HEART DISEASE IN

PREGNANCY
 INTRODUCTION
 Incidence - 1% Kuklina EV et al. BJOG 2011;118:345–52.

 RHD(88%) with isolated MS: commonest heart disease in developing country(e.g.

India) Bhatla N et al.Int J Gynaecol Obstet. 2003 Aug;82(2):153-9

 Etiology in developed countries changed from Rheumatic to congenital

(comprises >50% in pregnancy)
Merz WM et al. J Perinat Med 2011;39:251–6
 Hospitalizations for CHD, arrhythmias, cardiomyopathy, and CHF: steadily
increased in past years
 15% of patients : No history of pre-existing heart disease
Merz WM et al.J Perinat Med 2011;39:251–6

Diagnosis delayed as shortness of breath, decreased

exercise tolerance, and peripheral edema attributed to
normal pregnancy
 MATERNAL MORBIDITY AND
MORTALITY
 Leading cause of death in women of 25 to 44 year.
Kung HC et al:NVSR56(10):121,2008

 Decline in maternal mortality from cardiac disease since 1950 from

5.6 to 0.3 per 100 000 births Am J Public Health ,1998

 Maternal mortality ~2.7% Avila WS et al:Clin Cardiol 26:135,2003

 In US-10% of maternal deaths

 In India – 4% of maternal deaths Indian J Matern Child Health. 1995 JIPMER

 Serious complication e.g. CHF, arrythmias and stroke in 12-20%

 NYHA Class III or IV seen in 10% of cardiac patients, 85% maternal
deaths occur in this group
 PHYSIOLOGICAL CHANGES OF
PREGNANCY
Pregnant (35– Postpartum (11–13 Change
38 wks) wks)
Cardiac Output (L/min) 6.2 ± 1.0 4.3 ± 0.9 +43%

Heart Rate(beats/min) 83 ± 10 71 ±10 +17%

Systemic vascular resistance 1210± 266 1530s ±520 -21%

(dyne/sec/cm5)
Pulmonary Vascular Resistance 78± 22 119 ± 47 -34%
MAP (mm Hg) 90± 6 86± 8 NSC

PCWP (mm Hg) 8± 2 6± 2 NSC

CVP(mm Hg) 4 ±3 4 ±3 NSC

S. colloid OP (mm Hg) 18.0± 1.5 20.8± 1.0 -14%

Uterine blood flow 2% of CO 17% of CO +88%

CO during diff. stages of gestation, labor,
and immediately postpartum compared
with nonpregnant women
HIGH RISK PERIOD FOR HEART
FAILURE
6-8 wks : peripheral vasodilatation- CO increases by 20%
Between 28-32 weeks. pregnancy- induced hypervolemia and
cardiac output reach their maximum
Labor and delivery
Immediate post partum
4-5 days after delivery

Most heart failure develops peripartum

when number of common obstetrical conditions
place undue burdens on cardiac function
Etheridge MJ Med J Aust 2:277, 1977
 CLINICAL INDICATORS OF HEART
DISEASE DURING PREGNANCY
Symptoms Clinical findings
• Cyanosis
• Progressive dyspnea
• Clubbing
• Nocturnal cough
• Systolic murmur grade 3/6 or
• Hemoptysis more
• Syncope • Diastolic murmur
• Chest pain • Cardiomegaly
• Persistent split S2
• Persistent arrhythmia
• Persistent neck vein distention
• Criteria for pulmonary
hypertension
 Clinical classification of heart
disease:New York Heart
Association(NYHA) classification
• Uncomplicated- No limitation of physical activity
Class I

• Slight limitation of physical activity: comfortable at rest, ordinary

Class II activity causes fatigue, palpitation, dyspnea, or angina

• Marked limitation of physical activity: comfortable at rest <

ordinary activity causes fatigue ,palpitation , dyspnea , or angina
Class III pain.

• Severly compromised-inability to perform any physical activity

without discomfort : Symptoms of cardiac insufficiency or angina
Class IV may develop even at rest.
 PHYSICAL EXAMINATION
 Weight, Height
 General appearance including specific facies and cyanosis, pallor,
clubbing, edema.
 Oro-dental hygiene
 Pulses in all extremities, JVP.
 Blood pressure
 Inspection-scar mark, Precordial thrill
 Thoracic auscultation: presence of crepts, signs of effusion or
bronchospasm
 Heart auscultation: rhythm, rate, S1 and S2 characteristics,
presence of S3 or S4,murmurs
 Fundal height and fetal heart
 INVESTIGATIONS
 Routine ANC investigations

 ECG

 Echocardiography:In pregnant patient with unexplained or new

CVS signs or symptoms ESC 2011.European Heart Journal (2011) 32, 3147–3197

 Chest X-ray : If other methods fail to diagnose cause of dyspnoea, cough.

 MRI :Useful in complex heart disease , pathology of aorta

 CT: Diagnosis or definite exclusion of pulmonary embolism

 Cardiac catheterization: During coronary angiography

 Exercise testing: assess objectively functional capacity,

Exercise-induced arrhythmias,

Follow-up of grown up CHD

PREGNANCY INDUCED CHANGES
Modality Change
Examination finding Jugular venous distension
Mammary souffle
S2 P increased; S2 split
S1 M increased and widely split
Occasional S3,venous hum
Aortic or pulmonary flow murmurs
ECG ~15-degree LAD , and mild ST changes in inferior
Diaphragm elevated in advancing leads
pregnancy Atrial and ventricular premature contractions
No change in voltage findings

Chest Radiography Heart silhouette normally larger in pregnancy

Echocardiography Slightly but significantly

increased TR, left atrial end-diastolic
dimension, and left ventricular mass
 Effects of radiation on the fetus
Depend on radiation dose and POG (Max:8-15 wk)
Fetal risk:congenital malformations, intellectual disability, IUGR, or
pregnancy loss
Risk not increased if maternal radiation exp. <50 mGy
ACOG Number 299,. Obstet Gynecol 2004;104:647–651
Threshold of increased risk :not definitely determined
>100 mGy : increased
 50 and 100 mGy : less clear ESC2011 European Heart Journal (2011) 32, 3147
MANGEMENT
OPTIONS
 MANAGEMENT AREAS
1) Risk stratification, Pre-conceptional
counseling
2) Ante partum management,
3) Peripartum management,
4) Multidisciplinary Care
 PRE PREGNANCY
 H/O cardiac symptoms and complication

