CARDIOVASCULAR DISEASES IN

PREGNANCY
KEY POINTS

� Cardiac disease is a leading cause of maternal morbidity and mortality in pregnancy.

� Pregnancy is associated with major cardiovascular changes
� All women with cardiac disease should receive pre=pregnancy counselling
� Congenital heart disease has increased in prevalence worldwide
� Rheumatic heart disease is still common in indigenous and pacific populations
� Mechanical heart valves are problematic in pregnancy due to anticoagulation issues
� The highest risk cardiac conditions are pulmonary hypertension, cardiomyopathy, stenoic
valve lesions, ischemic heart disease and cyanotic congenital heart disease
� Neonatal outcomes correlate with maternal cardiac status and maternal outcomes
PHYSIOLOGICAL CONSIDERATIONS IN
PREGNANCY

�Cardiac output increases approximately 40 percent

during pregnancy. Almost half of this total increase
takes place by 8 weeks and is maximal by mid-
pregnancy
�Later in pregnancy, resting pulse and stroke volume
increase even more because of increased end-
diastolic ventricular volume that results from
pregnancy hypervolemia
RHEUMATIC HEART DISEASE

� Most common form of cardiac disease in pregnant women

� Most common valvular disease in women of childbearing age
� Rheumatic heart disease is a complication of rheumatic fever in which
the heart valves have been permanently damaged. 
� During pregnancy, there is an increase in blood volume which results in
increased pressure on the heart valves. For pregnant women with
rheumatic heart disease, an increased pressure on the damaged heart
valve leads to increased maternal and fetal risks.
 CONGENITAL HEART DISEASE

� Most common form of heart disease complicating pregnancy

� What is the commonest congenital heart disease in pregnancy?
The most common congenital heart diseases in pregnant women, which
account for nearly 60% of cases, are patent ductus arteriosus, atrial septal defect
and ventricular septal defect.
� Does congenital heart disease affect pregnancy?
Patient with congenital heart disease can affect the baby. The baby may be
smaller if heart does not pump as efficiently as it should and delivers less oxygen and
nutrients to the placenta and to the developing baby. Babies may be born prematurely.
 ATRIAL SEPTAL DEFECT
PATENT DUCTUS ARTERIOSUS

VENTRICULAR SEPTAL
DEFECT
CYANOTIC HEART DISEASE

� Any heart defect present at birth that reduces the amount of oxygen delivered to
the body. It's also called critical congenital heart disease or CCHD.
� Right to left shunting
� Remember the blood flow; blood will not flow to the lungs it would not get
oxygenated
� Patient’s with cyanotic heart disease do poorly during pregnancy
� Tetralogy of Fallot – most common
* large ventricular septal defect, pulmonary stenosis, right ventricular
hypertrophy, and an overriding aorta that receives blood from both the right and left
ventricles
Tetralogy of Fallot includes
four defects:

• Narrowing of the lung valve

(pulmonary valve stenosis)
• A hole between the bottom heart
chambers (ventricular septal
defect) 
• Shifting of the body's main artery
(aorta) 
• Thickening of the right lower heart
chamber (right ventricular
hypertrophy)
MITRAL VALVE PROLAPSE

� also known as click-murmur syndrome, Barlow's syndrome, balloon mitral valve, or floppy
valve syndrome
� 6-10% of women of child bearing age are affected
� Prolapse of the mitral valve leaflets into left atrium during ventricular systole causing some
backflow of blood
� Most women wee asymptomatic and they are able to tolerate the pregnancy well
BACTERIAL ENDOCARDITIS

� Inflammation of the inner lining of the heart usually involving the heart valves
� Tricuspid valve is infected
� Parenteral substance abusers represent a growing number of pregnant women at high risk
for acquiring bacterial endocarditis
� Causative agents: Staphylococcus aureus, streptococcus pneumonia
� Symptoms: Fever for 2 weeks, pleuritic chest pain, dyspnea, exertion, orthopnea and
cardiac murmur
PERIPARTUM CARDIOMYOPATHY

