CARDIAC DISEASE

IN PREGANACY
AYELE TESHOME(MD)
Introduction
.
Heart disease is the leading cause of death in women in the
United States and the third leading cause in individuals who are
25 to 44 years of age
Heart disease of varying severity complicates about 1 percent of
pregnancies, and associated maternal mortality has decreased
remarkably over the past 50 years.
For example, Sachs and associates (1988) reported that maternal
mortality from cardiac disease fell from 5.6 to 0.3 per 100,000
live births in Massachusetts from 1954 through 1985.
Despite this, heart disease still contributes significantly to
maternal mortality, both in the United States and throughout the
world.
Berg and colleagues (2003) reported that cardiomyopathy alone
was responsible for 7.7 percent of 3201 pregnancy-related deaths
in the United States between 1991 and 1997.
Cardiac disease accounted for 40 of 105 indirect maternal
deaths in the United Kingdom between 1994 and 1996
Physiological Considerations
.Associated with Heart Disease in
Pregnancy
the marked hemodynamic changes stimulated by pregnancy
have a profound effect on underlying heart disease.
The most important consideration is that during pregnancy,
cardiac output is increased by as much as 50 percent.
Capeless and Clapp (1989) have shown that almost half of
the total increase occurs by 8 weeks, and it is maximized
by midpregnancy.
The early increase can be attributed to augmented stroke
volume that results from decreased vascular resistance.
Later in pregnancy, resting pulse increases, and stroke
volume increases even more, presumably because of increased
diastolic filling from the expanded blood volume.
These changes are even more profound in multifetal pregnancy
An important study by Clark and colleagues (1989) contributed
greatly to the understanding of cardiovascular physiology during
. pregnancy.
Using right-sided heart catheterization, these investigators
measured hemodynamic function in 10 healthy primigravid women.
Pregnancy values were compared with values measured again 11 to
13 weeks postpartum
At or near term, cardiac output in the lateral recumbent position
was increased 43 percent by virtue of elevated pulse rate and
stroke volume.
Systemic and pulmonary vascular resistance were concomitantly
decreased, and importantly, there was no change in intrinsic left
ventricular contractility.
As shown in Figure 510, pregnancy is characterized by
normal left ventricular function, and not hyperdynamic function as once
thought.
These investigators concluded that maintenance of normal left
ventricular filling pressures comes about as the result of ventricular
dilatation.
Because significant hemodynamic alterations are
. apparent early in pregnancy, women with severe
cardiac dysfunction may experience worsening of
heart failure before midpregnancy.
In others, heart failure develops after 28 weeks, when
pregnancy-induced hypervolemia is maximal.
In the majority, however, heart failure develops
peripartum when the physiological capability for
rapid changes in cardiac output may be overwhelmed
in the presence of structural cardiac disease.
In the series by Etheridge and Pepperell (1977), of
542 women whose pregnancies were complicated by
heart disease, 8 of 10 maternal deaths occurred during
the puerperium.
Diagnosis of Heart Disease
. Asadaptations
shown in Figure 441, many of the physiological
of normal pregnancy alter physical findings,
making the diagnosis of heart disease more difficult.
For example, in normal pregnancy,
functional systolic heart murmurs are quite common;

respiratory effort is accentuated, at times suggesting dyspnea

edema in the lower extremities usually develops after midpregnancy.

It is important not to diagnose heart disease during

pregnancy when none exists, and at the same time not to
fail to detect and appropriately treat heart disease when it
does exist.
Listed in Table 442 are a number of clinical findings that
may suggest heart disease.
Pregnant women who have none of these findings rarely have
serious heart disease.
1.Diagnostic Studies

.
Most diagnostic cardiovascular studies are noninvasive and can be conducted safely
in pregnant women.
In most cases, conventional testing, including electrocardiography,
echocardiography, and chest radiography, provides necessary data.
Radiolabeled 99Tc-albumin or red cells may be used to evaluate ventricular
function.
The estimated fetal radiation exposure for a 20-mCi dose is 120 mrad, well below the
accepted level for significant teratogenic or oncogenic effect
Thallium201 is used to evaluate regional coronary perfusion.
A standard dose yields a fetal exposure of 300 to 1100 mrad and depends on the stage
of gestation.
If indicated, right-sided heart catheterization can be performed with limited fluoroscopy.
On rare occasions, it may be necessary to perform left-sided heart catheterization.
In women with clear indications, any minimal theoretical risk is outweighed by maternal
benefits.

