JUNIOR GROUP

PRESENTATION
ON
HEART DISEASE IN
PREGNANCY

SUBMITTED TO SUBMITTED BY

Mrs SMITHA MAM LOVELY TOMER

ASSISTANT PROFESSOR MSc. NSG. 2 nd YEAR

HFCON HFCON

INTRODUCTION:
Cardiac disease in the pregnant patient can present challenges in cardiovascular and maternal-
foetal management. It is important to understand that even in normal patients; pregnancy
imposes some dramatic physiologic changes upon the cardiovascular system. These include
an increase in plasma volume by 50%, an increase in resting pulse by 17%, and an increase in
cardiac output by 50%. After delivery, the heart rate normalizes within 10 days; by 3 months
postpartum, stroke volume, cardiac output, and systemic vascular resistance return to the pre-
pregnancy state. Pregnancy stresses the cardiovascular system, often worsening known heart
disorders; mild disorders may first become evident during pregnancy.

INCIDENCE AND TYPES:

The incidence of cardiac lesion is less than 1% amongst hospital deliveries. The commonest
cardiac lesion is of rheumatic origin followed by the congenital ones. The ratio between
the two has fallen over the past two decades from 10: 1 to about 3: 1 or even 1: 1 in advanced
countries. Adequate treatment of rheumatic fever by appropriate antibiotics to cope with the
group A β-haemolytic streptococcal infection, pari passu with the advancement in cardiac
surgery to rectify the congenital heart lesions, are responsible for the change in the profile.

Rheumatic valvular lesion predominantly includes mitral stenosis (80%). Predominant

congenital lesions include patent ductus arteriosus, atrial or ventricular septal defect,
pulmonary stenosis, coarctation of aorta and Fallot’s tetralogy. Rare causes are hypertensive,
thyrotoxic, syphilitic or coronary cardiac diseases.

Changes in cardiovascular dynamics during pregnancy:

In normal pregnancy the cardiovascular dynamics alter in order to meet the increased
demands of the fetoplacental unit. This increases the workload of the heart quite significantly.
The major cardiac changes to occur are:

 an increase in cardiac output by 40%

 an increase in blood volume by 35%
 A decrease in total peripheral resistance (Nolan 1990).

These changes commence in early pregnancy and gradually reach a maximum at the 30th
week, where they are maintained until term. Oestrogens and prostaglandins are thought to be
the mediators of the alterations in haemodynamic during pregnancy. These changes are
associated with several clinical signs:

 The increased cardiac output may produce a physiological systolic flow in one-third of
pregnant women.
 The heart dilates and a third heart sound is common.
 As the uterus enlarges, the heart may be displaced upwards by the growing uterus.
 During the third stage of labour 300-400 ml of blood is added to the circulating volume
by the contracting uterus.
EFFECT OF CARDIOVASCULAR PHYSIOLOGY ON HEART
LESION:
Marked hemodynamic changes in pregnancy and cardiac output in particular, have profound
effects on heart disease. A normal heart has got enough reserve power so that the extra load
can well be tackled. While a damaged heart with good reserve can even withstand the strain
but if the reserve is poor, cardiac failure occurs sooner or later. The cardiac failure occurs
during pregnancy around 30 weeks, during labour and mostly soon following delivery.
Factors responsible for cardiac failure:

(1) Advanced age

(2) Cardiac arrhythmias or left ventricular hypertrophy

(3) History of previous heart failure

(4) Appearance of “risk factors” in pregnancy is: infection, anaemia, hypertension, excessive
weight gain and multiple pregnancies.

(5) Inadequate supervision.

EFFECTS OF HEART LESION ON PREGNANCY: There is a tendency of

preterm delivery and prematurity. IUGR is quite common in cyanotic heart diseases.

PROGNOSIS

 Maternal
 Foetal

1. MATERNAL: The prognosis depends on:

(1) Nature of lesion

(2) Functional capacity of the heart

(3) Quality of medical supervision provided during pregnancy, labour and puerperium

(4) Presence of other risk factors mentioned earlier

(5) Whether patient has undergone corrective surgery or not.

