CARDIAC DISEASES IN

PREGNANCY
 DESCRIPTION

This involves a variety of heart conditions

both congenital and acquired that
complicate pregnancy
 RISK FACTORS

• RHEUMATIC FEVER
• CONGENITAL DEFECTS OF THE HEART
• ARTERIOSCLEROSIS
• MI
• PULMONARY DISEASES
• RENAL DISEASES HEART SURGERY
 CARDIOVASCULAR
DISORDERS

●about 1% of pregnancies complicated

by heart diseases
● leading cause of maternal mortality

●Mortality rate 50% in case pulmonary

hypertension
 PHYSIOLOGIC ADAPTATION TO
PREGNANCY
● Increase blood volume on 40 -50 %
Cardiac hypertrophy
● Increase cardiac output 30-50%
● Decreased systemic vascular resistance
● The heart elevated upward and rotated forward to the left
● Pulse increase about 10-15 beat/min after 14-20 weeks,
palpitation
● Disturbed rhythm: arrhythmia, premature atrial contractions,
premature ventricalar systole
● Increase clot factors (VII, VIII, IX, X, fibrinogen)
● Cardiac output changes during labor and birth
● Intravascular volume changes just after childbirth
 PHYSIOLOGIC ADAPTATION TO
PREGNANCY
● If cardiac changes are not well tolerated
cardiac failure can develop during pregnancy,
labour, postpartum
● If myocardial disease develops, valvular
disease exists or congenital heart defect is
present, cardial decompensation is
anticipated
PERCENT CHANGE IN HEART RATE, STROKE
VOLUME, AND CARDIAC OUTPUT
MEASURED IN THE LATERAL POSITION
THROUGHOUT PREGNANCY COMPARED
WITH PREGNANCY VALUES
 CARDIAC TESTS PERFORMED

● Doppler echocardiography
● Stress testing
 CARDIAC TESTS PERFORMED
● Magnetic Resonance Imaging

● Pulmonary Artery Catheterization: Great help

in managing high risk patient during
pregnancy, labor and delivery

● Cardiac Catheterization
■ Can be done
 PREGNANCY RESULT IN CASE
OF CARDIOVASCULAR
● miscarriages
DISORDERS
● Preterm labor and birth
● IUGR
● Congenital heart lesions (4-16%)
● Maternal mortality
 NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION (NYHA) OF HEART DISEASE

➢ CLASS I  No signs or symptoms of

cardiac decompensation.
➢ CLASS II  No symptoms at rest but minor
limitation of physical activity.
➢ CLASS III  No symptoms at rest but marked
limitation of physical activity.
➢ CLASS IV  Symptoms present at rest increses
discomfort with any kind of physical
activity.
 WHAT IS THE PROGNOSIS FOR A
WOMAN WITH A CARDIAC DISEASE
DEPENDING ON THE NYHA RISK
GROUP CLASSIFICATION?
 PROGNOSIS DEPENDING ON THE
FUNCTIONAL STATUS

❖In general, women in NYHA classes I and II

lesions usually do well during pregnancy and have
a favorable prognosis with a mortality rate of <1%.