2.Electrocardiography
As the diaphragm is elevated in advancing pregnancy, there is an average 15-
degree left-axis deviation in the electrocardiogram (ECG), and mild ST
changes may be seen in the inferior leads.
Atrial and ventricular premature contractions are relatively frequent
Pregnancy does not alter voltage findings
3.Chest Radiography

.
Anteroposterior and lateral chest radiographs may be useful
when heart disease is suspected clinically.
When used with a lead apron shield, fetal radiation exposure is
minimized
Slight heart enlargement cannot be detected accurately by
radiography because the heart silhouette normally is larger in
pregnancy.
That said, gross cardiomegaly can usually be excluded.
4.Echocardiography
The widespread use of echocardiography has allowed accurate
diagnosis of most heart diseases during pregnancy.
It allows noninvasive evaluation of structural and functional
cardiac factors.
Some normal pregnancy-induced changes include tricuspid
regurgitation as well as significantly increased left atrial size
and left ventricular outflow cross-sectional area
Clinical Classification
.
There is no clinically applicable test for accurately measuring functional
cardiac capacity.
A helpful clinical classification was first published in 1928 by the New York
Heart Association (NYHA) and was revised for the eighth time in 1979.
This classification is based on past and present disability and is
uninfluenced by physical signs.
Class I. Uncompromised (no limitation of physical activity):These women do
not have symptoms of cardiac insufficiency or experience anginal pain.
Class II. Slight limitation of physical activity: These women are comfortable
at rest, but if ordinary physical activity is undertaken, discomfort results in
the form of excessive fatigue, palpitation, dyspnea, or anginal pain.
Class III. Marked limitation of physical activity: These women are
comfortable at rest, but less than ordinary activity causes excessive fatigue,
palpitation, dyspnea, or anginal pain.
Class IV. Severely compromised (inability to perform any physical activity
without discomfort): Symptoms of cardiac insufficiency or angina may
develop even at rest, and if any physical activity is undertaken, discomfort is
increased.
Siu and associates (2001) expanded on the NYHA classification and
developed a scoring system for predicting cardiac complications during
.pregnancy based on their prospective analysis of 562 consecutive
pregnant women with heart disease in 13 Canadian teaching hospitals.
Predictors of cardiac complications included the following:
Prior heart failure, transient ischemic attack, arrhythmia, or stroke.
Baseline NYHA class III or greater or cyanosis.
Left-sided heart obstruction defined as mitral valve area below 2 cm2, aortic
valve area below 1.5 cm2, or peak left ventricular outflow tract gradient
above 30 mm Hg by echocardiography.
Ejection fraction less than 40 percent.
The risk of pulmonary edema, sustained arrhythmia, stroke,
cardiac arrest, or cardiac death was substantively increased with
one of these factors and even more so with two or more factors.
In another study of 1000 pregnant women with heart disease from
Brazil, Avila and co-workers (2003) reported that 25 percent had
cardiovascular complications during pregnancy.
These included heart failure (12 percent), arrhythmias (6 percent),
thromboembolism, angina, hypoxemia, and infective endocarditis.
Maternal mortality was 2.7 percent.
Preconceptional Counseling
.
Women with heart disease may benefit from counseling before
deciding to become pregnant (see Chap. 7, Other Chronic
Diseases). Maternal mortality generally varies directly with
functional classification at pregnancy onset, however, this
relationship may change as pregnancy progresses. In the
study cited earlier, Siu and colleagues (2001) observed a 6-
percent incidence of heart failure in nearly 600 women with
NYHA class I or II disease. Their experiences, as well as those
of McFaul and co-workers (1988), were that there were no
maternal deaths in 1041 of women with class I or II disease.
In some women, life-threatening cardiac abnormalities can be
reversed by corrective surgery, and subsequent pregnancy is
less dangerous. In other cases, such as women with
mechanical valves and those who are taking warfarin, fetal
considerations predominate. The classification scheme shown
in Table 443 stratifies the mortality risk to aid in counseling.