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Heart disease is the leading cause of non obstetrical cause for perinatal and maternal
mortality and morbidity and still a challenging health care problem.
1-3
The prevalence of
heart disease in pregnancy is 0,3 3,5 %.4,5 Pregnancy for women with heart disease is of
moderate to high risk. A normal heart is able to tolerate the physiological hemodynamic
changes during pregnancy (decrease of systemic vessel resistance, increase of blood
volume, increase of heart rate and cardiac output).1,6-8 For a pregnant woman with an
impaired cardiac function these changes increase the cardiac burden and may lead to
maternal and perinatal complications during pregnancy and delivery.1,9,10 Woman with
cardiovascular disease tends to have a preterm baby.11 While many women with a history
of heart disease may go through a pregnancy without difficulty, assessing overall
maternal and neonatal risks and monitoring the pregnancy consistently is mandatory.5
Heart disease in pregnancy is also hard to diagnose. Many signs and symptoms of normal
pregnancy can imitate heart disease. The most common symptom is dyspnoe (75 %). It
should be considered abnormal if there was activity impairment.6 Electrocardiogram and
echocardiography still remains an invaluable tool in evaluation of pregnant woman with
suspected heart disease, as it carries no risk to the woman or her fetus. 6,7 In this study, we
report maternal and fetal outcomes of 112 singleton deliveries with heart disease who
delivered their babies in Cipto Mangunkusumo General Hospital throughout 2009
2013.
Methods
This study was a restrospective evaluation of pregnancy outcome with heart disease. All
cases were followed during pregnancy, labour and delivery at the Cipto Mangunkusumo
General Hospital from January 2009 to December 2013. Data were collected through the
database including: History of cardiac disease, maternal age (divided into three groups :
<19 years old, 20 35 years old, and >35 years old), parity, history of ANC, MAP,
Ejection Fraction of heart by echo, mode of delivery, age of gestation. Neonatal outcomes
included APGAR Score at 1 and 5 minutes, IUFD, Preterm birth, birth weight. Maternal
outcomes included maternal death and mode of delivery. Data analysis was performed
using SPSS for Mac 20.0. Means and standard deviations (SD) or median were calculated
as appropriate.
Result
Data of 112 women with cardiac disease were obtained. They were all singleton
deliveries. The average age of the patients was 31 years old, with an age range of 17 - 47
years. The majority of patients were multiparous (n = 75, 67%) with normal ejection
fraction (n = 41, 61.2%) and all of them were had routine antenatal care (n = 112, 100%).
Variables
Maternal Age
< 19 years
19 35 years
No. (N = 112)
30 (26.8%)
3 (2.7%)
79 (70.5%)
37 (33%)
75 (67%)
26 (38.8%)
41 (61.2%)
112 (100%)
0
(0%)
58 (53.7%)
50 (46.3%)
The distribution of these patients by the type of heart disease is presented in table 2. The
most common heart disease was Vavular heart disease which was reported in 37.5% of
patients (n = 42, 37.5%), followed by heart failure (n = 27, 24.1%), Congenital Heart
Disease ( n = 14, 12.5%), PPCM (n = 13, 11.6%),HHD (n = 12, 10.7%), and arrhythmia
(n = 4, 3.6%). Congenital heart disease in these patients including : TOF, Eisenmenger,
VSD, and ASD. In these patients, 2 out of 4 arrythmia were caused by AV block.
Cardiac Disease
Congestive Heart Failure
Valvular Heart Disease
PPCM
No. (N = 112)
27 (24.1%)
42 (37.5%)
13 (11.6%)
HHD
Congenital Heart Disease
Arrythmia
30 (10.7%)
14 (12.5%)
4 (3.6%)
In total of 112 singleton deliveries obtained, caesarian section was found to be the most
predominant for mode of delivery (n = 82, 75.2%), spontaneous vaginal deliveries was
found in 27 (24.8%). Maternal death were occurred in 4 (3.6%) patients. IUFD were
occurred in 7(6.3%) neonates. Preterm deliveries occurred in 67 (59.8%) and median
duration of pregnancies was 36 weeks (range 8 40). There were 51 (51%) neonates with
low birth weight (<2500 g) with median birth weight 2400g (range 360 3800) . Low
APGAR score at 1 minute was found in 20 (22.2%) whereas low APGAR score at 5
minutes was found in 2 (2.2%) neonates.
Variables
Mode of Delivery
Caesarian Section
Vaginal delivery
Maternal Death
Yes
No. (N = 112)
No
104 (92.9%)
82 (75.2%)
27 (24.8%)
4 (3.6%%)
IUFD
Yes
7 (6.3%)
No
93 (93%)
Preterm Birth
< 37 weeks
67 (59.8%)
> 37 weeks
43 (38.4%)
51 (51%)
> 2500 g
49 (49%)
20 (22.2%)
>7
70 (62.5%)
<7
2 (2.2%)
>7
88 (97.8%)
Discussion
A number of registries on women with heart disease in pregnancy have been reported in
the past. However, they are predominantly from the developed world with a focus on
women presenting with operated CHD. They, therefore, do not cover the entire burden of
CVD in pregnancy particular to Indonesian population. This study was to evaluate the
clinical of maternal and fetal outcome in a tertiary hospital in Indonesia where
appropriate workup by obstetrician and cardiologist is needed. The study has a shown a
disease pattern markedly different that seen in developed countries, which CHD and
RHD become the two most prevalent cases in High - Income countries as stated by Liu H
et al.12 Our study reported that the highest prevalence of pregnancy complicated with
heart disease was valvular heart disease (n = 42, 37.5%) and the second highest was CHF
(n = 27,24.1%). Mode of delivery ( n = 82, 75.2%) The maternal outcome for this study
was quite good, with maternal death occurred in only 4 (3.6%) women. The perinatal
outcome, we found that there were significant numbers in low APGAR score at 1 minutes
(n = 20, 22.2%), Low birth weight (n = 51, 51%), and preterm birth (n = 67, 59.8%).
These factors may be caused by prenatal stress during pregnancy where there is a change
in hemodynamic of pregnant women with CVD as stated by Plana-Ripoll O et al. In our
study, we found that there was an improvement of APGAR score at 5 minutes, which
means that the rate of survival of neonates increased.
Conclusion
There is still lack of data concerning about pregnancy complicated with heart disease in
developing countries, however our data show a disease pattern in Indonesia, markedly
different to that of the developed countries. This study presents that valvular heart disease
was found to be the most prevalent case among all cardiac diseases in pregnant mother.
References
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