❖Patients in NYHA classes III and IV may have a

mortality rate of 5% to 15%. These patientsshould
be advised against becoming pregnant.
WHAT ARE THE CLINICAL FEATURES IN A
NORMAL PREGNANCY WHICH CAN
MIMIC A CARDIAC DISEASE ?
The clinical features in a normal pregnancy
which can mimic a cardiac disease are
1. Dyspnea - due to hyperventilation, elevated
diaphragm..
2. Pedal Edema
3. Cardiac impulse- Diffused and shifted laterally
from elevated diaphragm.
4. Jugular veins may be distended and JVP
raised.
 ASSOCIATED CARDIOVASCULAR
DISORDERS CONT
● Acquired cardiac disease
■ Mitral valve stenosis
■ Aortic stenosis
■ Ischemic heart disease
◆ Myocardial infarction (MI)
■ Other cardiac diseases
◆ (PPCM) Pulmonary hypertension
◆ Marfan syndrome
◆ Infective endocarditis
◆ Eisenmenger syndrome
◆ Valve replacement
◆ Peripartum cardiomyopathy
ARIAL SEPTAL DEFECT
● Left-to-right shunt
● Undetected because
woman is asymptomatic
● Uncomplicated
pregnancy
● Right-side heart failure or
arrhythmia as a result of
increased blood volume
 VENTRICULAR SEPTAL
DEFECT
● Left-to-right shunt
● Diagnosed and corrected during
infancy and childhood, not
common in pregnancy
● Not complicated pregnancy
● Risk for: arrhythmias, heart failure,
pulmonary hypertension
● Management
■ Rest
■ decrease of
physical
activity
■ anticoagula
nts
 PATENT DUCTUS
ARTERIOSUS
● Left-to-right shunt
● Diagnosed and corrected during
infancy
● Possible complications
■ arrhythmias,
■ heart
■ failure,
■ pulmonary hypertension
■ Endocarditis
● Pulmonary emboli
Management
■ Rest
■ decrease of physical activity
■ anticoagulants
CONGENITAL HEART DISEASE
ACYANOTIC LESIONS
 COARCTATION OF THE AORTA
● Pregnancy safe for mother with
uncomplicated coarctation
● Complications
■ Hypertension
■ Congestive heart failure
■ Aortic rupture
● Management
■ Rest
■ Antihypertensive medications (beta-blockers)
■ Vaginal birth with epidural anesthesia and
shortening of the II stage (vacuum- or
forceps assisted)
■ Antibiotic prophylaxis
CONGENITAL HEART DISEASE
CYANOTIC LESIONS
TETRALOGY OF FALLOT
● 1. Ventricular septal defect.
● 2. overriding aorta
● 3. right ventricular hypertrophy
● 4. pulmonary stenosis
● Right-to-left shunt
● Corrected at childhood
● Management
■ Anticoagulant
■ Oxygen
■ hemodynamic monitoring
ACQUIRED HEART DISEASES
 MITRAL
STENOSIS

● The pressure gradient across the narrow valve

increases secondary to the increased heart rate and
blood volume
● Left atrial pressure increases, back pressure into the
lungs causes breathlessness, swelling in the
legs and may lead to atrial arrhythmias.
● Stretching of the atrium can also occur causing
palpitations and arrhythmia.
 MITRAL STENOSIS

● Maternal mortality rate in classes III and IV

■ 5 %without arterial fibrillation
■ 15% with arterial fibrillation

● There is marked increase in the following

issues regarding the fetus
■ Rate of prematurity
■ Fetal growth retardation
■ Low neonatal birth weight
 MITRAL
STENOSIS
● Therapeutic approach is:
■ to reduce the heart rate
■ and decrease left atrial pressure
◆ Restrict physical activity
◆ Restrict salt intake
◆ diuretics
◆ Beta blockers
◆ Digoxin (if patient is in a. fib)
◆ Calcium channel blockers
● if medical therapy is ineffective surgery
may be necessary after 20 weeks
■ Balloon valvuloplasty
■ Surgery (repair/replacement)
 MITRAL
STENOSIS
● Vaginal delivery can be permitted in most
patients
● Hemodynamic monitoring is recommended
(Swan) and should be continued several
hours following delivery
 AORTIC STENOSIS
● AS lead to obstruction to
left ventricular ejection
● Mild AS is usually
tolerated
● Moderate to severe AS is
likely to be associated with
symptomatic deterioration
during pregnancy
● Women with valve area
<1.0 should consider valve
replacement prior to
pregnancy
 AORTIC STENOSIS
● Symptoms often develop in the 2nd and 3rd trimester
■ Exertional dyspnea
■ Chest pain
■ Syncope

● Fetal effects included

■ Intrauterine growth retardation
■ Premature delivery
■ Reduced birth weight
■ Increase in cardiac defects
 ISCHEMIC HEART
DISEASE
● MI is rare in childbearing woman
● Risk factors increase
■ Age
■ Smoking
■ Stress
■ Cocaine use
■ Hyperbilirubinemia
■ DM
■ Family history of
■ IHD
■ Hypertension
Oral
contraceptives
 ISCHEMIC HEART
DISEASE
● Mangement
■ Oxygen
■ Aspirin
■ Beta-blockers
■ Nitrates
■ Heparin
■ Side-lying
■ position
Vaginal birth is preferable with avoiding of maternal
■ pushing (vacuum- or forceps-assisted)
Diuretic postpartum
OTHER HEART DISEASES
 PRIMARY PULMONARY
HYPERTENSION
● Constriction of the arteriolar vessels in the
lung, leads to increase in the pulmonary
artery pressure right ventricular
hypertension, hypertrophy, dilatation, right
ventricular failure with tricuspid
regurgitation
● Associated with high maternal mortality
estimated to be 50%, half of them occurs
a few hours to several days post partum
usually related to sudden death or
progressive RV failure, although the exact
cause of death is not clear
● Deterioration usually occurs in the
second/third trimester
 PRIMARY PULMONARY
HYPERTENSION
● Symptoms may include
■ Fatigue
■ Dyspnea
■ Chest pain
■ Edema and ascites
■ Syncope