Maternal mortality is lowest in rheumatic heart lesions and acyanotic group of heart
diseases—less than 1%. With elevation of pulmonary vascular resistance especially with
cyanotic heart lesions, the mortality may be raised to even 50% (Eisenmenger’s syndrome).
Most of the deaths occur due to cardiac failure and the maximum deaths occur following
birth. The other causes of death are—

(a) Pulmonary oedema

(b) Pulmonary embolism

(c) Active rheumatic carditis

(d) Sub-acute bacterial endocarditis and

(e) Rupture of cerebral aneurysm in coarctation of aorta.

However, with improved medical care, surgical correction of the congenital lesions and better
obstetric care, the maternal mortality has been reduced markedly. Pregnancy however, does
not affect the long-term survival of a woman with rheumatic heart lesion provided she
survives pregnancy itself.

2. FETAL: In rheumatic heart lesions, the foetal outcome is usually good and in no way
different from the patients without any heart lesion. However, in cyanotic group of heart
lesion, there is increased foetal loss (45%) due to abortion, IUGR and prematurity. Foetal
congenital cardiac disease is increased by 3–10% if either of the parents have
congenital lesions.

DIAGNOSIS:
 Anatomical and Physiological Changes During Pregnancy that Mimic Cardiac
Disease: 
 Hyper dynamic circulation  
 Systolic ejection murmur at left sternal border (due to increased blood flow across the
aortic and pulmonary valves)  
 Dyspnoea, decreased exercise tolerance, fatigue, syncope  
 Tachycardia, shift of ventricular apex  
 Continuous murmur at 2nd to 4th intercostal space— mammary soufflé  
 Loud first sound with splitting

 Diagnosis of Heart Disease in Pregnancy:  

 Symptoms: Breathlessness, nocturnal cough, syncope, and chest pain  
 Signs: Chest murmurs—pan systolic, late systolic, louder ejection systolic or diastolic
associated with a thrill.  
 Cardiac enlargement, arrhythmia  
 Chest radiography (using lead shield): Cardiomegaly, increased pulmonary vascular
markings, enlargement of pulmonary veins.
 Electrocardiography: T wave inversion, biatrial enlargement, dysrhythmias  
 Echocardiography (colour flow Doppler study): Structural abnormalities (ASD, VSD),
valve anatomy, valve area, function, left ventricular ejection fraction, pulmonary artery
systolic pressure  
 Cardiac MRI can delineate complex (anatomy when it is not well-evaluated by
echocardiography)

New York Heart Association (NYHA) Classification of Heart Disease

(Depending Upon the Cardiac Response to Physical Activity)

 Grade-I: Uncompromised and no limitation of physical activity

 Grade-II: Slightly compromised with slight limitation of physical activity. The patients
are comfortable at rest but ordinary physical activity causes discomfort
 Grade-III: Markedly compromised with marked limitation of activity. The patients are
comfortable at rest but discomfort occurs with less than ordinary activity
 Grade-IV: Severely compromised with discomfort even at rest
GENERAL MANAGEMENT
PRINCIPLES:

 Early diagnosis and evaluation of anatomical type and functional grade of the case.
 To detect the high risk factors and to prevent cardiac failure.
 Multidisciplinary team approach (obstetrician, cardiologist and neonatologist) and
mandatory hospital delivery.

 PRE CONCEPTION CARE & ADVICE: A woman, who knows that she has cardiac
disease, would be Wise to seek advice from both a cardiologist and an obstetrician before
becoming pregnant so that the risks of her condition can be discussed. In some cases,
preconception surgery such as mitral valvotomy may be advised. The woman should be
helped to control obesity, cut down smoking and choose a diet which will prevent
anaemia in order to minimise risk. It is advisable that family size should be limited, as the
increase with each pregnancy.

 ANTENATAL CARE: The patients with heart disease should be supervised in a

tertiary care hospital. The initial assessment should be made in consultation with a
cardiologist. Injection penidure LA-12 (benzathine penicillin) is given at intervals of 4
weeks throughout pregnancy and puerperium to prevent recurrence of rheumatic fever.
Counselling is to be done regarding prognosis and risks.

Special care in each antenatal visit is to detect and to treat the risk factors that precipitate
cardiac failure in pregnancy. Risk factors for cardiac failure are:

 Infections—Urinary tract, dental and respiratory tract.

 Anaemia
 Obesity
 Hypertension
 Arrhythmias
 Hyperthyroidism
 Drugs— Betamimetics.
 Dietary indiscretion: Excess intake of caffeine, alcohol, high calorie diet, excess salt.

