of heart failure
• Ask if mother has symptoms like dyspnea, orthopnea, PND,
• Thorough clinical examination and cardiovascular assessment
- the presence of anaemia
- the presence of any dental caries
- the blood pressure
- the presence of any arrhythmia
- any evidence of subacute bacterial endocarditis
– Determine the factors that can precipitate heart failure like twin pregnancy,
polyhydramnios, anaemia, hyperthyroidism, PIH/ Pre-eclampsia, respiratory
infections, arrhythmias.
– Prevention of anemia, infection, hypertension
Management
• Assess other factors :
- A history of previous cardiac failure
- Type of cardiac lesion
- Presence of any arrhythmia such as AF
- Presence of any valve replacement and whether
she is on anticoagulants
- Socioeconomic status of patient, distance of
house from hospital and availability of home help
Management
• Optimise mother’s condition
• Investigations like :-
• baseline haemoglobin level
• urea and electrolytes
• ECG
• Echocardiogram (ejection fraction; less than
40% carries a poor prognosis.
Mode of delivery
• Always best to wait for spontaneous labour
• Only induced if there is obstetric indication like IUGR,PIH.
• General principle is to minimise cardiac stress
– Vaginal delivery
• In labour, frequent assessment of vital signs, urine output, pulse
oximetry, put on continuous ecg monitoring.
– Propped up in bed, nursed in the left-lateral position to prevent
aortocaval compression, oxygen freely available.
– Adequate pain relief is important – often slow infusion
• epidural or parenteral opiates such as morphine.
• 2nd stage of labor: assisted delivery is indicated to avoid
maternal pushing increasing stress on heart.
. 3rd stage, iv ergometrine should be avoided to prevent sudden
increase in venous return when the uterus contract, syntocinon
should be used instead.
Mode of delivery
• Caesarean delivery
• Dependent on obstetric reasons
• If cardiologist decides that the mother may not be able to withstand the
• Best delivered by an elective Caesarean section at 38 weeks.
Physical examination:
goitre (usually with/without
bruit) in Graves’ disease
proximal muscle weakness,
hyperreflexia
warm, sweaty palms
fine finger tremors
lid retraction, lid lag
resting tachycardia
Effect on mother Effect on fetus
• PIH,Pre-eclampsia • fetal tachycardia
• Miscarriage • premature birth
• Premature labour • IUGR
• Thyroid storm • stillbirth
• Maternal CCF • Goiter
• Heart failure
• Growth restriction
Management
• Antithyroid drug
– Propylthiouracil (PTU)
– Carbimazole
• If 1st diagnosed in pregnancy,carbimazole 15mg/PTU 150mg 8 hourly for 4-5w. Dose
progressively reduced until maintenance dose of 15mg carbimazole/150mg PTU daily
achieve satisfactory control.
• Monitor TFT monthly in mother, adjust dose accordingly.
• If adequate control and mother euthyroid, drugs stopped at 36w POG to avoid effects on
fetal thyroid
*Lowest possible dose should be used as it can cross placenta and cause goitre and
hypothyroidism in the fetus
* PTU is more preferred as carbimazole may cause scalp defects in newborn,
agranulocytosis / ototoxicity in mother
Secondary
– Hypothalamic-pituitary dysfunction
Screening
• Symptoms of hypothyroidism
• Goiter
• Family History of thyroid disease
Signs & symptoms
• Fatigue
• Dry skin
• Coarse hair
• Constipation
• Weight gain
• Cold intolerance
• Decreased concentration
• Depression
• Memory and mental impairment
• Myalgia
Risk to baby
• Low birth weight
• Stillbirth
• Impaired brain development
• Preterm birth
• Increase morbidity and mortality
• Cong. Hypothyroidism –cognitive, neurological & developmental
abnormalities
*These can largely be prevented if the disease is recognized and treated
immediately after birth.
Management
• Thyroid hormone replacement: Levothyroxine
(when TSH > 10mIU/L OR TSH 5-10mIU/L & goiter +/- TPOAb)
• Women with known hypothyroidism should test for TFT as
soon as pregnancy is detected and their dose adjusted to
maintain a TSH in the normal range. (0.3-3.0mIU/L)
• TFT should be checked every 6-8 weeks during pregnancy to
ensure that the woman has normal thyroid function
throughout pregnancy.
• After delivery, the woman may go back to pre-pregnancy dose
of levothyroxine
• It is also important to recognize that prenatal vitamins contain
iron and calcium that can impair the absorption of thyroid
hormone from the gastrointestinal tract. Consequently,
levothyroxine and prenatal vitamins should not be taken at
the same time and should be separated by at least 2-3 hrs.