 Establish functional status(NYHA)

 Drug intake (e.g. ACE inhibitor ,warfarin), replace with less

teratogenic drugs

 Assess clinical status and ventricular function

 Estimate maternal and fetal risks in specific cardiac condition

 Optimize medical management

 Correct aggravating conditions e.g. anaemia , arrythmia ,HTN

 Cardiac surgery if required

 PROBLEMS IN FETUS & NEONATE
 Adverse perinatal outcomes : 20-28% Drenthen W et al. Eur Heart J 2010;31:2124
 Miscarriage, IUGR,prematurity, death Gelson E et al.Obstet Gynecol 2011;117:886–91.
 Risk of recurrence of cardiac anomalies in offspring of women with
CHD(50% have same anomaly as mother)
 Neonatal mortality:1% and4% Drenthen W et al. Eur Heart J 2010;31:2124
 CONGENITAL HEART DISEASE IN FETUS WITH AFFECTED
FAMILY MEMBERS
Cardiac Lesion Previous sibling Father affected Mother affected
affected

Marfan syndrome NS 50 50

Aortic stenosis 2 3 15-18

Pulmonary stenosis 2 2 6-7

VSD 3 2 10-16

ASD 2.5 1.5 5-11

PDA 3 2.5 4

Coarctation of aorta NS NS 14

Fallot tetrology 2.5 1.5 2-3

Lupton M et al, Curr Opin Obstet Gynecol 14:137,2002

 FETAL ECHOCARDIOGRAPHY
• Diagnosis of congenital cardiac malformations can be made
as early as 13 weeks
Sensitivity :85% [95% CI78–90%]
Specificity :99% (95% CI 98–100%)
Rasiah SV et al .Ultrasound Obstet Gynecol 2006;28:110–116

• Optimum time : 18–22 weeks POG, visualization of heart

and outflow tracts optimal
• >30 weeks : becomes difficult , fetus more crowded
Thaman R et al. Heart 2003;89:752–756
• Evaluate : Cardiac anatomy and function
Arterial and venous flow
Rhythm
 MATERNAL MORTALITY & CARDIAC DISEASE
Group Cardiac disease Associated mortality risk

I ASD*,VSD*,PDA* <1%
Pulmonary/tricuspid valve disease
Corrected TOF
Bioprosthetic valve
MS, NYHA Class I, II
II COA without valvular involvement 5% - 15%
Uncorrected TOF
Marfan’s syndrome with normal aorta
Mechanical prosthetic valve
MS with AF or NYHA Class III, IV
AS
Previous myocardial infarction

III Pulmonary hypertension—primary or secondary 25% - 50%

COA with valvular involvement
Marfan’s syndrome with aortic involvement
Peripartum Cardiomyopathy Clark et al: Critical Care Obstetrics , ed 3. , 1997
• *Uncomplicated
 Modified WHO classification of maternal
cardiovascular risk
WHO I
WHO II–III (depending on individual)
Uncomplicated, small or mild
• Mild left ventricular impairment
- PS
• HOCM
- PDA
• Native or tissue valvular heart disease not
- MVP
considered WHO I or IV
• Successfully repaired simple lesions
• Marfan syndrome without aortic dilatation
(ASD,VSD,PDA,TAPVC).
• Aorta <45 mm in aortic disease associated
• Atrial or ventricular ectopic beats,
with bicuspid aortic valve
isolated
• Repaired coarctation

WHO III
WHO II (if otherwise well and
• Mechanical valve
uncomplicated)
• Systemic right ventricle
• Unoperated ASD,VSD
• Cyanotic heart disease (unrepaired)
• Repaired TOF
• Other complex congenital heart disease
• Most arrhythmias
• Aortic 40–45 mm in Marfan
• Aortic 45–50 mm in aortic disease
associated with bicuspid aortic valve
Thorne S et al. Heart 2006;92:1520–1525.
 PREDICTORS OF MAJOR CARDIAC EVENT IN
HEART DISEASE :CARPREG risk score
Predictor Odds P
Ratio (95% CI)

NYHA class > II or cyanosis N 6 (2–22) .009

Left heart Obstruction O 6 (3–14) .001

MVA< 2 cm2
AVA< 1.5 cm2
Peak LV outflow tract gradient >30 mm Hg by echo

Prior cardiac event or arrhythmia(symptomatic tachy or 6 (3–14) .001

P
bradyarrythmia requiring therapy)
Heart failure
Transient ischemic attack
Stroke before pregnancy
E
Systemic ventricular dysfunction 11 (4–34) .001
EF< 40%
Siu SC et al.Circulation 2001;104:515–21.
 ROLE OF PREDICTORS
Major cardiac event
 Pulmonary edema
 Arrhythmia requiring treatment
 Stroke or TIA of cardiac origin
 Cardiac arrest
 Cardiac death

No of predictors Risk

Zero 5%

One 27%

≥2 75%

Siu SC et al.Circulation 2001;104:515–21.

 Preconception assessment

NYHA NYHA class III &

class I & II IV

Cardiac Findings:
Pregnancy not adviced
imaging Pulmonary hypertension
based on risk
Severe systemic
ventricular dysfunction
Aortic root dilation
Acqired Congenital Severe left-side
cardiac cardiac obstructive lesions
disease disease

Genetics
consultation

Pregnancy a
High risk of recurrence
consideration Simpson. Maternal Cardiac Disease Update. Obstet
Gynecol 2012.
 PRENATAL
 Book in high risk center with Multidisciplinary approach
 Routinely question and examine for S/S of cardiac failure and
anemia
 Closely monitor vital signs and weight gain
 Counsel to report in case of symptoms of cardiac failure
 When risk of IUGR, serial USG every 2-4 wk in 3rd trimester
 Anesthesiology consultation
 Address future fertility desire and contraceptive plans
INDICATIONS OF HOSPITALIZATION
 NYHA Class III- IV
 Development of pulmonary edema,
arrhythmia's ,infective endocarditis,anaemia
 Sudden deterioration in Class of NYHA Class I-
II patient
 Pulmonary hypertension
 NYHA Class I-II : at least 2 wks prior to EDD,
condition individualised
 Heparin switch over : In case of mechanical
valve on oral anticoagulant
 in 1st trimester 6-12 wk
 At 36 wk
TERMINATION OF PREGNANCY

