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 B-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 indiees 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

➤ Prophylactie 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

(1) 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. Sterilization, 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

 O 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 arca ranges between 4 and 6 cm2. Symptoms usually appear when
stenosis narrows this to less than 2.5 cm2. Women with mitral valve arca ≤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 heyond 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, B 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:

(1) Cyanosis

(11) 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 he 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 L.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.

Marían'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:

(1) Cardiac failure within last month of pregnancy or within 5 months postpartum.

(1) 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), ẞ blocker and anticoagulant therapy.
Vaginal delivery is preferred. Epidural anaesthesia is ideal. There is no
contraindication of breastfeeding. Mortality is high (20-50%) duc 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 ẞ 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, 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 foctus. 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- foctal 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 I 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:

1. Myles; Textbook for midwives; V.Ruth Bennet; 13th edition; 2008; pg. no. 280-
284

2. d.c.dutta, textbook of obstetrics 8th edition, new central book agency ltd
pg.no.319-325

3. A v raman, maternity nursing, 19th edition, wolters kluwers pvt. ltd, pg. No.635-
642

4. https://www.msdmanuals.com/professional/gynecology-and-obstetrics/pregnancy-
com
 SUBJECT - OBSTETRICS AND
GYNEACOLOGY

CLASS
PRESENTATION ON
HEART DISEASE
IN PREGNANCY

SUBMITTED TO SUBMITTED BY
Ms. SUBHRA SARKAR Ms. BISHAKHAMAITY
SENIOR LECTURER MSC PART II STUDENT
COLLEGE OF NURSING COLLEGE OF NURSING
N.B.M.C.H N.B.M.C.H