 Physical care: Women with cardiac disease will require the same health and dietary
advice as other pregnant women. An important aspect of care is that of dental treatment
and antibiotic cover to eliminate sources of sepsis and reduce the risk of endocarditis. In
late pregnancy it may be advisable to restrict activity or admit the woman to hospital for
 rest and close monitoring. Obstetric management in pregnancy includes early ultrasound
examination of the foetus to confirm gestational age and detect congenital abnormality.
In those women who have cardiac disease the foetus should be monitored for the
following:
 Assessment of foetal growth and amniotic fluid volume both clinically and by ultrasound
 Monitoring the foetal heart rate by cardiotocography
 Measurement of foetal and maternal placental blood flow indices by Doppler
ultrasonography.

 Social care. With more frequent antenatal visits the midwife may need to give advice
about assistance with fares or transport to the hospital. If the mother is required to reduce
her physical activity and leave work earlier than she had planned, the midwife may need
to give advice regarding the Employment Protection Act and any DSS benefit to which
she may be entitled. If the problem is complex, referral to a social worker will be
appropriate. A woman who finds it necessary to restrict her activities in the home could
be put in contact With the home help service.

 Psychological care. Psychological support by the midwife is important during pregnancy,

particularly at times when there are intercurrent problems which may require admission to
hospital. Consideration must particularly be given to the emotional stress caused by a
woman being separated from her other children.

 ADMISSION: Elective:
 Grade–I: At least 2 weeks prior to the expected date of delivery
 Grade–II : At 28th week especially in case of unfavourable social surroundings
 Grade III and IV: As soon as pregnancy is diagnosed. The patient should be kept in the
hospital throughout pregnancy.
 Emergency:

(1) Deterioration of the functional grading

(2) Appearance of dyspnoea or cough or basal crepitation’s or tachyarrhythmia’s

(3) Appearance of any pregnancy complication like anaemia, preeclampsia.

MANAGEMENT DURING LABOR:

 PLACE OF INDUCTION: Induction is only considered safe if the benefits outweigh

the disadvantages. A failed induction leads to caesarean section and a risk of sepsis which
is especially dangerous for a damaged heart. Labour is not usually induced for
uncomplicated heart disease. If it is necessary to induce labour, the use of prostaglandins
is advocated but with caution as they are potent vasodilators and cause a marked rise in
 cardiac output. Interaction of any drugs the woman may be taking with the prostaglandin
must be considered prior to administration in case of adverse side-effects. Oxytocin by
intravenous infusion causes a degree of fluid retention and it is important for the midwife
to keep a careful record’ of fluid balance if this is used.

 LABOR:

First stage:
 Position: The patient should be in lateral recumbent position to minimize aortocaval
compression.
 Oxygen is to be administered (5–6 L/min) if required
 Analgesia in the majority, is best given by epidural
 Prophylactic antibiotics against bacterial endocarditis
 Fluids should not be infused more than 75 mL/hour to prevent pulmonary oedema.
 Careful watch of the pulse and respiration rate. If the pulse rate exceeds 110 per minute
in between uterine contractions, rapid digitalization is done by intravenous digoxin 0.5
mg.
 Cardiac monitoring and pulse oximetry can detect arrhythmias and hypoxemia early.
Central venous pressure monitoring may be needed in selected cases. Prophylactic
antibiotics for bacterial endocarditis: Antibiotic prophylaxis during labour and 48 hours
after delivery is considered appropriate. This is to prevent bacterial endocarditis. The
recommended regimens include intravenous ampicillin 2 g and gentamicin 1.5 mg/kg (not
to exceed 80 mg), at the onset or induction of labour followed by repeat doses 8 hours
interval. High risk patients are:

(a) Structural heart disease

(b) Rheumatic heart disease

(c) Cyanotic congenital heart disease

(d) Presence of dental and respiratory tract infections

(e) Hypertrophic cardiac myopathy

(f) Prosthetic heart valves

(g) Prior history of infective endocarditis

(h) Cardiac transplant

Second stage: This should be short and without undue exertion on the part of the mother.
Prolonged pushing withheld breath such as the Valsalva manoeuvre, which is undesirable for
healthy women, may be dangerous for a woman with heart disease. It raises the intrathoracic
pressure, pushes blood out of the thorax and impedes venous return, with the result that
cardiac output falls. Midwives may need to suggest to the woman that she avoids holding her
breath and follows her natural desire to push; giving several short pushes during each
contraction. In this way she will also avoid facial petechiae and subconjunctival
haemorrhages. Some doctors perform a forceps delivery electively, while others see no
reason for this if the woman is expected to deliver quickly and easily. Some midwives and
doctors advocate delivery in the left lateral position.