First trimester: safest time for termination

 surgical evacuation

Second trimester: should be avoided as far as possible

 PGE analogues :causes 65% increase in maternal
CO ,systemic absorption lower SVR and BP, and
increase HR, E2 > E1
 Oxytocin : cause fluid retention so titrate
judiciously
 Ethacrydine lactate
 Mechanical methods
LABOR AND DELIVERY
 24 hr availability of expert obstetric , cardiology ,anesthetic
and nursing care
 Elective induction reasonable so labour and delivery attended
by scheduled, experienced team
ESC guidelines2011:European Heart Journal (2011) 32, 3147–3197

 Labour in LLP to avoid hypotension

 Administer oxygen by mask
 Careful balance of input and output,fluid@ 75ml/hr
 Concentrated oxytocin
 Continuous ECG monitoring may be used
 Operative VD to cut short 2nd stage of labour
 Reserve Cesarean Section for obstetric indication
 ROUTE OF DELIVERY
Vaginal delivery preferred
Indications for elective LSCS:
 Any obstetric indications
Should be considered in
 Aortic dissection,acute or chronic
 Marfan syndrome with dilated aortic root (>4.5cm)
 Aortic aneurysm
 Endocarditis needing- emergency valve replacement at or near
term
 Severe AS
 History of recent MI
May be considered
 Marfan patients with an aortic diameter 40–45mm.
 In patients with high risk of valve thrombosis
ESC guidelines2011:European Heart Journal (2011) 32, 3147–3197
INDUCTION AND AUGMENTATION
 Mechanical methods method of choice: in higher functional classes and
patients with cyanotic lesions
 Prostaglandin - with lower functional classes without tachycardia or
history of asthma
 Induction of labor :relatively safe procedure, not associated with;
• Higher rate of cesarean delivery than in healthy women
• More maternal and neonatal complications than without cardiac
disease
Oron G et al BJOG2004
 INVASIVE MONITORING
Indications For CVP
• Pulmonary edema
• NYHA class III-IV
• Severe MS
• Pulmonary artery hypertension
• Prior history of CHF
Pulmonary-A catheterization
– EF <30%
– Contraindicated in
• Eisenmenger syndrome
• Severe MS : gives a falsely high LA pressure
• Heart block: may result in complete heart block
• H/O Mustard or Senning procedure
• Pulmonary vascular disease
 INFECTIVE ENDOCARDITIS
PROPHYLAXIS
 Overall incidence of I.E.:0.006% (1 per 100 000 pregnancies)
 Valvular or CHD: 0.5%
Avila WS et al.Clin Cardiol 2003;26:135–142

 Overused, because of previous liberal recommendations

 Efficacy to prevent IE questionable
 13 % of cases arising in patients with high-risk cardiac lesions do so after a
procedure
 Administer intrapartum to at risk only in presence of suspected bacteremia
or active infection
 Transient bacteremia at delivery 1 to 5 %.
 Optional in uncomplicated delivery at high risk for endocarditis

AHA 2007 GUIDELINES.Circulation. 2007;116:1736-1754

 INDICATIONS OF INFECTIVE
ENDOCARDITIS PROPHYLAXIX
Anticipated vaginal or cesarean delivery associated with infection AND

1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

2. Previous I.E.

3.Cardiac transplantation recipients who develop cardiac valvulopathy

4. CHD that meets one of conditions:

a. Unrepaired cyanotic defect including palliative shunts and conduits

b. Completely repaired defects with prosthetic material or device whether placed

by surgery of catheter intervention during 1st 6 months after procedure

c. Repaired defect with residual defects at site or adjacent to site of prosthetic

patch or device ACOG Committee Opinion No. 421. Obstet Gynecol 2008;112:1193–4
 Endocarditis prophylaxis not
recommended
Vaginal hysterectomy*
Vaginal delivery*
Caesarean section
In uninfected tissue:
Urethral catheterization
Uterine dilation and curettage
Therapeutic abortion
Sterilization procedures
Insertion or removal of intrauterine devices
* Prophylaxis is optional for high-risk patients
ACC/AHA 2006
 REGIMEN FOR I.E. PROPHYLAXIS
Situation Agent Single dose 30 to 60 min
Before Procedure

Oral Amoxicillin 2g

Unable to take oral medication Ampicillin,OR 2 g IM or IV

Cefazolin or ceftriaxone 1 g IM or IV

Allergic to penicillins oral Cephalexin,OR 2g

Clindamycin,OR 600 mg
Azithromycin or clarithromycin 500 mg

Allergic to penicillins & unable Cefazolin or ceftriaxone 1 g IM or IV

to take oral medication OR 600 mg IM or IV
Clindamycin

Anaphylaxis to penicillins Clindamycin 600 mg oral/IM/IV

If enterococcus infection Vancomycin also 1gm I.V.
concern
ACOG Committee Opinion No. 421. Obstet Gynecol 2008;112:1193–4
 Secondary Prevention of Rheumatic
Fever
Antibiotic Mode of Dose
administration

Benzathine Single I.M Inj. every 3-4 wk 1200000 units.

Benzylpenicillin
Penicillin V. Oral 250mg BD

Erythromycin Oral 250mg BD

Sulfonamide (e.g. Sulfadiazine, Oral 1gm daily

sulfadoxine,
sulfisoxazole)

Patient with carditis: For 10 yr after last attack, or at least until 25

(mild MR or healed) or yr age (whichever longer)
More severe valvular disease :Lifelong
After valve surgery: Lifelong WHO technical report series ; 923:2004
 ANALGESIC AND ANESTHETIC
CONSIDERATIONS
 Pain and apprehension increase CO to as much as 45–50%
Ueland K. I. Clin Perinatol 1988; 8: 155–64.

