1. CARDIAC DISEASE
IN PREGNANCY
DR SHAMSA TARIQ
ASSISTANT PROFESSOR
GYNE /OBST UNIT II
HOLY FAMILY HOSPITAL

2. 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

3. 





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

4. 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

5. RHEUMATIC HEART DISEASE
Mitral stenosis


Specific valvular disease
Increase Risk of
 Heart failure
 SABE
 Thromboembolic disease
 Increase of fetal wastage

6. 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.

7. OTHER CARDIAC LESION

Mitral insufficency

Aortic stenosis

8. CONGENITAL HEART DISEASE
1.
2.
3.
4.
5.
Atrial septal defects
Ventricular septal defects
Fallot tetrology
Primary Pulmonary hypertension (eisenmenger’s
syndrome )
Cyanotic heart disease

9. 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)

10. CAUSE OF DEATH
Overload
Pulmonary Congestion
Hypotension
Hypoxia
Sudden death

11. CARDIAC ARRHYTHMIAS
Benign

Paroxysmal atrial tachycardia

Supraventicular tachycardia
due to the structural changes in heart

12. CARDIAC ARRHYTHMIAS
Serious

Atrial fibrillation

Atrial flutter
assosiated with underlying cardiac disease
Management  same in pregnant & non
pregnant

13. 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.

14. Women prone to this condition gives h/o

Pre-eclampsia

Hypertension

Malnutrition

15. 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.

16. 
With I and II  Maternal and fetal  small

With III and IV Increases risk in both

17. PRENATAL MANAGEMENT

Management with the help of cardiologist .

Frequent antenatal visit and admissions in class III
and IV.

18. GUIDELINES FOR
MANAGEMENT
1.
Avoid excessive weight gain and odema
2.
Avoid sternuous activity
3.
Avoid anemia
4.
Early detection of a problem

19. AVOID EXCESSIVE WEIGHT
GAIN & ODEMA

Low sodium diet (2 gm/day)

Rest in left lateral position

Adequate sleep

20. AVOID STERNUOUS ACTIVITY

Unable to increase CO  to meet demand of
exercise

Extract more oxygen from arterial blood  large AV
difference  uteroplacental circulation suffer

21. 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

22. EARLY DETECTION OF A
PROBLEM
On each visit look for
 Infection
 Cardiac decompensation
 Pulmonary congestion
 Cardiac arrhythmias

23. SYMPTOMS OF CARDIAC
DECOMPENSATION




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Pulse increases more than 100 bpm
Engorged neck veins
Increase JVP
Liver, spleen enlarged and tender
Weight gain and generalized edema
Treatment
 Digitalization
 Diuretic

24. SYMPTOMS OF PULMONARY
CONGESTION
1.
2.
3.
4.
Dyspnoea
Orthopnea
Pulmonary creptation
Decrease vital capacity
Mostly appear at
 18-24 weeks
 During labour
 During delivery
 Immediate postpartum

25. 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

26. TO MINIMIZE INCREASE
CARDIAC OUTPUT

Assurance

Sedation

Epidural analgesia

27. TO CONTROL INFECTION

Prophylactic antibiotic (penicilline – gentamylin)

Early labour  postpartum (1-2 weeks)

28. 
Left lateral position  decrease risk of supine
hypotension

Increase oxygen carrying capacity of blood

29. IN SEVERE CARDIAC DISEASE
(III & IV)



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
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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

30. INVOLVEMENT OF
CARDIOLOGIST IS MUST
DURING LABOUR, DELIVERY
AND POSTPARTUM PERIOD

31. 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

32. 
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.