Third stage: Jo ergot-containing preparations should be used for the third stage of labour
(James 1989) as it causes a tonic contraction which returns 300-500 ml of blood to the venous
system. Syntocinon may be used in order to prevent haemorrhage as it has less effect on
blood vessels than ergometrine. If the woman is in heart failure, oxytocic’s should be
avoided. In the case of actual haemorrhage, Syntocinon can be given by infusion
accompanied by intravenous frusemide to prevent pulmonary oedema

PLACE OF CESAREAN SECTION: In general, there is no indication of caesarean section

for heart disease.

CARDIAC INDICATIONS OF CESAREAN DELIVERY:  

 Coarctation of aorta  
 Aortic dissection or aneurysm  
 Aortopathy with aortic root > 4 cm  
 Warfarin treatment within 2 weeks

In coarctation of aorta, elective caesarean section is indicated to prevent rupture of the aorta
or mycotic cerebral aneurysm. The anaesthesia should be given by expert anaesthetist using
either epidural (preferred) or general anaesthesia.

 PUERPERIUM:
 The patient is to be observed closely for the first 24 hours. Oxygen is administered.
Hourly pulse, BP and respiration are recorded. Diuretic may be used if there is volume
overload.
 The baby is examined very carefully for any sign of hereditary heart disease.
 Breastfeeding is not contraindicated unless there is failure. Anticoagulant therapy is not a
contraindication of breastfeeding. Drugs may be transmitted through breast milk.
 Antibiotic may continue up to 2 weeks after birth.
 When the woman has discussed the implications of future pregnancies on her condition
with the cardiologist and obstetrician, she may need help to choose a suitable method of
family spacing.
 The intrauterine contraceptive device has been associated with an increased risk of
infection which may lead to endocarditis. The combined pill increases the risk of
thromboembolism and hypertension but the progesterone-only pill and barrier methods
with spermicides are suitable alternatives. Sterilisation, if chosen, is usually delayed for
2-3 months after delivery.
 MANAGEMENT OF CARDIAC FAILURE IN PREGNANCY: The principles of
management are the same as in non pregnant state:
 Propped up position
 O2 administration
 Monitoring with ECG and pulse oximetry
 Diuretic: Frusemide (Loop) (40–80 mg) IV (anticipatory aggressive diuresis is needed
to avoid pulmonary congestion) Mechanical ventilation
 Injection morphine 15 mg IM
 Digoxin 0.5 mg IM followed by tab digoxin 0.25 mg P.O. (Digoxin crosses the placenta
and is excreted in breast milk)
 Dysrhythmias—quinidine or electrical cardio version
 Tachyarrhythmia’s—Adenosine (3–12 mg) IV or DC conversion

SPECIFIC HEART DISEASE DURING PREGNANCY AND THE

MANAGEMENT
 RHEUMATIC HEART DISEASE MITRAL STENOSIS:

 Mitral stenosis: It is the commonest heart lesion met during pregnancy. Normal mitral
valve area ranges between 4 and 6 cm2. Symptoms usually appear when stenosis narrows
this to less than 2.5 cm2. Women with mitral valve area ≤1 cm2, have the high rate of
pulmonary oedema (55%) and arrhythmia (33%). In asymptomatic cases, the mortality is
< 1% but once it is significantly symptomatic, mortality ranges between 5% and 15%.
During labour continuous epidural analgesia is ideal and intravenous fluid overload is to
be avoided.

 PLACE OF VALVOTOMY: It is better to withheld elective cardiac surgery during

pregnancy. Surgery should be considered in cases of unresponsive failure with pregnancy
beyond 12 weeks. Best time of surgery is between 14 weeks and 18 weeks. Valve
replacement, commissurotomy, balloon valvotomy can be carried out in early second
trimester. Atrial fibrillation is a complication. Digoxin, β blockers and anticoagulation
(heparin) should be used.

