1. UNDERSTANDING
HEART DISEASE IN
PREGNANCY
DR NAZIMAH IDRIS
O&G
HOSPITAL ALOR SETAR

2. • 0.4-5.0% of pregnant women
• Commonest non-obstetric cause of maternal
mortality in Malaysia – 10% of all maternal
deaths in 1996
• Most common disorders : rheumatic valve
disease, congenital heart disease,
cardiomyopathy

3. Physiological changes

4. Antenatal

5. Parameter
1st TM
2nd TM
3rd TM
Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pressure
Systemic vascular
resistance
↑
↑
↑
↑
↔
↓
↑
↓
↑↑
↑ ↑- ↑ ↑ ↑
↑↑↑
↑↑
↓
↓↓
↑↑
↓↓↓
↑↑↑
↑ ↑- ↑ ↑ ↑
↑, ↔ or ↓
↑ ↑- ↑ ↑ ↑
↔
↓
↔
↓↓

6. Blood volume
• Increases as pregnancy progresses, peaking
at 40-50% above non-pregnant level
between 32nd and 36th week, plateaus until
term.
• Clinical importance: physiological anaemia.
(RBC mass increases by only 17-40%)

7. Parameter
1st TM
2nd TM
3rd TM
Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pressure
Systemic vascular
resistance
↑
↑
↑
↑
↔
↓
↑
↓
↑↑
↑ ↑- ↑ ↑ ↑
↑↑↑
↑↑
↓
↓↓
↑↑
↓↓↓
↑↑↑
↑ ↑- ↑ ↑ ↑
↑, ↔ or ↓
↑ ↑- ↑ ↑ ↑
↔
↓
↔
↓↓

8. • Cardiac output increases by 30-50% above
the pre-pregnancy level and peaks around
end of 2nd TM (20th-24th week)
• Increase is due to increase in stroke volume
initially and then an increase in heart rate
by about 20%.
(CO = SV x HR)

9. Changes in CO, SV and HR in Pregnancy
↓BP due to ↓systemic vascular resistance

10. Parameter
1st TM
2nd TM
3rd TM
Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pressure
Systemic vascular
resistance
↑
↑
↑
↑
↔
↓
↑
↓
↑↑
↑ ↑- ↑ ↑ ↑
↑↑↑
↑↑
↓
↓↓
↑↑
↓↓↓
↑↑↑
↑ ↑- ↑ ↑ ↑
↑, ↔ or ↓
↑ ↑- ↑ ↑ ↑
↔
↓
↔
↓↓

11. • Fall in systemic vascular resistance
• Fall in blood pressure especially in
midpregnancy
• Increase in pulmonary blood flow, reduce
pulmonary vascular resistance, unchanged
pulmonary artery pressure
• Supine hypotension syndrome in late
pregnancy

12. Labour and delivery

13. • Anxiety, pain and uterine contractions
increase cardiac output by about 50%

14. Cardiac output changes

15. Postpartum

16. • Immediate postpartum – increase in venous
return due to relief of caval compression
and auto-transfusion from the contracting
uterus.
• Within hours – heart rate and cardiac output
starts to decrease

18. Note:
Physiological adaptations in healthy
women cannot be applied to patients
with pre-existing heart disease.

19. Management principles
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND
STRATIFICATION
OF MATERNAL
AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY
AND COMPLICATIONS OF HEART
DISEASE

20. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY

21. Pre-conceptual
counselling
• Target: Heart disease patients of
childbearing age and their
husband/family.
• Assessment: Maternal and fetal risks in
the event of pregnancy

22. Issues:
• - Effect of pregnancy on the heart
• - Effect of cardiac disorder on fetal
development
• - Effect of maternal drugs on fetus
• - risk of genetic transmission to fetus
• - need for compliance

23. • Patients with heart disease should be
encouraged to complete their family early and
discouraged from too many pregnancies
• High risk patients – advise for sterilization.
E.g. Pulmonary HPT, Eisenmenger’s
syndrome, Cyanotic heart disease, Poor left
ventricular function, Marfan’s syndrome

24. • Whenever possible, correct cardiac
lesions before pregnancy, e.g.
- Congenital defects
- Mitral stenosis – symptomatic or severe MS
with MV area <1.0 cm².
- Severe aortic stenosis (valve area <1.0
cm²), impaired exercise tolerance, reduced
left ventricular function.

25. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY

26. Detection of cardiac
disease in pregnancy
• History
• Physical examination
• Investigation
Note: Symptoms and signs of heart
disease and normal pregnancy may be
similar.