● Diagnostic test
■ Chest radiogram
■ ECG
■ EchoCG
■ Dopler studies
 PRIMARY PULMONARY
HYPERTENSION
● Fetal effects include
■ High incidence of prematurity
■ Fetal growth retardation
■ Fetal loss

● Pregnancy should be discouraged in all

patients with primary pulmonary HTN
 PRIMARY PULMONARY
HYPERTENSION
● For patients who chose to continue pregnancy
■ Nifedipin or prostacycline (for pulmonary
vasodilatation)
■ Anticoagulant
■ Continuous hemodynamic monitoring during labor
and delivery
◆Antiembolic strocking
◆Side-lying position
◆Oxygen therapy
◆Epidural analgesia
 MARFAN
●
SYNDROME
Autosomal dominant genetic disorder
characterized
■ weakness of the connective tissue,
■ resulting in joint deformities,
■ ocular lens dislocation,
■ weakness of aortic wall and root
◆ Mitral valve prolapse (90%)
◆ Aortic insufficiency (25%) risk of
aortic dissection and rupturing

● Pregnancy in patients with Marfan poses 2

problems
■ Cardiovascular complications of the mother
■ Risk of having a child who inherits Marfan’s
syndrome

● Cardiovascular problems
■ Dilation of the ascending aorta, may lead to
development of aortic regurgitation and heart
failure
■ Proximal and distal dissections of the aorta with
possible involvement of the coronaries
 MARFAN’S SYNDROME
● Obstetrical complications
■ Cervical incompetence
■ Abnormal placental location (previa)
■ Postpartum hemorrhage

● Preconception counseling
■ Patients with more than mild dilation of the aorta, or history of
aortic dissection should be advised against pregnancy
■ Progressive dilation of the aorta during gestation may occur
even with a normal-sized aorta
◆ Preconception echo evaluation allows for evaluation of the
aortic root, CT, MRI.
◆ Periodic echocardiographic follow-up is recommended
 MARFAN’S
SYNDROME
● Management
■ Vigorous physical activity should be avoided
■ Beta blockers (reduces the rate of aortic dilation)
■ If substantial dilation/dissection should occur,
depending on the stage of pregnancy
◆ therapeutic abortion,
◆ early delivery or
◆ surgical intervention should be considered
 INFECTIVE
ENDOCARDITIS
● Inflammation of endocardium
● Cause: microorganisms
● Clinical manifestation:
■ incompetence of heart valves
■ Congestive heart failure
■ Cerebral emboli
● Treatment
■ Antibiotics
 EISENMENGER
SYNDROME
● Right-to-left or bidirectional shunting at
atrial or ventricular level and
combined with elevated pulmonary
vascular resistance
● High risk of maternal (30-50%) and fetal
(50%) morbidity and mortality
● Pregnancy is contraindicated
(contraception or termination of
pregnancy)
● Death usually (75%) occurs between the
first few days and weeks after delivery,
but the cause is unclear
 EISENMENGER
SYNDROME
● Patients should be monitored closely for any signs of
deterioration
● Early elective hospitalization is recommended
● Activity is strictly limited
● Hemodynamic monitoring is required
● Anticoagulant???
● Prophylaxis of hypovolemia
● Oxygen
● Epidural analgesia
 CARDIOMYOPATHY
● Cardiomyopathies are diseases of the heart
muscle itself. People with cardiomyopathies --
sometimes called an enlarged heart -- have
hearts that are abnormally enlarged,
thickened, and/or stiffened. As a result, the
heart's ability to pump blood is weakened.
Without treatment, cardiomyopathies worsen
over time and often lead to heart failure and
abnormal heart rhythms.
 HYPERTROPHIC
CARDIOMYOPATHY
● Most cases have favorable outcomes
● Symptoms may worsen, especially in patients who
were already symptomatic
■ Increased SOB
■ Fatigue
■ Chest pain
■ Syncope
● The risk of the fetus of inheriting the disease is as
high as 50%
 OTHER TYPES ARE:
● Dilated cardimyopathy

