Cardiac Disease in Pregnancy Guideline - Quick Reference Guide

Women with cardiac disease in pregnancy are at high risk of complications and cardiac disease is
the leading cause of maternal death. This ‘Quick Reference Guide’ summarises the key points
from the Greater Manchester and Eastern Cheshire Maternal Medicine Network guideline which
has been developed to promote seamless, multidisciplinary care for women with cardiac disease in
pregnancy.
Joint obstetric and cardiology clinics
There is a Joint Obstetric Cardiology service at the following hospitals
Hospital Obstetrician Cardiologist Frequency
Wigan Amit Verma Nayyar Naqvi Monthly 3rd Tues am
St Mary’s Hospital Sarah Vause, Prof Clarke, Weekly Tues am
Tel: 0161 276 6426 Anna Roberts Prof Keavney
Risk stratification
Following multidisciplinary assessment and risk stratification, appropriate care can be arranged at
a district general hospital or tertiary unit according to the complexity of the cardiac disease:
 Low risk – care and delivery in local hospital, with escalation if clinical deterioration
 Moderate risk – refer to joint obstetric cardiac clinic for assessment, but care may be
shared with local hospital
 High risk – refer to joint obstetric cardiac clinic for care and delivery in tertiary centre
Low risk Moderate risk High risk
Uncomplicated, small or mild Unoperated atrial or ventricular Mechanical valve
septal defect Systemic right ventricle
- pulmonary stenosis
Repaired tetralogy of Fallot Fontan circulation
- patent ductus arteriosus Most arrhythmias Cyanotic or other complex congenital
Mild left ventricular impairment heart disease
- mitral valve prolapse
Hypertrophic cardiomyopathy Aortic dilatation >=40 mm in Marfan
Successfully repaired simple Native or tissue valvular heart syndrome
disease not considered WHO I Aortic dilatation >=45 mm in non
lesions (atrial or ventricular
or IV Marfan aortopathy
septal defect, patent ductus
arteriosus, anomalous Marfan syndrome without aortic Pulmonary arterial hypertension of
dilatation any cause
pulmonary venous drainage).
Aorta <45 mm in aortic disease Severe systemic ventricular
associated with bicuspid aortic dysfunction (LVEF <30%, NYHA III-
Atrial or ventricular ectopic beats valve IV)
Repaired coarctation Previous peripartum cardiomyopathy
with any residual impairment of left
ventricular function
Severe mitral stenosis, severe
symptomatic aortic stenosis
Native severe coarctation
Pre conception
All women of reproductive age with cardiac disease should have access to specialised
multidisciplinary preconception counselling in a joint obstetric and cardiac clinic, to empower them
to make choices about pregnancy. They should be given advice about contraception and how to
access services rapidly when they become pregnant.
Termination of pregnancy
Rapid access to termination of pregnancy services should be facilitated, if for whatever reason a
woman chooses this. The termination of pregnancy service should be able to provide the
appropriate level of medical care for the severity of the woman’s cardiac disease.

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 Antenatal care
All pregnant women with heart disease should be assessed clinically as soon as possible by the
multidisciplinary team.
All pregnant women with cardiac disease requiring treatment or care by other specialists should
have an integrated care plan developed and agreed between all specialities involved.
An escalation and transfer protocol must be available in all units should a woman with cardiac
disease deteriorate during pregnancy or post partum.
Intrapartum care
Senior input and multidisciplinary care are imperative
Aim for a vaginal delivery unless obstetric or cardiac indications for LSCS
Women with cardiac disease should see the obstetric anaesthetist antenatally to discuss
analgesia. When a woman with cardiac disease is admitted to the Delivery Suite the anaesthetic
staff should be involved early.
Fluid balance needs to be assessed accurately using an hourly input/output chart and an hourly
urometer in moderate and high risk cases.
Observations should be charted on a HDU chart in moderate and high risk cases
For some cardiac conditions hypotension is poorly tolerated. Prompt and accurate replacement of
lost volume is necessary. An arterial line may be indicated. This should be specified in the care
plan.
For other cardiac conditions, hypertensive surges may be poorly tolerated. Syntocinon is preferred
to syntometrine. For women with severe heart disease this may need to be given as a slow bolus
(Syntocinon 5u in 20 mls over 20 mins). This should be specified in the care plan.
.
For some women a short active second stage, or no active second stage may be necessary and
vaginal delivery should be assisted with forceps. If needed this should be specified in the care
plan.
Tocolytics, such as nifedipine, may severely compromise cardiac function. The use of tocolytics
should be discussed with the consultant. Atosiban is the tocolytic of choice for women with severe
cardiac disease as it has the least cardiovascular side effects.
Current NICE guidelines state that antibiotic prophylaxis against infective endocarditis should not
be offered for gynaecological and obstetric procedures or childbirth. However, there should be a
low threshold for antibiotic prophylaxis because of the serious nature of endocarditis and the low
risk of anaphylaxis.
For post partum haemorrhage, due to uterine hypotonia, mechanical methods such as bimanual
compression and a B Lynch suture can be used. Misoprostol should be used in preference to
hemabate as it has less vasoactive effects.
Postnatal Care
This is often a time of decompensation; hence close continued observation is appropriate. Staff
should not become complacent. Fluid balance should be monitored closely and there should be
daily medical review. An extended post natal stay may be indicated.
Women with cardiac disease should be supported with breastfeeding, given appropriate
contraception advice and offered lifestyle advice (diet, smoking, exercise).
Medication should be reviewed and appropriate cardiology follow-up arranged prior to discharge
from maternity care. A comprehensive discharge summary should be prepared by the woman’s
obstetrician.

GMEC SCN Cardiac Disease in Pregnancy Guideline_shortversion v1 Final 260118