Heart disease with pregnancy
Heart disease
Prepregnancy counselling
Most women with heart disease will be aware of their condition prior to
becoming pregnant. Ideally, these women should be fully assessed by an
obstetrician and cardiologist before embarking on a pregnancy and the
maternal and fetal risks carefully explained. A plan to optimize
medication should be made and if there is a possibility that the heart
disease will require surgical correction, it is recommended that this
should be undertaken before a pregnancy.
Issues which should be discussed are:
هs in art disease
• Risk of maternal death.
• Possible reduction of maternal life expectancy.
• Effects of pregnancy on cardiac disease.
• Mortality associated with high-risk conditions.
• Risk of fetus developing congenital heart disease.
• Risk of preterm labour and FGR.
• Need for frequent hospital attendance and possible admission.
• Intensive maternal and fetal monitoring during labour.
• Other options – contraception, adoption, surrogacy.
Timing of pregnancy.
Antenatal management
Experienced physicians and obstetricians should manage pregnant
women with significant heart disease , it is important to ask the pregnant
woman if she has noted any breathlessness, particularly at night, any
change in her heart rate or rhythm, any increased tiredness or a reduction
in exercise tolerance . Routine physical examination should include pulse
rate, blood pressure, jugular venous pressure, heart sounds, ankle and
sacral oedema and presence of basal crepitations. An echocardiogram at
the booking visit and at around 28 weeks’ gestation is usual.
Anticoagulation is essential in patients with congenital heart disease who
have pulmonary hypertension (PH) or artificial valve replacements, and
in those in or at risk of atrial fibrillation
Stages of heart failure – New York Heart Association
(NYHA) classification
Class Patient symptoms
1 Mild No limitation of physical activity. Ordinary physical activity does
not precipitate fatigue, palpitations, dyspnoea, angina
2 Mild Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation or dyspnoea
3 Moderate Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes fatigue, palpitation or dyspnoea
4 Severe Unable to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency at rest.
High risk cardiac conditions:
•
Systemic ventricular dysfunction (ejection fraction <30%,
NYHA Class III– IV).
• Pulmonary hypertension.
• Cyanotic congenital heart disease.
• Aortic pathology (dilated aortic root >4 cm, Marfan syndrome).
• Ischaemic heart disease.
• Left heart obstructive lesions (aortic, mitral stenosis).
• Prosthetic heart valves (metal).
• Previous peripartum cardiomyopathy.
• Fetal risks of maternal cardiac disease
conditions
fetal risks of maternal cardiac disease
car
diac disease
Recurrence (congenital heart disease).
Maternal cyanosis (fetal hypoxia).
Iatrogenic prematurity.
FGR.
Effects of maternal drugs (teratogenesis, growth restriction, fetal loss).
Management of labour and delivery:
Avoid induction of labour if possible.
Use prophylactic antibiotics.
Ensure fluid balance.
Avoid the supine position.
Discuss regional/epidural anaesthesia/analgesia with senior anaesthetist.
Keep the second stage short.
Use Syntocinon judiciously
Treatment of heart failure in pregnancy
The development of heart failure in pregnancy is dangerous, but the
principles of treatment are the same as in the non-pregnant individual.
The woman should be admitted and the diagnosis confirmed by clinical
examination for signs of heart failure and by echocardiography
confirming ventricular dysfunction. Drug therapy may include diuretics,
vasodilators and digoxin. Oxygen and morphine may also be required.
. In all cases, assessment of fetal wellbeing is essential and should include
fetal ultrasound to assess fetal growth and regular cardiotocography
(CTG). If there is evidence of fetal compromise, premature delivery may
be considered.
Risk factors for heart failure development:
Risk factors for the
develop
Respiratory or urinary infections.
Anaemia.
Obesity.
Corticosteroids.
Tocolytics.
Multiple gestation.
Hypertension.
Arrhythmias.
Pain-related stress.
Fluid overload.
Specific conditions
Ischaemic heart disease
Most pregnant women with myocardial infarction (MI) are >40 years.
The underlying pathology is frequently dissection and it is the primary
cause in the postpartum period.
Percutaneous transluminal coronary angioplasty PTCA is now
considered acceptable but should still be only used when absolutely
necessary, avoiding the time when the fetus is most susceptible to
radiation (8–15 weeks). There is little experience with thrombolytic
therapy in pregnancy, and although not apparently teratogenic, there are
risks of fetal and maternal haemorrhage.
Mitral and aortic stenosis
They result in an inability to increase cardiac output to meet the
demands of pregnancy.
Aortic stenosis (AS) is usually congenital and mitral stenosis usually
rheumatic in origin. For those with known mitral stenosis, 40%
experience worsening symptoms in the pregnancy, with the average time
of onset of pulmonary oedema at 30 weeks. The aim of treatment is to
reduce the heart rate, achieved through bed rest, oxygen, beta-blockade
and diuretic therapy. Balloon mitral valvotomy is the treatment of choice
after delivery, but can be considered in pregnancy depending on the
clinical condition and gestation. Pregnancy is usually well tolerated in
women with isolated , mild and moderate AS
As with mitral stenosis, bed rest and medical treatment aims to reduce
the heart rate to allow time for ventricular filling. If the woman’s
condition deteriorates before delivery is feasible, surgical intervention
such as balloon or surgical aortic valvotomy can be considered, although
there is less experience and success than with mitral stenosis.
Pulmonary hypertension
PH is characterized by an increase in the pulmonary vascular resistance
resulting in an increased workload placed on the right side of the heart.
The main symptoms are fatigue, breathlessness and syncope, and clinical
signs are those of right heart failure.. Specific treatments shown to
improve symptoms and survival include endothelin blockers, such as
bosentan, and phosphodiesterase inhibitors such as sildenafil.
In women with PH, pregnancy is associated with a high risk of maternal
death. The demands of increasing blood volume and cardiac output may
not be met by an already compromised right ventricle, Women may
deteriorate early (second trimester) or in the immediate postpartum
period. Close monitoring by a multidisciplinary team is crucial as the
mortality of the condition remains high at 30–50%.
Peripartum cardiomyopathy
Peripartum cardiomyopathy (PPCM), is an uncommon form of heart
failure that happens during the last month of pregnancy or up to five
months after giving birth.
PPCM is a
form of the condition, Women who develop
peripartum cardiomyopathy are at high risk of developing the same
condition with future pregnancies
PPCM is diagnosed when the following three criteria are met:
1.
develops in the last month of pregnancy or within 5
months of delivery.
2. Heart pumping function is reduced, with an
less than 45% (typically measured by an echocardiogram)A normal
EF can be between 55 and 70.
3. No other cause for heart failure with reduced EF can be found.
Treatment is with:
•
Angiotensin converting enzyme, or ACE, inhibitors –
•
Beta blockers
•
Diuretics
•
Digitalis
•
Anticoagulants –