Pregnancy in most women with heart disease pregnancy has a maternal and fetal outcome. The patients with Eisenmenger syndrome, pulmonary vascular obstructive disease, maternal death during pregnancy in women with heart disease is sporadic.
Profound changes occur in the cardiovascular system during pregnancy and the differences observed are:
- The cardiac output increases from 4.5 L/min before pregnancy to 6.7 L/ min.
- Heart rate raised by 10-15 beats per minute between 14-20 week
- Plasma and blood volume increase by 40-50% between 12-34th weeks. Slightly lowered until the 20.
I had earlier shared Cardiogenic Shock vs Heart Failure I hope you read the post.
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Types of heart disease
Rheumatic heart disease:
Usually, mitral stenosis is common. Symptoms occur when stenosis narrows the valve to less than 2.5 cm2. There is a chance of pulmonary edema.
Congenital heart disease:
These may be of cyanotic varieties like Atrial Septal Defect (ASD), ventricular septal defect (VSD), or and distorted red cells .
These sickle-shaped cells block the microcirculation causing increased destruction, hemolysis, anemia, & jaundice.
Rheumatic heart disease
- Mitral stenosis is the most typical heart lesion met during pregnancy. Normal mitral valve area ranges between 4 and 6 cm2
- Symptoms usually appear when stenosis narrows this to less than 2.5 cm2. Women with mitral valve area <1 cm2 have a high rate of pulmonary edema (55%) and arrhythmia (33%).
- Diagnosis and management have been mentions earlier. During labor, continuous epidural analgesia is ideal, and intravenous fluid overload is to avoid.
- Left ventricular failure.
Suggested read: Angina Pectoris Occurs When….
- Valve replacement,
- Aortic balloon valvuloplasty may stay fixed as a palliative surgery
Congenital heart disease
Atrial Septal Defect (ASD):
Atrial Septal defect (ASD) is a hole in the wall between the two upper chambers of your heart. The condition is present at birth. ASD (ostium secundum type) is the most common congenital heart lesion during pregnancy. Even uncorrected ASD tolerates pregnancy and labor well.
Congestive cardiac failure unresponsive to medical therapy requires surgical Correction. Shunt reversal is a significant risk that may develop in hypovolemia.
Patent Ductus Arteriosus (PDA):
The presence of continuous murmur at the upper left sternal border is suggestive of the diagnosis.
Most patients with PDA tolerate pregnancy well. Pulmonary hypertension may cause maternal death. Surgical Correction during pregnancy can be performed provided there is no pulmonary hypertension.
I also wrote a article on Portal Hypertension: Symptoms, Causes, Diagnosis, and Treatment also you can read.
Mitral Valve Prolapse (MVP):
Is the commonest congenital valvular lesion. Most of them are asymptomatic. Women tolerate pregnancy and labor well. Endocarditis prophylaxis is giving.
Fallot’s tetra logy:
It is the most common form of cyanotic heart lesion. It is a combination of (a) Ventricular Septal defect, (b) pulmonary valve stenosis, (c) right ventricular hypertrophy, and (d) an overriding aorta.
- After surgical Correction, patients tolerate pregnancy well. Surgically uncorrected patients are at increased risk.
- Complications like bacterial endocarditic, brain abscess, and cerebral embolism are more common.
- Maternal mortality is 5-10%, and prenatal mortality is 30-40%.
- Systemic hypotension is dangerous, which may lead even to death. Epidural or spinal anesthesia avoids. Pregnancy is discouraged in women with uncorrected tetra logy
Other congenital heart lesions
Coarctation of the aorta:
- The maternal risks are hypertension, aortic dissection, bacterial endocarditic, and cerebral hemorrhage due to ruptured intracranial aneurysms.
- Maternal mortality is high 3-9%. Fetal loss is also increasing to 25%.
- Should do surgical Correction before pregnancy.
- Termination of pregnancy should seriously be considering.
- Elective cesarean section is preferred to minimize dissection associated with labor.
Important diagnostic criteria are:
- Cardiac failure within the last month of pregnancy or five months postpartum.
- No determinable cause for failure.
- Absence of previous heart disease.
- Left ventricular dysfunction as evidenced on echocardiography-
- Ejection fraction less than 45%
- The patients are usually multiparous and young (20-35 years). They complain of weakness, shortness of breath, cough, nocturnal dyspnea, and pulse.
I have already covered:
- Effective antenatal care plays critical part management of these cases.
- A thorough examination should be made when the patient presents to determine the grading and nature of the heart’s lesion.
- Grade, I and II patients can treat as out-patients.
- At every visit, the patient should ask whether there is an increase in breathlessness on exertion or limitation of activities increasing dyspnoea, orthopnoea, the cough should observe.
- Physical examination may reveal congestion at the lungs’ base when signs of congestive heart failure are present. The patients should be hospitalizes.
Management during labor
- Vaginal delivery at term: Vaginal delivery is the safest. The cesarean section must avoid if possible, as a cardiac patient does not stand laparotomy well.
- During vaginal delivery patient should be in bed at rest, and when the head comes at the perineum, should avoid extra strain on the heart by using outlet forceps or vacuum extractor.
- The strict control of IV fluids.
- Provision of adequate analgesia like pethidine or morphine.
- Avoidance of ergometrine to prevent extra load on the heart
- Oxygen and necessary drugs should be available.
Here are 3 guides that you can refer to learn more about:
Observation after delivery: after delivery, hemodynamic changes occur due to canal decompression and volume loading through auto compression of blood from the uterus
The hospital’s discharge should routinely be delayed until at least 24-72 hours after delivery, depending on underlying heart disease.
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