• Continuous lumbar epidural analgesia with LA, opioids or

both optimal
1st stage • Limited sympathetic blockade helpful with MV lesions,
decrease preload and afterload

• Epidural analgesia or anaesthesia continued

• Pudendal nerve block, not as complete analgesia as
2nd stage epidural, employed as adjunct or used alone
 CHOICE OF ANESTHESIA FOR CS
 Epidural anaesthesia:
 Least hemodynamic alteration,
 Slower onset of blockade and thus more
controllable hemodynamic alterations
 GA:
Equally as safe when abrupt changes associated with laryngoscopy
and intubation, blunted by appropriate pharmacological agents
 SPA :
Appropriate for some patients with well-compensated lesions, IV
volume management to maintain preload, SVR
 POSTNATAL
 Monitor fluid balance
 Firs 24-72 hr significant fluid shift occur,can lead to CHF
 Look for complication:
PPH
Anemia,
Infection, and
Thromboembolism
 Rapid injection of oxytocin not to be given : can cause
significant hypotension
 Early assisted ambulation
 Formulate effective contraception plan
 WHO CLASSIFICATION OF RISK FROM CONTRACEPTIVE USE
& PREGNANCY IN CARDIOVASCULAR DISEASE
Risk for contraceptive method by
WHO class cardiac condition
WHO 1 Always No higher than general population
useable
WHO 2 Broadly Small increased; advantages generally
useable outweigh risks
WHO 3 Caution in Usually outweigh advantages. Other
use methods preferable. Exceptions if:
1. Patient accepts risks and rejects
alternatives
2. Risk of pregnancy very high and
other methods less effective
WHO 4 Do not use Method contraindicated:
unacceptable health risk
Heart. 2006 October; 92(10): 1520–1525.
Pregnancy risk by cardiac
condition
No higher than general
population
Small increased maternal
mortality and morbidity
Significant increased maternal
mortality and morbidity. Expert
cardiac and obstetric care
Pregnancy contraindicated: very
high risk of maternal mortality or
morbidity. Discuss termination .
 U.S. Medical Eligibility Criteria for
Contraceptive Use, 2010
Ischemic heart PPCM (NYHA PPCM
Valvular heart disease disease I,II) (NYHAIII,IV)
Uncomplicated Complicated

COC/P/R Initia. Cont. <6mt >6mth 4

2 4
4 4 4 4

POP 1 1 2 3 1 1 2
DMPA 1 1 3 3 1 1 2
Implants 1 1 2 3 1 1 2

LNG-IUD 1 1(2 in WHO) 2 3 2 2 2

Cu-IUD 1 1(2 in WHO) 1 2 2 2

Barrier 1 1 1
VALVULAR
HEART
DISEASES
 MITRAL STENOSIS
 Rheumatic etiology in 75%

 Normal adult mitral valve area =4-6cm2

 Mild MS:1.5-2CM2
 Mod MS:1-1.5CM2
 Severe MS:<1cm2, LAP of >25 mm Hg is required to maintain CO

Management
 Limit physical activity
 Restrict dietary sodium ,start diuretic
 β1-blocker if PAH
 New-onset AF, I.V.verapamil, 5 to 10 mg, or electrocardioversion
 For chronic fibrillation, digoxin, a -blocker, or CCB
 MITRAL STENOSIS
Maternal mortality MS: 0-3% Lesniak-Sobelga A et al, Int J Cardiol 2004;94:15–23.
Fetal complications:Prematurity :20–30%,
IUGR 5–20% (more common with MVA<1.0 cm2)
Stillbirth:1–3% Hameed A et al.J Am Coll Cardiol 2001;37:893–899
.

•Maternal complications(~35%)
Pulmonary edema , 25% cardiac failure 1st time during pregnancy
Thromboembolism
Heart failure in 43 %
Arrhythmias in 20 %
PAH Hameed A et alJ Am Coll Cardiol 37:893,2001
•Increased risk of complications – MVA<2cm2
•Intervention in pregnancy if despite optimal medical treatment,
NYHA class III/IV and/or systolic PAP >50 mmHg at echo
ESC guidelines Eur Heart J 2007;28:230–268.
 SURGICAL PROCEDURES
Mitral commissurotomy
Open
Fetal mortality of 20-30%
Closed
Fetal mortality2-12%:procedure of choice during pregnancy

Percutaneous mitral valvuloplasty

Replaced surgery
Good haemo-dynamic results
Not commonly available in developing countries
5% risk of MR
Relative contraindications : LA thrombus and significant MR

Perinatal mortality : 33% (open repair) vs 5%(Percutaneous valvuloplasty)

Similar functional outcome
de Souza et al J Am Coll Cardiol 2001;37:144-152. 46.
 MITRAL INSUFFICIENCY
Chronic MR
RHD ,MVP Acute MR
LV dilatation of any etiology(e.g. DCMP) Calcified Rupture of chorda tendineae
mitral annulus Infarction of papillary muscle
Ischemic heart disease Leaflet perforation from infective
MVvegetations— Libman-Sacks endocarditis( endocarditis.
APLAS,SLE)

 Well tolerated, decreased SVR : less regurgitation

 Heart failure: rarely develops
 Maternal morbidity: IE
Arrhythmias
 Surgery needed when
 Ruptured chordae tendinae
 Acute severe worsening of MR
 When surgery required repair preferred to replacement
 LVEF<50%.
 LV end-systolic dimension >55mm.
 AORTIC STENOSIS
 Disease of aging, in younger <30 yrs,most likely congenital lesion.
 Asymptomatic until valve area<1/3 of original size or< 1 cm2.
Silversides CK et alCan J Cardiol 2010;26:e80 –97

 Complication : Heart failure (10%)

Sudden death from arrhythmias(3-25%) Yap SC. Int J Cardiol 2008;126:240–246
 Elective repair if :Symptomatic, gradients ≥30 mm Hg or
Asymptomatic with LVEF< 50%
Bicuspid aortic valve aortic diameter is >50 mm
Valve area <0.8cm2 John AS,.Ann Thorac Surg 2011;91:1191–6