● Consticted myopathy
PROSTHETIC
VALVES AND
PREGNANCY

Anticoagulation
 VALVE
REPLACEMENT
10.What is warfarin fetal embryopathy ?
Warfarin use in first trimester can be
teratogenic and can cause fetal
embryopathy( 15 to 25 % ) which includes
· Nasal cartilage hypoplasia,
· Stippling of bones,
· IUGR and
·
 WARFARIN VS.
HEPARIN
Heparin
Warfarin
● Crosses the placenta.
● ↑early abortion, prematurity,
and embryopathy when used in
1st trimester (6th–12th weeks).
● CNS & Eye abnormalities (2nd
& 3rd trimester).
● Bleeding in the fetus
(especially at delivery)
■ Should be stopped before
delivery.
● Does not cross the placenta
● No teratogenicity
● No fetal bleeding
● Twice daily SC injection
● Risk of osteoporosis
■ <2% symptomatic fractures.
■ but 30% decrease in bone density.
● Risk for thrombocytopenia
● ↑↑ Risk of thrombosis

“warfarin embryopathy”: Nasal hypoplasia, Bone epiphysis, optic atrophy,

blindness, seizures.
Overall risk around 5%. Decreases with the use of UFH in the first 3 months
 Dose-dependent Fetal Complications of warfarin in
pregnant women with Mechanical Heart Valves
Outcome of pregnancies
WARFARI Healthy fetuses Fetal Total
N DOSE complications
(MG)
≤5 28 5/33 (15%) 33
• 27 FT • 4 SA
•1 PR • 1 GR
•0 WE (0%)

>5 3 FT 22/25 (88%) 25

• 2 WE (9%)
• 18 SA
• 1 SB
• 1 VSD

Total 31 27 58

FT = full term, GR = growth retardation; PR = preterm; SA = spontaneous abortion; SB =

still birth; WE = warfarin embryopathy

.
 UNFRACTIONATED
●
HEPARIN
4X higher incidence of Thrombo-embolism
during pregnancy than oral anticoagulants .

1. Hanania G, et al. pregnancy in patients with valvular prosthesis-

retrospective cooperative study in France (155 Cases). J Arch Mal Coeur
Vaiss 1994;87:429-437.

● Failure of adjusted dose SC heparin to prevent

thrombo-embolic phenomena in pregnant
women (n= 40) with mechanical valve prosthesis.
■ Adjusted doses of SC heparin does not improve
fetal outcome and increases maternal mortality.
2. Salazare E, et al. Filure of adjusted dose heparin to prevent
thromboembolisc phenomena in pregnant patients with mechanical
cardiac valve prosthesis. J Am Coll Cardiol 1996;1698-1703.
Frequency of fetal and maternal complications according to the
anticoagulation regimen used during pregnancy in women
with mechanical heart valve prosthesis.
Adapted from Chen et al. (976 women, 1234 pregnancies)

Thrombo-
Spontaneou embolic
Embryopath Maternal death
Anticoagulation regimen y (%)
s abortion complications (%)
(%)
(%)
Vitamin K antagonist 6.4 25 31/788 (3.9%) 10/561 (1.8%)
throughout pregnancy

Heparin throughout 0 24 7/21 (33%) 3/20 (15%)

pregnancy
• Low dose 0 20 60 40

• Adjusted dose 0 25 25 6.7

Heparin during first 3.4 25 21/229 (9.2%) 7/167 (4.2%)