 AORTIC STENOSIS: Most cases of aortic stenosis are congenital, some are
rheumatic in origin. Normal aortic valve area is 3–4 cm. When it is reduced to less than or
equal to 1 cm, stenosis is significant. Maternal mortality of significant aortic stenosis is
about 15–20% with perinatal loss of about 30%. Epidural anaesthesia is contraindicated.
During labour, fluid therapy (125–150 mL/h) should not be restricted. Left ventricular
after load is high and the pregnant patient is sensitive to haemorrhage.

Common symptoms are angina, syncope and left ventricular failure. Medical management is
not helpful in a symptomatic patient. Valve replacement is the definitive treatment.
Mechanical valves need anticoagulation. Open heart surgery is preferably avoided in
pregnancy. Aortic balloon valvuloplasty may be done as a palliative procedure.
 CONGENITAL HEART DISEASE: With increasing number of surgical
correction of the congenital heart lesions from infancy to adulthood, more and more
pregnancies with congenital lesions are met in day-to-day practice. These patients pose
little problem in obstetrics. But when pregnancy occurs in uncorrected congenital lesions,
problems are very much there especially in a cyanotic group. Risk to the offspring of
congenital heart disease is high (3–13%). Major maternal risks in pregnancy are:
(i) Cyanosis
(ii) Left ventricular dysfunction
(iii) Pulmonary hypertension.

The common maternal complications are:

(i) Congestive cardiac failure

(ii) Pulmonary oedema
(iii) Arrhythmia
(iv) Hypertension.

All women should have foetal echocardiography examination at mid pregnancy.

A. Acyanotic (L to R shunt)

 Atrial Septal Defect (ASD): ASD (ostium secundum type) is the most common
congenital heart lesion during pregnancy. Even uncorrected ASD tolerates pregnancy and
labour well. Congestive cardiac failure unresponsive to medical therapy requires surgical
correction. Shunt reversal is the major risk which may develop in hypovolemia. Such
cases may occur in haemorrhagic conditions and following injudicious administration of
epidural anaesthesia. In the absence of arrhythmias, and pulmonary hypertension, ASD
does not usually complicate pregnancy.
 
 Patent Ductus Arteriosus (PDA): Presence of continuous murmur at the upper left
sternal border is suggestive of diagnosis. Most patients with PDA tolerate pregnancy well.
Pulmonary hypertension may cause maternal death. Surgical correction during pregnancy
can be performed provided there is no pulmonary hypertension. Epidural analgesia is
better avoided to minimize shunt reversal due to systemic hypotension. Foetal loss may
be up to 7% and there is 4% chance that the child of this parent will suffer from the same
abnormality. Endocarditis prophylaxis should be given.  
 Ventricular Septal Defect (VSD): In general, if the defect is less than 1.25 cm2,
pulmonary hypertension and heart failure do not develop. Pregnancy is well tolerated
with small to moderate left to right shunt or with moderate pulmonary hypertension. The
major risk is shunt reversal leading to circulatory collapse and cyanosis. Hypotension is to
be avoided. Foetal loss may be up to 20%.  
 Mitral Valve Prolapse (MVP): Is the commonest congenital valvular lesion. Most of
them are asymptomatic. Women tolerate pregnancy and labour well. Endocarditis
prophylaxis is given.

B. Cyanotic (R to L shunt)  
 Fallot’s tetralogy: It is the most common form of cyanotic heart lesion. It is a
combination of :

(a) Ventricular septal defect,

(b) Pulmonary valve stenosis,

(c) Right ventricular hypertrophy and

(d) An overriding aorta.

After surgical correction, patients tolerate pregnancy well. Surgically uncorrected patients are
at increased risk. Complications like bacterial endocarditis, brain abscess and cerebral
embolism are more common. Maternal mortality is 5–10% and the perinatal mortality is 30–
40%. IUGR is common. Systemic hypotension is dangerous which may lead even to death.
Epidural or spinal anaesthesia is avoided. Pregnancy is discouraged in women with
uncorrected tetralogy.  