 MANAGEMENT:
 Avoid decreased preload and maintenance CO: Manage on “wet” side
 Mild to moderate : well tolerated, close observation
 Symptomatic : limitation of activity & prompt treatment of infections
 AORTIC INSUFFICIENCY
CHRONIC ACUTE
RHD Bacterial endocarditis
connective-tissue abnormalities Aortic dissection
congenital lesions.
Marfan syndrome, aortic root dilate
 Appetite suppressants fenfluramine and
dexfenfluramine and to ergotderived
 dopamine agonists
 With chronic disease: LV hypertrophy and Dilatation
 Well tolerated during pregnancy
Diminished SVR: Improve lesion
 Symptoms of heart failure develop: Diuretics and bed rest
 Surgery
• Severe regurgitation.
• Left ventricular ejection fraction <50%.
• Left ventricular end-systolic dimension >55mm.
Severity of Valve Disease in
Adults- ACC/AHA 2006
 PREGNANCY AFTER VALVE
REPLACEMENT
Porcine tissue valves :
Safer
Thrombosis : rare
Valvular dysfunction, deterioration, or failure common(5 to 25 %)
Less durable, and valve replacement averages 10 to 15 yrs
Pregnancy :not accelerate rate of degeneration
Elkayam U et al, J Am Coll Cardiol 46:403, 2005on
Mechanical valves :Thromboembolism of prosthesis and
Haemorrhage from anticoagulation

(7%) (19%)
(3.4%) (7%)
(3%)
(2.4%)
(12%)
 ANTICOAGULATION
 Recommended in
Mechanical heart valves,
AF(3 wk before cardioversion≥ 48 h duration, duration unknown)
Pulmonary hypertension
RHD-MV & normal sinus rhythm with LA diameter > 55 mm,
(target INR, 2.5; range, 2.0-3.0)
 Oral anticoagulation: safest approach for mother
Sillesen. Eur J Cardiothorac Surg2011;40:448–454.

 Warfarin throughout pregnancy till 36wks (3.9% trombosis)

Older generation prosthesis(mitral ): starr edwards and Bjork- Shiley ,
H/o thromboembolism

Bates Sm et al.the Seventh ACCP Conference Chest 2004;126(suppl):627S– 44S

 Options for Anticoagulation With
Mechanical Heart Valves in Pregnancy
Drug Regimens Dosing Monitoring Test Target Goal Thrombo Death
sis
UFH Begin at aPTT or >2 times control 33% 15%
throughout 17,500-20,000 Anti-Factor Xa 0.35-0.70U/ml
pregnancy U q12h level 4-6 hr after
injection
LMWH Begin with Antifactor Xa 1.0–1.2 units/mL, 9%
throughout 1mg/kg level 4hr after 4–6 h after
Pregnancy enoxaparinq12 dose injection
h
UFH or LMWH Heparin q12h Same as above Same as above for 9.2% 4%
in 1st tri and Warfarin daily for heparins; INR heparins; INR of
again at 35–36 for warfarin 3.0 (2.5–3.5)
wk, warfarin for warfarin
from 14-36 wk
Lack of well designed trials does not allow
Aspirin added 75-100 mg
identification ofNone
one approach as clearly superior to
to all above daily
others Bates Sm et al.the Seventh ACCP Conference on
Antithrombotic and Thrombolytic TherapyChest 2004;126(suppl):627S– 44S
 COMPARISON OF DIFFERENT
ANTICOAGULANT
Advantage
UFH(Category C) •Safe for fetus
LMWH(Category C) •More predictable therapeutic
effect
•Low risk of bleeding complication
•Lower risk of osteoporosis and
thrombocytopenia
Warfarin (Category D) •Currently safest and most
efficacious regimen to prevent
thromboembolic events
MMR: Warfarin usage - 1.8%
Heparin usage - 4.2%
Chan WS. Arch Intern Med
2000;160:191–196.
Disadvantage
•Increase incidence of valve
thrombosis than warfarin
•Osteoporosis
•Trombocytopenia
•Increase incidence of valve
thrombosis than warfarin
•No antidote available
•Increased fetal risk, both early
and late(warfarin
embryopathy)
•Increased risk of abortions
•Fetal anticoagulation and
bleeding , particularly if taken
within 2 wk of labour
 WARFARIN EMBRYOPATHY OR FETAL
WARFARIN SYNDROME
 6-9 wk
Risk of embryopathy lower if dose of warfarin ≤ 5 mg/day
 Embryopathy 0-10 %, and spontaneous abortion 72 %
Schaefer C,.Thromb Haemost 2006;95:949–957.

 Classical features Rare malformations

Nasal hypoplasia described
Chondrodysplasia punctata (epiphysealDandy Walker
and vertebral bone stippling) malformation
• Common malformations Holoprosencephaly
Situs inversus
Cleft lip and (or) palate
Coarctation of aorta
Choanal stenosis/atresia Gastroschisis
Malformed ears
Urinary tract anomalies
 Epiphyseal
stippling

Depressed nasal bridge

Flat upturned nose
Absent nasal bones
THROMBOSIS OF PROSTHETIC HEART
VALVES DURING PREGNANCY
 Risk 6 fold - pregnancy,11 fold -puerperium

 Greater for older-generation prosthetic valves in mitral position

- Bjork- Shiley tilting disc as compared with St. Jude valve

 Mortality rates : 10% - 40%

 C/F:dyspnoea and/or an embolic event

 Investigation: Transthoracic echoc

Transoesophageal echoc
Fluoroscopy with limited fetal risk
 TREATMENT OF VALVE THROMBOSIS
 Right-sided prosthetic valve thrombosis
In absence of contraindications fibrinolytic therapy preferred over
surgical intervention

 Left-sided PVT & large thrombus area(0.8 cm 2 )

Early surgery over fibrinolytic therapy
If contraindications to surgery :fibrinolytic therapy

 Left-sided PVT and small thrombus area ( , 0.8 cm 2 )

Fibrinolytic therapy over surgery
IV UFH accompanied by serial Doppler echocardiography to
document thrombus resolution or improvement
ACCP2012 Guidelines.Chest 2012;141;7S-47S
INTRAPARTUM AND POST PARTUM ANTECOAGULATION