trimester, then vitamin K
antagonists
(with or without heparin before
delivery)
 LOW-DOSE ASA
● The additional use of low-dose aspirin should
be considered, particularly in
◆Women with high-risk valves.
◆Patients with cyanosis.
◆Patients with intra-cardiac shunts.
◆Women with previous TIAs and/or
strokes.
◆And women with atrial fibrillation.
 LMWH
● Do not cross the placenta.
● Do not require frequent PTT monitoring
● and have a longer half-life than UFH.
● The data to support the use of LMWH, however, is not yet
available.
● A successful use of LMWH was reported in small number of
patients and more information is required before LMWH
can be recommended for anticoagulation in a patient with a
prosthetic valve during pregnancy1.
● Recently, two cases of LMWH treatment failure resulting in
thrombosed prosthetic heart valves were reported in
● 20002.
LMWH should not be recommended at the present time in
patients with heart valve prostheses during pregnancy.
 MECHANICAL VALVES AND
ANTICOAGULATION DURING
PREGNANCY
● Heparin may not prevent valve thrombosis: ?

how much ?route.

● Adequate anticoagulation difficult.
● Heparin can produce osteoporosis.
● Little data regarding LMWH.
● Warfarin can cause embryopathy.
● Baby ASA safe + probably beneficial.
1-4% mortality in pregnant women with
mechanical valve prosthesis, Whatever the
anticoagulation regimen.
No Ideal Solution
 SUGGESTED ALGORITHM FOR THE
MANAGEMENT OF
ANTICOAGULATION IN PATIENTS WITH
MECHANICAL PROSTHETIC HEART
VALVESPregnancy
DURINGinPREGNANCY
patients with
prosthetic heart valves

Higher risk Lower risk

First-generation prosthesis Second-generation prosthesis
And any mechanical prosthesis in the
In the mitral position aortic position

Coumadin to INR SC or IV (better) SC Heparin SC heparin

3.0-4.5 for 36 heparin-(aPTT 2.5-3.5) (aPTT 2.0-3.0) (aPTT 2.0-3.0)
weeks followed by for 12 weeks for 12 Throughout
IV heparin to weeks pregnancy
aPTT of > 2.5-3.5 Coumadin
(INR 3.0-4.5) Coumadin 1-4% mortality in
to 36th week (INR 2.5-3.0) pregnant women with
to 36th mechanical valve
IV heparin week prosthesis, Whatever
(aPTT > 2.5)
the anticoagulation
SC Heparin regimen.
 MODE OF DELIVERY
Vaginal delivery
● With facilitated second stage
is preferred & safe
● Invasive hemodynamic
monitoring only in:
■ Severe valve stenosis
■ Recent heart failure.
■ Severe cyanotic heart disease
■ Pulmonary HTN.
Breast-feeding
• Can be encouraged in women
taking anticoagulants.
• Heparin is not secreted in
breast milk
• and the amount of warfarin is
low.
Cesarean section
● Avoids physical stress of labor
● but not free from hemodynamic
consequences.
● Indications in CHD only for:
■ Obstetric reasons.
■ Therapeutic anticoagulation with
coumadin at onset pf labor.
■ Pulmonary hypertension.
■ Unstable aortic lesion with risk of
dissection.
■ Severe obstructive lesions
 ENDOCARDITIS PROPHYLAXIS
● Antibiotic prophylaxis at the time of delivery is not recommended for
patients expected to have uncomplicated vaginal delivery or
cesarian section, unless clinically overt infection is present 12,
● Patients at high risk for endocarditis may receive antibiotics at the
discretion of their physician2:
■ Those with prosthetic heart valves.
■ Previous IE.

Antibiotics for prophylaxis against endocarditis

Ampicillin No major adverse Given along with gentamicin 2 gr IV or IM within 30 min before
effects B to high-risk patients to delivery.
prevent IE And 1 gr PO, IV or IM 6 hrs later.
Vancomycine No major adverse Given along with gentamicin Cm I gr IV over 1-2 hours, given 30 min
effects to high-risk patients to before delivery.
prevent IE

Gentamicin No major adverse Given along with Ampicilline 1.5 mg/kg within 30 min before
effects C or Gentamicin to high-risk delivery (max 120 mg)
patients to prevent IE
 PERIPARTUM
CARDIOMYOPATHY
● A form of dilated CMP with LV systolic dysfunction that
results in the signs and symptoms of heart failure
● Criteria
■ Development in last month of pregnancy or the first 5 months
after delivery
■ Absence of heart disease prior to last month of pregnancy
■ Absence of identifiable cause of heart failure
■ LV systolic dysfunction