 Eisenmenger’s syndrome: Patients with Eisenmenger’s syndrome have pulmonary

hypertension with shunt (right to left) through an open ductus, an atrial or ventricular
septal defect. Maternal mortality is about 50% and so also the perinatal loss (50%).
Termination of pregnancy should be seriously considered. Heparin should be used
throughout pregnancy as there is risk of systemic and pulmonary thromboembolism.
Epidural anaesthesia is contraindicated. Inhaled nitric oxide or I.V. prostacyclin is used as
a pulmonary vasodilator. To maintain hemodynamic stability, pulmonary artery catheter
and a peripheral artery catheter are used. Complications are: CCF, haemoptysis,
arrhythmia, cerebrovascular accident and hypoxemia; hyper viscosity syndrome and
sudden death.

C. Other congenital heart lesions  

 Coarctation of aorta: The maternal risks are hypertension, aortic dissection, bacterial
endocarditis and cerebral haemorrhage due to ruptured intracranial aneurysms. Maternal
mortality is high 3–9%. Foetal loss is also increased to 25%. Surgical correction should
be done prior to pregnancy. Termination of pregnancy should be seriously considered.
Elective caesarean section is preferred to minimize dissection associated with labour.

 Primary pulmonary hypertension is characterized by increased thickening of muscular

layer of pulmonary arterioles. The cause remains unknown. Maternal mortality is about
50%, majority die (75%) postpartum. The foetal outlook is also gloomy. Termination of
pregnancy is indicated. Bed rest should be imposed from 20 weeks of pregnancy.
 Anticoagulant (heparin) is administered. Sildenafil is used as a potent vasodilator as it
increases endogenous nitric oxide. Oral nifedipine or I.V. prostacyclin helps pulmonary
vasodilatation. Epidural morphine gives effective analgesia without any hemodynamic
change. Women with pulmonary hypertension and right ventricular dysfunction are
strongly discouraged to become pregnant.  

 Marfan’s syndrome: Marfan’s syndrome is an autosomal dominant condition. There is

50% chance of transmission to the offspring. Dilatation of aorta more than 40 mm as
evidenced from echocardiography is a contraindication of pregnancy. Beta blocking drugs
should be used to maintain resting heart rate around 70 bpm. Hypertension should be
avoided to prevent aortic dissection. Vaginal delivery is desirable with shortening of
second stage. When the aortic root diameter measures more than 4 cm, mortality
increases to 25%. Women with aortic diameter more than 5.5 cm should have graft and
valve replacement before pregnancy.  

 Prosthetic valves are used for significant valvular disease. Mechanical valves are durable
but require anticoagulation. The risk of thromboembolism is high with low molecular
weight heparin rather than warfarin. Bioprosthetic valves (Porcine) are superior to
mechanical valves.

D. Cardiomyopathies
 Peripartum cardiomyopathy: Important diagnostic criteria are:
(i) Cardiac failure within last month of pregnancy or within 5 months postpartum.
(ii) No determinable cause for failure.
(iii) Absence of previous heart disease.
(iv) Left ventricular dysfunction as evidenced on echocardiography:
 Ejection fraction less than 45%
 Left ventricular end diastolic dimension more than 2.7 cm/m2.

Peripartum cardiomyopathy is a diagnosis of exclusion. The patients are usually multiparous

and young (20–35 years). They complain of weakness, shortness of breath, cough, nocturnal
dyspnoea and palpitation. Examination reveals—tachycardia, arrhythmia, peripheral oedema
and pulmonary rales. Pregnancy is poorly tolerated in women with dilated cardiomyopathy.

The treatment is bed rest, digoxin, diuretics (preload reduction), hydralazine or ACE
inhibitors (postpartum) (afterload reduction), β blocker and anticoagulant therapy. Vaginal
delivery is preferred. Epidural anaesthesia is ideal. There is no contraindication of
breastfeeding. Mortality is high (20–50%)—due to CCF, arrhythmia or thromboembolism. It
may recur in subsequent pregnancies.
 Myocardial infarction is rare in pregnancy. Management is mostly as in nonpregnant
state. Coronary angioplasty, stenting and thrombolytic therapy have been done in
pregnancy when indicated. Supine position and hypotension should be avoided.

