Cardiac Disease in Pregnancy

Vihara Dewi Mahendra,S.ked

Nasratul Ilmi ,S.ked

Introduction
Pregnancy, labor and delivery are
associated with burdens on the
cardiovascular system
The outcome of pregnancy is related to
functional class and underlying heart
disease

Hemodynamic Modifications during

Pregnancy
Blood volume starts to rise at 5th week
Systemic vascular resistance and blood
pressure are decreased
Resting heart rate increases by 10-20
beats/min
Cardiac output increases by 30-50%

High Risk Pregnancy

Advise avoidance of pregnancy
Mitral stenosis with functional class II-IV
Mitral and aortic regurgitation with functional class III,
IV
Severe pulmonary hypertension
Left ventricular dysfunction
Marfans syndrome with dilated aortic root
(> 40 mm)
Cyanotic heart disease
Severe obstructive lesion (aortic stenosis, pulmonary
stenosis)

High Risk Pregnancy

Close follow up required
Prosthetic valve
Mild to moderate valvular heart disease
Marfans syndrome without aortic root
dilatation

Suspicious Symptoms and Signs of

Cardiac Disease in Pregnancy

Progressive dyspnea
Syncope
Chest pain
Cyanosis
Left parasternal heave
A grade III/VI or greater systolic murmur
Any diastolic murmurs
S4 gallop
Fixed split of S2
Opening snap

Cardiovascular Disease
in Pregnancy
Valvular Heart disease
Rheumatic heart disease
Prosthetic heart valves
Hypertension
Congenital heart disease
Peripartum cardiomyopathy
Marfan syndrome and aortic regurgitation
Arrhythmias

Hypertension in Pregnancy
Complicates 6-8 % of all pregnancies
Complications
Cerebral hemorrhage
Hepatic failure
Acute renal failure
Abrutio placenta
Pregnancy outcomes relate with underlying
causes of HT

Cardiovascular Drugs
in Pregnancy
Drug

Use in pregnancy

Digoxin
Beta-blocker
Nifedipine
Hydralazine
Nitrate
IHD
Diuretics
ACEI
Amiodarone

HF, arrhythmia
HT,MS, IHD
HT
HT, HF

HF,HT
HT, HF
Arrhythmias

Safety

Safe
Safe
Safe
Safe
Limited data
+/Unsafe
Unsafe

Pharmacological Treatment

Methydopa: first line agent; 750 mg-4 g

Betablocker
Calcium channel blocker
Hydralazine
Diuretics:
Contraindicated in preeclampsia
May reduce uteroplacental flow

ACEI and ARB blocker: renal agenesis

Cardiovascular Evaluation
in Pregnancy
History
Physical examination
Investigations
ECG
Echocardiography

Hypertensive Disorder
Classification and definition
Chronic HT: HT prior or before 20 wks of gestation
Preeclampsia-eclampsia: proteinuria with new HTafter
20 wks of pregnancy
Pre-eclampsia superimposed on chronic HT: increased
BP (30/15); change in proteinuria or target organ
damage
Gestational HT: new HT after 20 wks of pregnancy
without proteinuria
Transient HT: elevated HT during or after pregnancy
without sings of preeclampsia

Mitral Stenosis
Most common valve disease in pregnancy
Valve area < 1.5 cm2 increases risk of
Pulmonary edema
Heart failure
Arrhythmias
Intrauterine growth retardation
Closed follow up is necessary
Doppler echo at 3 and 5 month and
monthly thereafter

Diagnostic Assessment
Echocardiography

Confirm diagnosis
Determine the severity of stenosis
Pulmonary artery pressure and RV function
Mitral valve score to determine the success of
percutaneous mitral balloon valvuloplasty

Medical Management
Most pregnant woman with mitral stenosis
can be managed medically
Limit activity
Restrict salt and fluid
Diuretic if needed

Medical Management
Digoxin is useful in atrial fibrillation
Rheumatic prophylaxis
Penicillin V 250 mg X 2
Benzathine Penicillin IM q 3 weeks
Betablocker

Beta-blocker in Pregnancy
Beta-1 selective agents ;metoprolol and
atenolol limits the risk interaction with
uterine contraction
Cross placenta and excrete in breast milk
No serious adverse effects on neonates
Fetal bradycardia and hypoglycemia have
been reported

Percutaneous Balloon
Mitral Valvuloplasty (PBMV)
Should be considered after failure of
aggressive medical treatment
Radiation exposure and technical
difficulties are major limitations
Transesophageal echocardiography
guidance may decrease the fluoroscopy time
and maternal complications

Surgical Intervention
Indicated in patients who failed medical
treatment
Should be performed between 24-28 weeks
gestation
Maternal mortality rate 1.5-5%
Fetal mortality rate 20-30 % in open heart
surgery
Closed mitral valvotomy is preferable
safe for mother
fetal mortality of 2-12%

ATRIAL FIBRILLATION

 Digoxin 0.25 to 0.5 mg IV, then 0.25 mg IV 4 to 6 hrly to

maximum of 1 mg
Propanolol 1 mg IV over 2 minutes, may repeat every 5 min
to maximum of 5 mg, maintenance 1 to 3 mg IV 4 hrly

Calcium channel blocker

Diltiazem 15 to 20 mg IV over 2 min, may repeat in 15 min,
maintenance 5 to 15 mg per hr by continuous IV infusion
Verapamil 5 to 10 mg IV over 2 min, may repeat in 30 min