● Etiology is unknown
● Theories
■ Genetic predisposition
■ Autoimmunity
■ Viral infection
 PERIPARTUM
CARDIOMYOPATHY
● Associated risk factors:
■ Age - over 35
■ twin pregnancy
■ gestational hypertension
■ Multiparity
■ African-american race
■ use of tocolytic therapy

● Motality rate 25-50%

 PERIPARTUM
CARDIOMYOPATHY
● Clinical findings
■ Left ventricular failure
◆ Dyspnea
◆ Fatigue
◆ Edema
◆ Enlarged heart
◆ Tachycardia
◆ arrhythmias
 PERIPARTUM
CARDIOMYOPATHY
● clinical course varies
■ 50-60% of patients demonstrate complete recovery
within the first 6 months
■ The rest of the patients demonstrate either further clinical
deterioration, leading to cardiac transplant or premature
death, or persistent LV dysfunction and chronic heart
failure
■ No agreement on recommendation for future
pregnancies
■ Pregnancy contraindicated
◆ Persistent cardiomegaly
◆ Cardiac dysfunction
 PERIPARTUM
CARDIOMYOPATHY
● Management
■ Acute heart failure treatment with O2,
diuretics, digoxin and vasodilators
(hydralazine is safe)
■ Because of the increased incidence of
thromboembolic events, anticoagulation
therapy is recommended
11. WHAT ARE THE RISK FACTORS FOR
CARDIAC FAILURE DURING
PREGNANCY ?
Risk factors for cardiac failure during
pregnancy

❖ Infection
❖ Anemia
❖ Obesity
❖ Hypertension
❖ Hyperthyroidism
❖ Multiple pregnancy
 PULMONARY HYPERTENSION AS A
Pulmonary hypertension
RISK OF ADVERSE
Increased rate of adverse maternal events
(Eisenmenger Syndrome) OUTCOME Up to 30-40% (↑ PVR)

When systolic PAP > 75% systemic pressure

↑ intravascular volume HF
(CO limited by Pulmonary vascular disease and Ventricular dysfunction)