Labour: managed as with standard cardiac care. Elective delivery within two weeks of
infarction should be avoided. Regional analgesia for pain in labour and β blockers for
tachycardia may be used. Maternal pushing is avoided and second stage is shortened by
forceps or vacuum. Syntocinon should be used in the third stage management as
ergometrine may cause coronary artery spasm. Diuretics to be used postpartum
percutaneous Trans luminal coronary angioplasty can be done successfully around 36 weeks
of pregnancy if needed.

ROLE & RESPONSIBILITIES OF NURSING CARE PROVIDED TO

PREGNANT WOMAN WITH CARDIAC DISEASE:
 Verbalizes the effects of her disease on pregnancy, labour and delivery, and perinatal
outcome.
 Identifies signs and symptoms of cardiac decompensation and obstetric complications and
reports them promptly.
 Implements the established treatment plan (e.g., limited activity and increased rest,
prescribed diet and medications, avoidance of contact with infected people) and prevents
potential complications.
 Maintains adequate cardiac output to meet maternal and foetal needs.
 Maintains adequate tissue perfusion and oxygenation to the maternal-foetal unit.
 Exhibits no signs or symptoms of thromboembolism or infection a Delivers a healthy
new-born at or near term.
 Secures the needed additional resources to assist with child care, household, and other
responsibilities

SUMMARY & CONCLUSION:

An increased prevalence of cardiovascular disease (CVD) has been found in women of
childbearing age, [1] with the presence of CVD in pregnant women posing a difficult clinical
scenario in which the responsibility of the treating physician extends to the unborn foetus.
Profound changes occur in the maternal circulation that has the potential to adversely affect
maternal and foetal health, especially in the presence of underlying heart conditions. Up to
4% of pregnancies may have cardiovascular complications despite no known prior disease.

Cardiac disease in the pregnant patient can present challenges in cardiovascular and maternal-
foetal management. It is important to understand that even in normal patients; pregnancy
imposes some dramatic physiologic changes upon the cardiovascular system. These include
an increase in plasma volume by 50%, an increase in resting pulse by 17%, and an increase in
cardiac output by 50%. After delivery, the heart rate normalizes within 10 days; by 3 months
postpartum, stroke volume, cardiac output, and systemic vascular resistance return to the pre-
pregnancy state

RESEARCH STUDY RELATED TO:

Pregnancy Outcomes in Women With Heart Disease

ABSTRACT:

Background Identifying women at high risk is an important aspect of care for women with
heart disease.

Objectives This study sought to: 1) examine cardiac complications during pregnancy and
their temporal trends; and 2) derive a risk stratification index.

Methods We prospectively enrolled consecutive pregnant women with heart disease and
determined their cardiac outcomes during pregnancy. Temporal trends in complications were
examined. A multivariate analysis was performed to identify predictors of cardiac
complications and these were incorporated into a new risk index.

Results In total, 1,938 pregnancies were included. Cardiac complications occurred in 16% of
pregnancies and were primarily related to arrhythmias and heart failure. Although the overall
rates of cardiac complications during pregnancy did not change over the years, the frequency
of pulmonary edema decreased (8% from 1994 to 2001 vs. 4% from 2001 to 2014; p
value = 0.012). Ten predictors of maternal cardiac complications were identified: 5 general
predictors (prior cardiac events or arrhythmias, poor functional class or cyanosis, high-risk
valve disease/left ventricular outflow tract obstruction, systemic ventricular dysfunction, no
prior cardiac interventions); 4 lesion-specific predictors (mechanical valves, high-risk
aortopathies, pulmonary hypertension, coronary artery disease); and 1 delivery of care
predictor (late pregnancy assessment). These 10 predictors were incorporated into a new risk
index (CARPREG II [Cardiac Disease in Pregnancy Study]).

Conclusions Pregnancy in women with heart disease continues to be associated with

significant morbidity, although mortality is rare. Prediction of maternal cardiac complications
in women with heart disease is enhanced by integration of general, lesion-specific, and
delivery of care variables.

BIBLIOGRAPHY:
 Myles; Textbook for midwives; V.Ruth Bennet; 13th edition; 2008; pg. no. 280-284
 d.c .dutta, textbook of obstetrics 8th edition, new central book agency ltd pg.no.319-325
 A v raman, maternity nursing, 19th edition, wolters kluwers pvt. .ltd, pg. No.635-642
 https://www.msdmanuals.com/professional/gynecology-and-obstetrics/pregnancy-com