OBSTETRICS

2. Prevalence of heart diseases is about 1%
Two types of heart diseases- Rheumatic
Congenital
Rheumatic- Mitral stenosis (prominent in 90%)
Congenital- Atrial septal defect(ASD)
Echo cardiography –useful investigation in pregnancy
Advantage – no radiation exposure
ECG – useful in diagnosing arrhythmias

3. Complications :
 CONGESTIVE CARDIAC FAILURE
 ACUTE PULMONARY OEDEMA
 ARRHYTHMIAS
 SUBACUTE BACTERIAL ENDOCARDITIS

4. CONGESTIVE CARDIAC FAILURE
o Principle – same treatment as given in non-pregnant state
o Digoxin – to increase force of contraction
- to decrease rate of contraction
- also used in some women, not in failures but
at high risk of atrial fibrillation ( severe mitral
valve diseases)
o Diuretics (frusemide) administered

5. ACUTE PULMONARY OEDEMA
o Common – Tight Mitral stenosis
o Symptoms- acute paroxysmal nocturnal dyspnoea
- cough
- haemoptysis
- expectoration of frothy sputum
o Diuresis indicated with Frusemide
o Morphine and frusemide given intra venously
o Aminophylline as an IV infusion
o Indication for balloon valvuloplasty or closed mitral valvotomy in
pregnancy :- life threatening pulmonary oedema not responding to medical
management and recurrent episodes

6. ARRHYTHMIAS
o Variation from normal rhythm or rate of heart beat
o Anti-Arrhythmic drugs administered- Digoxin
-Beta-blockers (Propranolol &
Verapamil)
o Digoxin- cardiotonic glycoside obtained from Digitalis lanata
- consist of 3 sugars and digoxigenin
-used to control ventricular rate in atrial fibrillation and for
congestive cardiac failure with atrial fibrillation
o Beta – blockers :- to slow down heart rate

7. SUBACUTE BACTERIAL ENDOCARDITIS
o Common – in mitral stenosis ( especially in those with prosthetic
valves)
o Common organism involved : Streptococcus viridans
Streptococcus faecalis
Staphylococcus aureus
o Clinical features: fever
haematuria
haemoptysis
o Blood cultures necessary to start appropriate antibiotic therapy
o Mortality around 30%

8. CARDIAC SURGERY IN PREGNANCY
 Previously in mitral stenosis, Closed mitral valvotomy was done
 Nowadays, Balloon valvuloplasty is done, if the valve is pliable
and not calcified and regurgitation is minimal
 Main disadvantage is Radiation exposure
 Safest time to do any procedure is second trimester after 20
wks
 In severe cases with non pliable valve, open heart surgery is
done. But chance of fetal loss is very high

9. Maternal and fetal outcome in cardiac diseases
 Maternal outcome:- Low risk(mortality <1%)
 Moderate risk (mortality 5-15%)
 High risk (mortality 25-50%)

10. LOW RISK( Mortality <1%)
 ASD, VSD and PDA
 Pulmonary or tricuspid diseases
 Mitral valve prolapse
 Corrected congenital heart diseases without residual dysfunction
 Mitral stenosis NYHA class 1 and2

11. MODERATE RISK(Mortality 5-15%
Mitral stenosis with AF
Aortic stenosis
Uncorrected tetralogy of Falot(TOF)
Uncomplicated coarctation
Marfan syndrome with normal aorta
Coartation of aorta
Previous myocardial infarction
History of peripatum cardiomyopathy with no residual ventricular
dysfunction

12. HIGH RISK (Mortality 25-50%)
 Primary pulmonary hypertension
 Eisemengers syndrome
 Complicated coarctation
 Marfan syndrome with aortic involvement

13. Factors affecting maternal prognosis
 NYHA functional class
 Presence of pulmonary hypertension
 Cyanotic heart diseases
 Type of lesion

14. FETAL OUTCOME
 Prematurity
 IUGR
 Risk of congenital heart diseases in fetus
 Mothers with Rheumatic heart disease and congenital heart diseases:-
fetal outcome is good with mild IUGR
 Fetus is at high risk of having a congenital heart disease, when the
mother is affected with the same

15. TYPES OF HEART DISEASES IN PREGNANCY
 Rheumatic heart diseases
 Pregnancy followed by valve replacement
 Congenital heart diseases

16. RHEUMATIC HEART DISEASE
 MITRAL STENOSIS
 It accounts for 90% case of rheumatic heart diseases in pregnancy.
 Normal mitral valve area 4cm2
 Critical or severe stenosis- 1 cm2
 Moderate stenosis-1-2.5cm2
 Mild stenosis-2.5-4 cm2
 Mortality high in patients in NYHA Class III and IV
 Many women with MS develops cardiac failure for the first time in pregnancy.
 Cardiac surgery is best done before pregnancy

17.  Balloon valvuloplasty- prefered procedure in the 2nd trimester(after 20
weeks).
 In case of symptoms of pulmonary congestion- sodium is restricted in diet
and diuretics is started.
 Beta blockers given to reduce cardiac response to anxiety and activity.
 New onset of atrial fibrillation-intravenous verapamil can be given.
 Chronic fibrillation- Digoxin or beta blockers.
 Persistent fibrillation- Heparin
 Vaginal delivery is preferred.
 Epidural analgesia is ideal.
 Bacterial endocarditis prophylaxis important.