↓ SVR (after 1st trimester) ↑R-L Shunt Cyanosis

Exacerbated during labor and delivery

Bed rest (2nd trimester), O2 (if helpful), ? Anticoagulation,

Cesarian section, invasive monitoring, early ambulation
 CARE MANAGEMENT
● Preconceptual councelling
■ Peripartum risk
● Pregnancy
■ Decisions after evaluation risk
◆If possible – multidisciplinary approch
(cardiologist, perinsatologist,
anesthesiologist, ginecologist)
 ASSESSMENT
● Interview
■ Personal medical history
■ Heart disease (congenital, streptococcal infections, rheumatic
fever, valvular disease, endocarditis, angina, MI)
■ Factors increase stress of the heart (anemia, infection, edema)
■ Review cardiovascular and pulmonary system
◆ Chest pain, edema on face, hand, feet, hypertension,
heart murmur, palpitation,dyspnea, diaphoesis, pallor,
syncope
■ ◆ Cough, hemoptysis, shortness of breath,
■ Medication
Emotional status (depression, anxiety, fear of morbidity and
mortality for herself and featus)
 ASSESSMENT
● Examination
■ Vital sign
■ Oxygen saturation level
■ Pattern of edema
■ Discomphort of pregnancy
■ Weight gain
■ Sign of potential cardiac decompensation
 SIGN OF POTENTIAL
CARDIAC
DECOMPENSATIO
N
● Subjective symptoms
■ Increasing fatigue or difficulty of
breathing or both with usual activities
■ Feeling of smothering
■ Frequent cough
■ Palpitations; feeling that her heart is
racing
■ Swelling of face, feet, legs, fingers
 CONTI…….
● Objective signs
■ Irregular weak, rapid pulse (more 100b/m)
■ Progressive generalised edema
■ Cracles at the base of lungsafter 2
inspirations and exhalations
■ Orthopnea; increasing dyspnea
■ Rapid respirations (more 25 b/m)
■ Moist, frequent cough
■ Increasing fatique
■ Cyanosis of lips and nail beds
 ASSESSMENT
● Lab
■ Urinalisis
■ CBC
■ Blood chemistry
■ ECG
■ EchoCG
■ Pulse oximetry
■ Chest film
■ Fetal ultrasound
■ NST
 ANTEPARTUM CARE
● Critical period 28-32 weeks – hemodinamic
changes reach their maximum
● Reduce emotional stress, hypertension, anemia,
hyperthyroidism, obesity
● Class I and II
■ 8-10 h of sleeping + 30 min naps after eating
■ Activities: housework, shopping, exercise limited
● Class II
■ Avoid any activities that causes even minor signs of
cardiac decompensation
■ Admit to the hospital near term
● Class III, IV
■ Bed rest at the hospital
 ANTEPARTUM CARE
● Treatment of infections of GI, UT, Respiratory
● Adequate nutrition (folic acid, protein, fluid, fiber)
● Medication:
■ anticoagulant –
◆heparin (large molecule does not cross the placenta)
● Recurrent vein thrombosis
● Pulmonary embolus
● rheumatic heart disease
● Prostetic valves
● Cyanotic congenital heart defects
◆Monitiring clotting factors (blood test)
◆Avoid food high in vit K (raw, dark green and leafy
vegetables
◆Folic acid
 ANTEPARTUM CARE
● Digoxin: crosses placenta
● Procainamide: crosses placenta, no known teratogenic
effects
● Verapamil: crosses placenta, can produce maternal
hypotension
● Propranolol: crosses placenta, no known teratogenic
effects, associated with fetak bradicardia, IUGR, preterm
labour, neonatal respiratory depression
● Warfarin: crosses placenta, fetal anomalies, and
hemorrhage, congenital malformation, preterm birth,
stillbirth
● Furosemide: crosses placenta, no known teratogenic
effects, thiazides: crosses placenta, neonatal jaudice,
thrombocitopenia, anemia
 CONTI…..
● Lidocaine: crosses placenta, safe as long as
toxic leves avoided
● Quinidine: crosses placenta, no known
teratogenic effects, neonatal
thrombocytopenia
● Nifedipine: crosses placenta, maternal
hypotension
● Diazoxide: crosses placenta, hyperglycemia,
potential relaxant of uterine smooth muscle
● Sodium nitroprusside: crosses placenta, only
in critical care unit
 ANTEPARTUM CARE
● Heart surgery
■ Ideal scenario – before pregnancy
■ If need present – early at the second trim

Closed cardiac surgery – low risk

Open heart surgery – high risk r/t with

artificial circulation an temporary
hypoxia
 INTRAPARTUM CARE
● Routine assessment of laboring woman
● Assessment of cardiac
● decompensation Arterial blood gases
● ECG
● BP, Ps, Oxymetry
● Position: elevated upper part of body or side-lying
● Management of discomfort: supportive care, epidural analgesia
● Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline)
● Labour induction (syntocinon)
● Cervical rippening (prostaglandins)
● Vaginal birth
■ in side-lying position
■ Oxygen mask
■ Episiotomy
■ vacuum
■ extraction
● CS:Forceps
risk r/t with dramatic fluid shifts, sustained hemodinamic changes
and increased blood loss
● Dilute oxytocin is indicated, ergot products are contraindicated
 POSTPARTUM CARE
● First 24-48 h are the most hemodinamically difficult
● Assessment
■ Vital sign
■ Oxygen saturation levels
■ Lung and heart auscultation
■ Edema
■ Character of bleeding, uterine tone
■ Fundal height
■ Urinary output
■ Pain
● Activity rest pattern
● Elevated the head of the bed
● Family member help
● Brestfeeding is not
contraindicated
13. WHICH IS THE IDEAL CONTRACEPTIVE
FOR WOMEN WITH HEART
DISEASE ?
Contraception
1. OC pills are not ideal as they can cause thrombo
embolism.
2. IUCD can cause infection- endocarditis.
3. Barrier contraceptives – Have high failure rates.
4. Progestin only pills or Long acting
progesterone
injectableare better
PILL - Desogestrel
INJECTABLES
a. Medroxy
progesterone
150mg IM
every 3
months.
 PREGNANCY AND
CHD
CONCLUSIONS
● MOST WOMEN WITH HEART DISEASE
CAN HAVE A PREGNANCY PROPER
CARE.

● PRE-PREGNANCY EVALUATION
MANDATORY.

● HIGH-RISK CASES BENEFIT FROM

COMBINED HIGH-RISK OB AND CARDIAC
THANKS