Cardiac Disease In Pregnancy

Introduction

Cardiac disease in pregnancy is a rare but potentially serious clinical entity. It occurs in about 1% of all pregnancies.
Incidence and prevalence of all heart disease varies from place to place.
Rheumatic heart disease is more
commonly found in less affluent societies
while congenital heart disease now
accounts for approximately 50% of
cardiac diseases in pregnancy in the UK.

Types

Acquired

Rheumatic heart diseases

  • Mitral > Aortic > Tricuspid > Pulmonary Cardiomyopathies
  • Particularly peripartum cardiomyopathy which could be either congestive or obstructive
  • Pre-existing hypertensive heart disease
  • Ischaemic heart disease

Congenital

Acyanotic heart disease

  • Atrial septal defect, ventricular septal defect, patent ductus arteriosus, etc.

Cyanotic heart disease

  • Tetralogy of Fallot, Eisenmenger’s
    syndrome,
  • Acquired forms of cardiac disease appear to be more lethal in
    association with pregnancy, in women aged 25 years or more, and in third or later pregnancies
  • Congenital malformations are more
    prevalent in younger women and in those of llower parity

Clinical features

Severity of heart disease in pregnancy: The New York Heart Association Guidelines (1965) is used. This relies on the cardiac response to physical activity; it may not bear any relationship to the extent of the lesion present

Class 1

  • No limitation of physical activity

Class 2

  • Slight to moderate limitation of physical activity: ordinary day-to-day activities

cause dyspnoea

Class 3

  • Marked limitation of activity.
  • Minimal exertion causes dyspnoea

Class 4

  • Symptoms at rest; unable to carry out any physical activity without dyspnoea; orthopnoea may be present

Other symptoms

  • Palpitations
  • Nasal stuffiness
  • Dizziness; light headedness; syncope
  • Epigastric or sub-xiphoid pain; bloating, heartburn
  • Heat intolerance, sweating and flushing

Signs

  • Plethoric facies
  • Odema (legs; occasionally hands and face)
  • Varicoseveins
  • Bounding pulses and capillary
    pulsations.
  • Capillary telangiectasia.
  • Prominent jugular venous
    pulsations.
  • Lateral displacement of cardiac
    apex.
  • Sinus tachycardia; ectopic beats
  • Third heart sound
  • Widely split S and S heart sounds 1
  • Murmurs.
  • Crepitations

Investigations

  • Full Blood Count
  • Serum Electrolytes, Urea and Creatinine
  • Urinalysis
  • Blood Glucose
  • Bedside crude clotting time
  • Echocardiography (Doppler)
  • Electrocardiography
  • Serial blood cultures (if infective endocarditis is suspected)
  • Chest radiograph is better avoided in pregnancy

Management

Pre-pregnancy

  • Fully evaluate patient in conjunction with a cardiologist
  • Surgically correct any defect that is amenable
  • Counsel on the following points:
    • Risk of maternal death
    • Possible reduction of maternal life expectancy
    • Risk of fetus developing congenital heart disease; fetal growth restriction
    • Possibility of pre-term labour
    • Need for frequent hospital attendance; possible admission
    • Need for intensive maternal and fetal monitoring in labour

Antenatal Care

  • Joint management with the cardiologist
  • Extreme vigilance: most features of cardiac failure are present in pregnancy
  • Watch out for respiratory tract infection or urinary tract infection and treat aggressively
  • Watch out for anaemia, obesity and
    multiple gestations for intensive care.
  • Intensive care also required when other medical or psychological conditions co-exist.

Examination:

  • Ankle and sacral edema
  • Pulse rate and rhythm
  • Blood pressure
  • Jugular venous pressure
  • Basal crepitations
  • Symphysio-fundal height (SFH) measurement.
  • Competent dental care:
    • Full inspection
    • Advise on oral hygiene
    • Dental treatment e.g. tooth extraction should be done under antibiotic cover to prevent infective endocarditis
  • Admission
    • Individualised; usually when
      complications or intercurrent illnesses occur

Supportive measures

Elastic stockings or tights to prevent pooling of blood in the veins of the lower limb

  • Indicated, for example, in patients with congenital heart disease, with pulmonary hypertension; artificial valve: replacements; those with atrial fibrillation

Termination of pregnancy and sterilization

  • Best option in severe debilitating cases

Congestive Cardiac Failure

Manage as if non-pregnant (in conjunction with a cardiologist)
Fetal surveillance:

  • Ultrasound scan particularly for cardiac anomaly at 22 weeks
  • Delivery:
    • Either for maternal or fetal indications.
  • Cardiac surgery in pregnancy if indicated
  • Management of labour in women with cardiac disease
    • Avoid induction of labour if possible
  • Prophylactic antibiotics to prevent bacterial endocarditis
  • Careful fluid balance
  • Avoid the supine position
  • Epidural anaesthesia by a senior anaesthetist
  • Shorten 2 stage with low cavity forceps delivery
  • Oxytocin for third stage; ergometrine is contraindicated
  • Oxygen should be available and used if needed

Complications

Maternal

  • Mortality:
    • 25-50% in Eisenmenger’s syndrome;
    • 5% in tetralogy of Fallot;
    • 1% in rheumatic heart disease
  • Congestive cardiac failure: Greatest risk in the immediate postpartum period

Fetal

  • Rheumatic heart disease:
  • Intrauterine growth restriction;
    pre-term delivery
  • Cyanotic congenital heart disease:
  • Poor outcomes; up 40% fetal loss
  • Uncorrected coarctation of aorta:
  • Fetal growth restriction in > 10% of cases
  • Pre-maturity
  • Small for gestation age
  • Intrauterine growth restriction
  • Intrauterine fetal death
  • 10-15% chance of baby having congenital heart disease