 I.V. UFH agent of choice during intrapartum period

 As can be easily adjusted
 Discontinue 4–6 hours before regional anesthesia and
delivery
 In absence of contraindication, restart heparin
postpartum:6–12 hours after VD
12–24 hours after CS
 Warfarin start night after delivery if no bleeding
complications
 Overlap heparin until an INR ≥ 2
Bates SM. Chest 2004;126(suppl):627S– 44S
 CARDIAC SURGERY IN MOTHER DURING
PREGNANCY
 MMR with cardiopulmonary bypass :1.5 -5%(similar to nonpregnant
women)
 Foetal mortality rate:20% Sutton SW et al. Perfusion 20:359, 2005
 Best period: 13th to 28th week
 Only when :Medical therapy or interventional procedures fail
Mother’s life threatened
 Cardiopulmonary bypass: hamper uteroplacental perfusion -complement
activation, particulate and air embolism, non-pulsatile flow, hypotension,
hypothermia
 Hypothermia -uterine contractions, coagulation disorders, arrhythmias.
 To decrease complication
Pump flow rate>2.5L/min/m2,
Normothermic perfusion pressure>70mmHg,pulsatile flow
Hematocrit >28% Chandrasekhar S et al Anesth Analg 108:777, 2009
 CONGENITAL HEART DISEASE
Incidence : 8 per 1000 live born infants
Morbidity depends on individual lesion
Complication : 20 % mothers and
30 % neonates Khairy P et al:Circulation 113:517, 2006

Most common :bicuspid aortic valve

Cyanotic Acyanotic
Tetralogy of Fallot(M.C.) ASD(2nd M.C.)
Transposition of the great AV canal
arteries VSD
Single ventricle PDA
Truncus arteriosus Coarctation of the aorta
TAPVC Congenitally corrected L-TGA
Ebstein’s anomaly AS
Eisenmenger’s disease PS
 ATRIAL SEPTAL DEFECT
 1/1500 live births(women > men)
 3 types: Secundum 75%
Primum 15%
Sinus Venosus 10%
Cor Sinus
 Treatment options:
 Percutaneous Closure
 Only for secundum (contra. in others)
 Adequate superior/inferior rim around ASD
 No R-L shunting
 Surgical Closure
Good prognosis:
 Closure age < 25, PA pressure <40
 If >25 or PA>40, decreased survival due to CHF, stroke
 Maternal complications:
PAH
Eisenmengers syndrome
Supraventricular arrythmias
RVF
Paradoxical thrombi
 ATRIAL SEPTAL DEFECT
 Well tolerated in absence of PAH
 Prepregnancy :
Evaluate for closure,
Look for secondary complications,
Discourage pregnancy if significant PAH
 Prenatal, Labour and delivery:
Routine care in absence of supraventricular arrythmias ,PAH
Generally well tolerated,
Monitor for arrythmia,BP
Restrict fluid
 Postnatal
Routine in absence of secondary complication
Ambulation to decrease risk of DVT and paradoxical embolisation
VENTICULAR SEPTAL DEFECT
 Uncommon in adults

 Small defect close spontaneously or corrected in childhood(90%)

 Maternal morbidity related to size of VSD and PAH

 Most – paramembranous

 Defects < 1.25 cm2 :PAH and heart failure rare

 Defect size> AV orifice – symptoms develop rapidly

 Pregnancy well tolerated: small- mod shunts

 Poor prognosis

Pulmonary hypertension

Eissenmenger
VENTICULAR SEPTAL DEFECT
 Prepregnancy:
Evaluate for PAH, consider repair its absence
Counsel about risk of heart disease in fetus(10-16%)
 Prenatal:
Follow with serial echo(size of defect ,degree of shunt, PAH)
Offer termination in patient with PAH
 Labour and delivery:
Avoid hypotension to prevent shunt reversal
 Posatnatal :
Encourage ambulation to avoid risk of DVT and paradoxical
embolisation
No contraceptive restriction in absence of PAH
 TETRALOGY OF FALLOT

 4 features
 VSD
 Overriding Aorta
 Pulmonic Stenosis
 RVH
 Corrected TOF well tolerated only arrhythmia reported
 Pulmonary regurgitation:70% to 85% of patients
 Uncorrected TOF: pregnancy increases L R shunting,MMR:25-50%
 High risk factors
– Pre pregnancy hct > 65%, pregnancy wastage – 100%
– History of CHF
– Cardiomegaly
– RV pressure >120mmhg
– Strain pattern on ECG
– Oxygen saturation <80% Obs and Gynae clinic of N A2004
 TETROLOGY OF FALLOT
Fetal outcome
 Uncorrected TOF :increased spontaneous abortion
 Live birth rate : 40%
PRENATAL
 After correction, patients with PR: monitor for arrhythmias and right heart failure
 Uncorrected :offer termination.
Pregnancy : Monitor hematocrit
Supplemental O2
Serial obstetric USG to monitor for IUGR
LABOR ,DELIVERY and POSTNATAL
 Uncorrected : careful fluid management and maintain BP
 Treat hypotension to prevented shunt reversal
 Reliable contraceptive plan, with permanent sterilization
 All reversible contraception : category 1 or 2 in patients with corrected and
uncomplicated TOF
 PULMONARY HYPERTENSION
 Mean pulmonary artery pressure >25 mm Hg
Hatano S et al WHO; 1975.
 Maternal mortality 30-50% Bedard E et al Eur Heart J 2009;30:256–265.

