1. Heart disease with pregnancy
Salah T Fayed
Prof. OB & GYN

2. Classification Anatomical: according to the structural defect
Etiological: according to the pathology behind the defect
Functional: according to the performance status of the patient

3. Etiological Classification
Congenital
Rheumatic
Ischemic
Cardiomyopathy
Miscellaneous

4. Common Cardiac Diseases
Rheumatic:
mitral stenosis and incompetence
aortic stenosis and incompetence
Congenital heart disease:
Mitral valve prolapse
Aortic stenosis
ASD, VSD, PDA

5. Rare Cardiac Diseases Ischemic heart disease
Cyanotic heart diseases as:
Fallot’ tetralogy and Eisenmenger’ syndrome
Marfan syndrome
Heart block

6. Functional classification
New York Association of heart disease (NYAH) classification:
Grade I: asymptomatic leading normal life
Grade II: symptomatic with heavy exercise
Grade III: symptomatic with normal exercise
Grade IV: symptomatic at rest
The most useful as it determines the management and the method of termination

7. Physiological hemodynamic changes
Increased blood volume specially plasma
Increased heart rate
Increased Cardiac output
Decreased peripheral resistance
Increased preload
Net increase in work done by the heart

8. Effect of pregnancy on heart disease
The normal physiological changes that occur during pregnancy have adverse effect on the cardiac condition and the functional grade
Patient with grade I may become grade II or III during pregnancy
Patient with grade III disease may develop intractable failure necessitating termination

9. Counseling before pregnancy
The following conditions should be refrained from pregnancy and if got pregnant termination should be considered as they carry a very high maternal mortality rate
Severe aortic stenosis
Cyanotic heart disease as Fallot’s tetralogy
Pulmonary hypertension specially with right to left shunt Eisenmenger’ syndrome
Cardiomyopathy
Ischemic heart disease specially if unstable

10. Cardiac diseases that poorly tolerate pregnancy
Stenotic lesions: Aortic stenosis and tight mitral stenosis
Cyanotic heart disease: Fallots tetralogy and Eisenmenger syndrome
Primary pulmonary hypertension
Ischemic heart disease
Cardiomyopathy

11. Effect of heart disease on pregnancy
Hypoxia in cyanotic heart disease
Decreased fetal blood flow in low cardiac output lesions resulting in Fetal growth restriction and possibly fetal death
Increased incidence of congenital heart babies of pregnant woman with congenital heart disease

12. Antenatal care for cardiac patient
Conducted by Obstetrician and cardiologist
Avoid and promptly treat infections
Avoid un-necessary effort ( advise rest)
Limit salt intake
Avoid and treat anemia as it increases work done by the heart
Inquire about symptoms of de-compensation and complications

13. Special situations Patients with prosthetic valve:
Heparin during the first trimester followed by oral anticoagulant till 37 weeks
Shift to heparin till delivery
Anticoagulation is also indicated in patients with AF and those with cyanotic heart

14. Antenatal care: history
Left side failure: cough, hemoptysis, dyspnea, orthopnea, PND
Right side failure: LL edema, upper abdominal pain
Low cardiac output: fatigue, blackouts, fainting attacks
Arrhythmia: palpitation
Symptoms of Rheumatic activity
Symptoms of thromboembolic complications

15. Indications for hospitalization
Failure
Rheumatic activity
SBE
Deterioration on home based treatment
Thromboembolic disease (TED)
Cyanotic heart
Proper anticoagulation
Failure in previous pregnancy
For planned delivery
Establishment of anticoagulant therapy

16. Cardiologic drugs and the neonate
Diuretics are commonly used to decrease
Cardiac preload
Diuretics: may decrease the blood volume resulting in placental insufficiency with Fetal IUGR
Thiazides increase the incidence of neonatal jaundice and may affect the electrolyte balance

17. Cardiologic drugs and the neonate
Digoxin: main indication is rapid arrhythmias specially AF
Also in heart failure
It can cause conduction problems in the fetal heart ( heart block)
Serious problems nay occur in case of digitalis toxicity

18. Beta blockers Antihypertensive and slow down tachyarrhythmias
May cause neonatal hypoglycemia
Neonatal bradycardia

19. Cardiac Surgery during pregnancy
Should be avoided as possible , yet some extreme emergencies mandate intervention
Tight mitral stenosis with intractable pulmonary hypertension, valvotomy
Thrombosis on top of prosthetic valve, re-replacement of the valve
Open heart surgery carries high fetal mortality

20. Indications for caesarean section
Cyanotic heart disease
Ischemic heart disease
Aortic stenosis
Primary pulmonary hypertension
Marfan syndrome
Heart failure

21. Labor in cardiac patient
By far the most common cases met with are rheumatic heart diseases
Patients with grade I and II are allowed to go into spontaneous labor
Patient with grade III and IV are delivered by CS with close hemodynamic monitoring
The following are the important points in management

22. Management of first stage
Position: Semi sitting
Fluids: not more than 75ml/ hr
Pain: adequate analgesia (narcotics, epidural)
Oxygen inhalation
Antibiotics: guard against SBE (amoxicillin + gentamycin)
Monitoring for failure: chest auscultation + oxygen saturation
( pulse-oximeter)

23. Counseling for contraception
Estrogen containing methods (as COCS) are contraindicated in patients with valve lesion
Progestin only methods are allowed
IUCD is accepted with antibiotic prophylaxis against SBE
Sterilization may rarely be considered in patients with grade IV or cyanotic heart

24. Management of second stage
Avoid extra-effort to prevent maternal exhaustion and to avoid extra work by the heart by:
1- Shortening of second stage by forceps or ventouse
2- Avoid bearing down

25. Management of third stage
Active management of third stage to deliver the placenta
Avoid IV Ergometrin (methergine)
Ensure complete delivery of the placenta
Oxytocin drip
Decrease the pre-load by IV diuretics
Ensure bladder emptying to avoid reflex atony
Continue antibiotic prophylaxis

26. Physiological hemodynamic changes during first stage of labor
Increased cardiac output due to:
1- Squeezing of blood by uterine contraction
2- increased heart rate due pain and anxiety

27. Physiologic postpartum hemodynamic changes
Increased venous return
Increased stroke volume
Increased cardiac output
These changes are due to:
1- Shift of the of the blood from the placental bed to the maternal circulation
2- Release of vena cava compression by the gravid uterus

28. Counseling for contraception
Before discharge from the hospital patient should have an appointment to discuss possible contraceptive options
Long term contraception is not recommended if the patient is planning to have further pregnancies to avoid late pregnancy with worse cardiac condition unless surgical correction is planned