Heart Disease in Pregnancy

Dr Wan Md Hafizi bin Wan Mohamad

Outlines
Epidemiology
Hemodynamic changes
Maternal risk
Complication
Clinical Approach
- Sign and symptoms
- Physical examination
Management
-Preconception
- Antenatal mangement
- Intrapartum management
- Postpartum management



Epidemiology in Malaysia
Accounts for 12% of maternal disease in 1996.
Commonest cause of indirect maternal death
in Malaysia
In Sarawak there were a total of 9 maternal
deaths from hearth diseases in the 3 years
period between 2010-2012

How comman?
Coronary artery disease is uncomman in pre-
menopausal women of child-bearing age
Most common; congenital heart disease or
rheumatic valvular heart disease
Cardiac complications result from
hemodynamic changes that occur during
pregnancy
CVS adaptation in pregnancy
Cardiac output: increased by 45%
Stroke volume: increased
Heart rate: increase by 10-20bpm
Blood pressure: reduced in the 1
st
and 2
nd

trimester

Hemodynamic during pregnancy
Peripheral resistant decrease increase uterine
blood flow
Blood volume increase 40-45%
Heart rate increase10-20%

Cardiac output increase 30%

Venous pressure in lower extremities increase
pedal edema
Maternal Risk
High risk heart disease
Pulmonary hypertension (>60% systemic pressure)
Dilated cardiomyopathy, ejection fraction <40%
Symptomatic obstructive lesions (delay pregnancy until
the obstruction has been corrected)
-aortic stenosis
-Mitral stenosis
-Pulmonary stenosis
-Coarctation of the aorta
Marfan syndromes with aortic root >40mm diameter
Cyanotic lesions
Moderate risk
- COA
- Prosthetic valve on coagulation
Low Risk
- Pulmonary stenosis
- Uncomplicated AR/MR
- Uncomplicated septal defect (ASD/VSD)

Cilical Approach
Symptoms :
- fatigue at rest
- exertional chest pain
- exertional sveer dyspnea
- orthopneia (progressively)
- PND
- syncope
- palpitation (dysaryytmia, if tacycardia may
normal for pregnant women)

Signs
General
- anemia
- clubbing
- Pulses (arrhythmias)
- Blood pressure
- JVP increase
- cyanosis
- ankle edema

Chest examination :
- shifted apex beat
- loud diastolic murmur
- cardiomegaly
- basal crepitation
Management
1. Precontraception
counselling regarding :
effect of hemodynamic changes and maternal risk
Effect of fetal growth
Effect of materanl drug and complicance
Genetic transmission
Need for frequent admission and long stay
Encourage for complete family earlier and
discourage from multiple pregnancy
Contraception
Barrier method: compliance issue
Spermicides: high failure rate
COCP: avoid in IHD, valvular heart disease and
plmonary hypertension
Implanon: very useful
IUCD: contraindicated in prostatic valve,
endocarditis
Antenatal Management
1. Booking
all mother should examine CVS properly
if suspected, refer to cardiologist for ECHO
2. Antenatal Clinic
History: look for any heart failure symptoms with
access of NYHA
PE :look any sign of heart failure
Investigation: Hb,ECG, ECHO (if sx suggestive)

3. Factor aggravate heart failure identified and treat
- Anemia
- HPT
- Infection(UTI or URTI)
- Hyperthyroidism
- Arrhythmias
- Multiple gestation
4. Advice about :
- Rest
- Smoking cessation
- Compliance of hematinic
5. Anticogulant
- anticoagulant theraphy is indicated if patient had
previous valve replacement and severe heart disease
- 3 types regime can be used :
- continue warfarin throughout preganancy, replace heparin for
delivery ( 1-2 weeks prior for delivery)
- replacement warfarin with heparin in 1
st
trimester
- use heparin throughout pregnancy
6. Time and mode of delivery:
Mild and moderate heart disease :
- aim for SVD, avoid induction of labour
Severe heart disease /develop acute heart failure
- admit patient early
- prepare for preterm labour for sever heart disease
patient

Intrapartum Management
Aim for deliver within 6 hours
Stop heparin before pregnancy
Prop up left lateral
Continue CTG, ECG and Sp02
Give 02 (3L/min)
Give epidural anesthesia
Antibiotics epidural given in severe cases:
- IV ampicillin 2gr STAT and 8hr later (2 doses)
- IV gentamicin 800mg and 8hr later ( 2doses)
Avoid fluid overload
Shortened 2
nd
stage 3 good maternal push / by using
instrumental delivery
For 3
rd
stage, give syntocinon (dont give ergometrine)