 Incidence 1.6/1,00,000 deliveries

 Pregnancy with severe PAH: offer termination and consider sterilization
 Diagnosis:Diagnose cautiously
 Cardiac catheterization:gold standard
 In nonpregnant good correlation in cardiac catheterization and
echo-derived pressures
 In pregnancy echo PAP overestimated, with ~1/3rd elevated
pressures normal on catheterization
 Factors associated with poor outcome
• Late diagnosis and late admission
• Lack of improvement in SaO2 with oxygen
Bedard E, et al.Eur Heart J 2009;30:256–265.
 PAH PRENATAL
 Early 3rd trimester,
 In-hospital bedrest with O2 therapy (FIO2 of 0.4)
 Digoxin :concomitant intermittent or chronic AF
 Diuretic with signs of RV failure and fluid retention
 CCB use reported, improvement in CO, Nifedipine 90 -120 mg daily
Sitbon O. Circulation 2005;111: 3105–3111
 Initiate early thromboembolism prophylaxis
 With severe disease,
Chest pain full anticoagulation
Oxygen saturation <80%
 Newer drugs: prostacyclin analogues, phosphodiesterase inhibitors, sildenafil
(Viagra), inhaled NO, endothelin-receptor antagonists (e.g., bosentan )
Barst RJ. N Engl J Med 1996;334:296–302
 PAH INTRAPARTUM
 Majority delivered preterm :Grave risk to mother and
25% of babies with IUGR
 Oxygen supplementation 5 to 6 L/min
 Radial artery line to allow continuous BP monitoring and
blood gas sampling
 Adequate preload to maintain cardiac output.
 Maintain stable BP, moniter blood loss carefully
 Maternal mortality 25% in vaginal delivery and
22% in cesarean section
 Cesarean rate ~60%
 PAH POSTNATAL
 Thromboembolism prophylaxis and oxygen therapy

 Excessive blood loss or right-sided heart failure as a result of fluid shifts

can lead to sudden death.

 Wean NO slowly

 If prostacyclin used, longterm therapy can continue, through a central

venous catheter

 Controlled diuresis

 Depo-Provera or progesterone implants may be considered

 COC and standard IUDs should be avoided

 EISENMENGER’S SYNDROME
 Maternal mortality 20–50%, occurring most peri- or post-partum period
Presbitero P et al.Circulation 1994;89:2673–2676.

 15-year survival rate is >75% in nonpregnant

 Cesarean delivery greater risk, mortality rates ~70%.
 Fetal complication
IUGR common
SaO2<85%, with a live birth unlikely(<12%)
Early miscarriage
Preterm delivery ,up to 85% of pregnancies
 Neonatal survival rate of babies alive at birth ~ 90%.
 Discourage pregnancy ,offer permanent sterilization
 Even first-trimester termination: MMR of 5% to 10%.
 PRIPARTUM CARDIOMYOPATHY
 Noted as early as 1800s, but first attributed to cardiomyopathy by Gouley
and colleagues in 1937
Gouley BA et al Am J Med Sci 1937;19:185–99
 Incidence: vary by geographic location 1:15,000 pregnancies(US)
1:299(a well-studied population in Haiti)
1:100 (a small region of sub-Saharan Africa) Mayosi B.Heart 2007;93:1176–83
 Risk factors: Hypertension
Preeclampsia
Multiparity
Multiple gestations
African descent
Older maternal age
Prolactin
 Mortality :25–50% majority within few months of delivery.
Mayosi B.. Heart 2007;93:1176–83.
 Cardiac transplantation eventually necessary in 10%
Amos AM. Am Heart J 2006;152:509–13.
 CLINICAL CRITERIA FOR THE
DIAGNOSIS OF PPCM
 Development of cardiac failure in last month of pregnancy or within 5
months post partum
 Absence of another identifiable cause for cardiac failure
 Absence of recognizable heart disease before last month of
pregnancy
 LV systolic dysfunction shown by echo data such as depressed
shortening fraction
EF<45%, OR
M-mode fractional shortening <30%, or both, AND
LV end-diastolic dimension of >2.7 cm/m2
Pearson GD et al.(National Institutes of Health)JAMA 283:1183, 2000

Diagnosis of exclusion , should be suspected in

women presenting with symptoms of heart failure
during peripartum period
 PPCM
 Recovery: 28% (75% took>12 months to attain this)
Fett JD et al.Int J Obstet Gynecol 104:125, 2009
 Findings at initial presentation predicting persistent dysfunction
Fractional shortening <20%,
Left end-diastolic dimension > 6 cm
Left end-systolic dimension >5.5 cm
EF< 27%, and Chapa JB et al. Obstet Gynecol 2005;105:1303–8

LV thrombus Goland S et al.J Card Fail 2009;15:645–50

 Recurrence: Depends on LV function at start of pregnancy

EF RECURRENC
<45% 66.7%
<55% 46.2%
>55% 17% Elkayam U et al. N Engl J Med 2001;344:1567–71
 Offer termination who have persistent echo abnormalities
 PPCM
Pre pregnancy
 With normal cardiac function, pregnancy less contraindicated
 Inform potential for worsening cardiac function in pregnancy
Prenatal
 Echo to document ventricular size and function, mural thrombi
 Decreased activity, along with salt restriction
 Use diuretics, digoxin, and afterload reduction with hydralazine
 Prophylactic heparin
Postnatal
 ACE inhibitor for afterload reduction
 Endomyocardial biopsy :exclude treatable causes of
cardiomyopathy
Should not be performed routinely
Cooper LT.ESC.Eur Heart J 2007;28:3076–93
 MITRAL VALVE PROLAPSE
 Most common in women of reproductive age, prevalence 17%
 0.5-3% in general population
 Increase LV volume decrease prolapse
 Disappear in pregnancy in significant number
 C/F:palpitation,arrythmia,chest pain,syncope,fatigue,panic attacks
 O/E:midsystolic click, ± midsystolic to late systolic murmur
 Diagnosis : Echo MV prolapsing into LA ≥2mm on long axis view
 Complication:
Rare in reproductive age women,@0.2%/yr
Severe MR, IE, cerebral ischemia, sudden death
 Prenatal, labour , delivery and postpartum:
Observe for arrythmias,
Avoid caffeine, alcohol,tobacco,β mimetics
Use β blocker in symptomatic patient
 COARCTATION OF AORTA
 Untreated :poor prognosis and uncommon
 Corrected, maternal and fetal outcomes not significantly different
 Aanomalies associated :Bicuspid AV most common(20% -40% )
Cerebral artery Aneurysms(10%),
PDA,ASD,VSD and Turner syndrome
 Hypertensive disorders of pregnancy common >15%
 Major complications :CHF after long-standing hypertension
Bacterial endocarditis of bicuspid aortic valve
Aortic rupture or dissection more late pregnancy or early postpartum
Cerebral hemorrhage from circle of Willis aneurysms
 Maternal mortality rate:3%
 LABOUR DELIVERY AND POSTNATAL
Controle HTN in both intrapartum and postpartum periods
Decreases SVR
 MARFAN’S SYNDROME
 AD trait, high degree of penetrance
 Incidence: 2 to 3 per 10,000 ,no racial or ethnic predilection
Ammash NM et al Curr Probl Cardiol 33:7, 2008

 Mutations in fibrillin gene on chromosome 15q21 Dietz HC.Genomics 1991;9:355–61.