18. OTHER VALVULAR LESIONS
• Mitral regurgitation occurs due to mitral valve prolapse or may be rheumatic in
origin(well tolerated as decreased systemic vascular resistance cause less regurgitation.)
• Aortic stenosis is rare in pregnancy(disease of aging).
• Normal aortic valve area- 3-4 cm2
• Severe stenosis, Area<1cm2(Considered high risk and should be managed in hospital
with intensive monitoring)
• Main problem: Hypotension
• During labour, fluid therapy should not be restricted
• Epidural is best avoided in labour.

19. PREGNANCY FOLLOWING VALVE REPLACEMENT
 Women with severely damaged valve- prosthetic valve implanted.
 Main problems- mechanical prosthetic valves cause thromboembolism
and infective endocarditis.
 Maternal mortality- 3-4% with mechanical valves.

20. PROBLEMS OF ANTICOAGULATION
Warfarin-
• Cause warfarin embryopathy for fetus(includes chondrodysplasia punctata,
nasal hypoplasia, optic atrophy,microcephaly).
• Miscarriage.
• IUGR.
• Stillbirth.

21. Heparin-
• More safe as it will not cross placenta
• Intravenous heparin safe but impractical throughout pregnancy.
• High doses of subcutaneous heparin to be given(17500-20000units twice
daily).

22. CURRENT RECOMMENDATIONS(AHA)
 Discontinue warfarin at 6 weeks of conception.
 In high risk cases IV heparin infusion and in low risk cases,subcutaneous
heparin twice daily.
 Restart warfarin at 14 weeks.
 At 34-36 weeks restart IV heparin infusion.
 Labour to be a planned procedure.
 Stop heparin 6 hours before delivery.
 Restart heparin 6 hours after vaginal delivery and 12 hours after caesarean.

23.  Start warfarin after 3 days and withdraw heparin once the International
Normalisation Ratio is adjusted.
 Warfarin is safe in lactation.
 Infective endocarditis prophylaxis is mandatory.

24. MONITORING
 Women on heparin monitored by Activated Partial Thromboplastin Time
(APTT) twice weekly.
 Aim-double the APTT.
 Low molecular weight heparin-monitored with anti Xa 4 hours after the
dose.
 Weekly platelet count-to be on lookout for heparin induced
thrombocytopenia(HIT).

25.  Warfarin- monitored by prothrombin time .
 Aim – achieve an INR of 2.5-3 for mitral valve.
 For other valves INR between 2 and 2.5.
 Labour commences while on warfarin ,Vitamn K given as antidote.
 Heparin not stopped and excessive bleeding ,Protamine sulphate can be given.
 Urgent preterm delivery in a patient on anticoagulation-caesarean preferred to
reduce the risk of intracranial hemorrage in fully anticoagulated fetus.
 Mother on anticoagulation at time of delivery-anticoagulated newborn given
free frozen plasma and Vitamin K.

26. Congenital heart diseases
 Most common (60%):-ASD, VSD, PDA ,Aortic stenosis
 Less common (24%):-Pulmonary stenosis
 Tetralogy of Falot
 Coarctation of aorta
 Tricuspid atresia
 Transposition of vessels
 Rare :-Eisenmenger syndrome
 Primary pulmonary hypertension
 Ebstein anomaly

27. Atrial and ventricular septal defects and patent ductus arteriosus
• ASD : - most common defect in adults (usually septum secundum)
- safest congenital heart disease in pregnancy
- corrected by the time reproductive age attained
• VSD : also corrected by the time reproductive age attained
• PSD : corrected in childhood

28. Tetralogy of falLot
 Right to left shunt characterised by
1. large VSD
2. pulmonary stenosis
3. right ventricular hypertrophy
4.over-riding of aorta,which receives blood from both ventricles.
oEpidural analgesia is contraindicated(hypotension).

29. Eisenmenger syndrome
 Presence of pulmonary hypertension in a PDA, ASD, VSD resulting in
R->L shunt.
 Cyanotic congenital heart disease with a mortality of 50%
 If seen in first trimester- termination f pregnancy.
 Heparin used throughout pregnancy.
 Epidural analgesia contraindicated.

30. Coarctation of aorta
 Main problem-residual hypertension in 30%
 Risk of aortic dissection and paroxysmal hypertension- rupture of
coexisting berry aneurysm and intracranial haemorrhage.
 Risk of coexisting bicuspid aortic valve-> endocarditis.
 Caesarean delivery suggested(to prevent rupture of berry aneurysm and
avoid risk of aortic dissection).

31. MARFAN’S SYNDROME
 In pregnancy –risk of aortic dissection and aortic rupture.
 In case of aortic root dilatation-aortic root replacement done prior to pregnancy.
 Termination done in 1st trimester.
 Beta blockers reduce complications.
 Since condition is autosomal dominant 50% chance that offsprings may be
affected.

32. PRIMARY PULMONARY HYPERTENSION
 Maternal mortality-50%
 Termination advised in 1st trimester.
 Anticoagulation with heparin.

33. CARDIOMYOPATHY
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
 Majority familial –autosomal dominant.
 Beta blockers continued.

34. Peripartum cardiomyopathy
 Cardiac failure develops within last monthof pregnancy or within 5
months of delivery.
 Very rare and specific to pregnancy.
 More common in older obese multiparous women with hypertension.
 Associated complications-preeclampsia and multiple pregnancy.
 Management that of cardiac failure and anticoagulation.

35. CLINICAL CRITERIA FOR DIAGNOSIS
 Cardiac failure in the last month of pregnancy or within 5 months of
delivery.
 Absence of another identifiable cause for the cardiac failure.
 Absence of recognisable heart disease before the last month of pregnancy
 Echocardiography showing left ventricular systolic dysfunction(ejection
fraction<45%,M mode fractional shortening <30% and left ventricular end
diastolic dimension>2.7cm/m2)

36. THANK YOU