� Congestive failure with cardiomyopathy occurs between the last

trimester of pregnancy and the 5 post partum months
� The main pathologic features are reduced left ventricular ejection
fraction and impaired ventricular contractile power
� Clinical manifestations: breathlessness, tachycardia, arrythmia,
cardiomegaly and edema
EISENMENGERS SYNDROME

� Secondary pulmonary HPN from any cardiac lesion

� This syndrome is most likely to arise with VSD because high pressure
and high flow associated with these effects.
� Pregnant women with Eisenmenger syndrome tolerate hypotension
poorly, and death usually is caused by right ventricular failure with
cardiogenic shock
CLINICAL INDICATORS OF HEART DISEASE
DURING PREGNANCY
DIAGNOSTIC EVALUATION

� Physical Examination
� 2D Echo: if murmurs are heard
� NON INVASIVE :
*Complete blood count, ECG,
*Chest radiograph – to assess cardiac size, outline, pulmonary
vasculature and lung fields
*Echocardiography
*Clotting studies
CLASSIFICATION OF
FUNCTIONAL HEART
DISEASE
 WHO RISK
CLASSIFICATION OF
CARDIOVAACULAR
DISEASE AND
PREGNANCY
 MANAGEMENT

� PRECONCEPTION CARE:
a. Counselling
PERIPARTUM MANAGEMENT
CONSIDERATIONS

� Class I and II
a. Avoid contact with persons who have respiratory infections-
common cold
b. Pneumococcal and influenza vaccines are recommended
c. Cigarette smoking is prohibited
� Class III and IV (Rare)
a. Prolonged hospitalization
b. Bed rest
 MANAGEMENT

PHYSICAL AND PSYCHOLOGICAL CARE

a. General health advice can be given by a midwife with regards
to diet, weight, exercise, rest and prevention of anemia,
avoidance of tobacco, drugs and alcohol.
b. All women with heart diseases will require additional rest during
pregnancy
c. In late pregnancy women may require admission to hospital for
rest and close monitoring
d. Psychological support is given to the patient.
 MANAGEMENT

� STRESS, REST AND ACTIVITY

a. Minimum of 10 hours of sleep per night and additional morning and afternoon rest period
b. Limit activity
c. Complete bedrest in the 2nd half of pregnancy.
d. Custom-fitted support stockings
e. Improving muscle function.

� PREVENTION OF INFECTION
a. Febrile episodes increased cardiac demands are often associated with tachycardia.
b. Spread of the infectious organism may cause direct damage to the heart
c. Encourage early dental examination and dental carries
MANAGEMENT: Prevention of infection

d. Infection often cause pyrexia and tachycardia which will increase

cardiac output and put on added strain on the heart
e. An early dental examination is important to detect and treat dental
carries and gum disease which will precipitate endocarditis
f. Prophylactic antibiotic therapy
g. All invasive procedure should be performed in strict aseptic techniques
h. Minimize the number of vaginal examination
i. Proper perineal care should be emphasized and preventing UTI and
pyelonephritis
 MGT: LABOR AND DELIVERY
� Vaginal delivery is preferred
� Labor induction is safe
� CS is limited to OB indications (CHF and arrest disorders)
If for CS: Warfarin administration for 2 weeks
� Labor ; Semi recumbent position with lateral tilt
If supine: enlarged uterus compresses the large vessels blood flow coming from the
system going back to the heart will be decreased blood flow coming from the heart will
also be compromised uteroplacental blood flow is affected affecting the growth of the
baby increasing fetal morbidity and mortality
o Vital Signs are frequently taken between contractions to note tachycardia and
tachypnea
� Puerperium
Look for signs of Hemorrhage, anemia, infection, Thromboembolism
 CARE OF POST NATAL MOTHERS

� Advise patient if possible for the need of limited activity and additional rest
� Stool softeners may be prescribed to prevent straining on defecation
� Advise on new-born care