 Cardiac Complication
Progressive aortic dilatation :aortic insufficiency,MVP
Infective endocarditis
Dissecting aneurysm(most serious)
 Prognosis :aortic root diameter
 Risk of Dissection or rupture
 Aortic root diameter >4 cm : >10%
 Aortic root diameter < 4cm : <1%
 Use β blockers: reduce pulsatile pressure on aortic wall
 Surgical repair recommended in nonpregnant
Symptomatic or aortic root dimension ≥4.5cm
Rrapidly dilating aorta ≥0.5 cm/yr,
Elefteriades JA. J Thorac Cardiovasc Surg 2010;140:S5–9
 CARDIAC ARRHYTHMIAS
 Common in pregnancy
 Most are benign: sinus bradycardia & tachycardia, atrial and ventricular
premature contractions
 May exacerbate pre-existing arrhythmias because of increased
catecholamines and adrenergic receptor sensitivity
 Healthy, asymptomatic patients without underlying pathology: reassurance,
observation, and rest
 Supraventricular tachycardia often seen in pregnancy: vagal manoeuvres
or, if fails, i.v. adenosine
 AF: usually associated with underlying cardiac disease
 Any arrhythmias: cardiac decompensation can occur
 Recurrence
 Atrial arrhythmias 50%,
 Ventricular arrhythmias 25% Silversides CK. Am J Cardiol 97:1206, 2006
 MYOCARDIAL INFARCTION
 Iincidence of peripartum MI :1.1 per 100,000 deliveries
MacArthur A et al .Am J Obstet Gynecol 194:1027, 2006
 Approximately 20% during labor
40% Intrapartum
40% Postpartum
 Maternal mortality : 5% to 8% James AH et al.Circulation 113:1564, 2006
 Mortality approximately 20% in peripartum period
 Prematurity:43% in patients with antenatal MI
 Risk factors :increasing age, chronic hypertension, DM, HTN,
thrombophilia, and postpartum infection
 Diagnosis a challenge
Index of suspicion low
Physiologic changes of pregnancy may mimic S/S of MI
MYOCARDIAL INFARCTION
Prenatal
 Monitor for arrhythmias or CHF
 Management similar to nonpregnant patients
 Thrombolytic therapy relative C/I(risk of maternal and fetal
bleeding)
Labor and Delivery
 VD relatively safe in h/o MI
 CS: Obstetric indications ,MI in close proximity to labor or
unstable
 External cardiac monitoring necessary
 CARDIAC ARREST
 Frequency 1:20 000. Lewis G, CEMACH. 2007.
 CPR proceeds with modifications
 30 degree left lateral tilt
 Manual left uterine displacement in supine position
 Bag-mask ventilation with 100% oxygen before intubation
 Early intubation ,as increased risk of aspiration
 Chest compressions :just above mid sterum
 No change in recommendations for defibrillation
 Resuscitation unsuccessful, perimortem CS indicated
Life-saving for viable fetus, and
Improved effectiveness of resuscitation
 Consider at 4 minutes after onset of cardiac arrest if no return of
spontaneous circulation
 Optimal maternal and neonatal outcomes :delivery occurs within 5 min
AHA2010.Circulation. 2010;122:S829-S861
 Effects of cardiac drugs
Drugs Class FDA Placenta Transfer to Adverse
cat permeable breast effects
milk

Cephalosporin Antibiotics B Yes Yes No fetal adverse effects

Erythromycin reported
Penicillin
Digoxin Cardiac C Yes Yes Serum levels unreliable,
glycoside safe.
Diltiazem CCB C No Yes Possible teratogenic effects
(class IV)

Enalapril ACE inhibitor D Yes Yes(maximum Renal or tubular dysplasia,

1.6%) oligoamnion,
IUGR, ossification disorders
of skull, lung hypoplasia,
contractures, large
joints, anaemia, IUD

Hydralazine Vasodilator C Yes Yese(maximum Maternal side effect: lupus-

1%) like symptoms;
fetal tachyarrhythmias
 Effects of cardiac drugs
Drugs Class FDA Placenta Transfer to breast Adverse
cat permeable milk effects
Furosemide Diuretic C Yes Well tolerated; Oligoamnios
reduce milk
production

Glyceryl Nitrate B Unknown Unknown Bradycardia, tocolytic

trinitrate
LMWH Anticoagulant B No No

UFH Anticoagulant B No No Long-term:

osteoporosis and
thrombocytopenia

Labetalol α-/ β-blocker C Yes Yes IUGR

(2nd and 3rd
trimester), neonatal
bradycardia and
hypotension
Drugs
Effects of cardiac drugs
Class FDA Placenta Transfer to breast Adverse effects
cat permeable milk
Warfarin Vitamin K D Yes Yes (maximum Coumarin-
antagonist 10%), well embryopathy ,
tolerated as bleeding
inactive
Metabolite
Statins Lipid- X Yes Unknown Congenital anomalies
lowering
drugs
Nifedipine CCB C Yes Yes (maximum Tocolytic ;
1.8%) synergism with MgSO4
may induce
hypotension (mother)
and foetal hypoxia

Methyldopa Central α- B Yes Yes Mild neonatal

agonist hypotension
 Effects of cardiac drugs
Drugs Class FDA Placenta Transfer to Adverse effects
cat permeable breast
milk
Atenolol β-blocker D Yes Yes Hypospadias (1st
(class II) trimester); birth
defects,LBW,
bradycardia and
hypoglycaemia in fetus
(2nd and
3rd trimester).

Metoprolol β-blocker C Yes Yes Bradycardia and

(class II) hypoglycaemia in fetus.

Verapamil i.v. Calcium C Yes Yes may be associated

channel with a greater risk of
blocker hypotension and
(class IV) subsequent fetal
hypoperfusion.
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