27. History
• Dyspnea
• Palpitations
• Estimation of effort tolerance (NYHA
Functional Classification)
• History of rheumatic fever, cardiac
surgery and hypertension
• Drug history

28. NYHA Functional Class
• NYHA 1
no limitation. Ordinary physical activity
does not cause undue fatigue, dyspnoea
or palpitation.
• NYHA 2
slight limitation of activity. Comfortable
at rest. Ordinary physical activity results
fatigue, dyspnoea or palpitation.
•
NYHA 3
marked limitation of physical activity.
Comfortable at rest but less than ordinary
activity will lead to symptoms.
• NYHA 4
symptoms of failure are present at rest. With
any physical activity, increased discomfort is
present.
in

29. Physical examination
• Clubbing, cyanosis, features of Marfan
Syndrome
• Pulse for arrhythmia
• BP
• JVP
• Precordial examination – murmurs, RV
hypertrophy, presence of loud second heart
sound (pulmonary hypertension)

30. Investigations
• ECG
• ECHO- sometimes this is the only
reliable method in determining whether
a cardiac murmur is significant/non
significant in a pregnant patient.

31. • THEREFORE,
THE THRESHOLD
FOR AN ECHO
SHOULD BE LOW.

32. RISK CATEGORIZATION
–
–
–
–
–
–
–
–
NYHA functional class.
Presence of cyanosis
Left and right ventricular function
Severity of pulmonary hypertension
Presence of valve/conduit stenosis
Presence of conduction defects/arrhythmias
Smoking
Multiple gestation

33. • NYHA Functional class:
- The maternal prognosis is strongly
related to NYHA functional class prior to
pregnancy.
• Maternal mortality varies from <1% in
those with NYHA 1 or 2 to around 7% in
those with NYHA 3 or 4.

34. Low risk
–
–
–
–
–
–
Uncomplicated septal defect.
Aortic and mitral regurgitation.
Pulmonary stenosis
Hypertrophic cardiomyopathy
Acyanotic Ebstein’s anomaly
Corrected transposition withour other
defects

35. Moderate risks
– Prosthetic valves on anticoagulant
– Coarctation of aorta

36. High maternal and fetal risks
– Pulmonary hypertension (pulmonary pressure
>75% systemic pressure)
– Eisenmenger syndrome
– Uncorrected Cyanotic heart disease
– Severe aortic stenosis
– Severe mitral stenosis
– Poor LVF(LVEF<40%) irrespective of etiology
– Marfan’s syndrome (aortic root diameter >40mm)

37. Additional fetal risks
• Impaired maternal functional class,
smoking and cyanosis are associated
with poor fetal outcomes.

38. Level of care
• HIGH RISK patients are ideally managed in
tertiary centre with a multidisciplinary team
approach.
• MODERATE RISK can be managed in
hospitals where specialists are available.
• LOW RISK can be managed in the clinic by
their primary care doctors.

39. Specialist referral
• Known heart disease or previous cardiac
surgery who have not been assessed or risk
categorised prior to pregnancy
• Moderate to high risk
• Worsening symptoms due to heart disease
• Suspected heart disease, to confirm or refute
diagnosis

40. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY

41. General principles of Mx
•
•
•
•
Assess maternal and fetal health.
Assess NYHA functional class.
Confirm clinical diagnosis.
Establish baseline hemodynamics
(LVEF, PAP by ECHO)
• Consider termination in high risk cases

42. • Identify factors that can precipitate
complications e.g. Anemia, infection,
hypertension - treat accordingly.
• Complications of heart disease should be
identified and treated.
–
–
–
–
Heart failure
Worsening left to right shunt
Thromboembolism
Arrhythmias

43. MANAGEMENT OF SPECIFIC
CONDITIONS

44. Valvular heart disease
• Mitral stenosis:
• -Mild to moderate (MV area >1 cm²)
tolerates pregnancy well with use of
diuretics and beta-blockers
• -Severe MS (MV area <1 cm² and/or
PHT) should be considered for mitral
vulvotomy during 2nd TM

45. • Mitral Regurgitation and Aortic Regurgitation –
generally well tolerated
• Mild to moderate Aortic stenosis – well tolerated
• Severe Aortic stenosis – if clinical deterioration is
evident – terminate pregnancy
• Pulmonary stenosis – rarely problematic
• Prosthetic heart valves –most tolerate pregnancy
well. Requires full anti-coagulation.

46. Congenital heart disease
• Risk of CHD to offspring is increased (3.416.1%)
• Low birth weight, prematurity and fetal
wastage increased in cyanotic mothers.
• Acyanotic CHD (ASD, VSD, PDA) – well
tolerated in pregnancy
• Cyanotic CHD – associated with Pulmonary
HPT.

47. Pulmonary Hypertension
• Present when the pulmonary artery systolic and
mean pressures are >30mmHg and >20mmHg.
• High maternal mortality – 40-50%, usually at the time
of delivery or early postpartum
• Mx:
- consider termination if early,
- anticoagulation, continuous O2 therapy, hydration if
near fetal viability

48. Anticoagulation in
pregnancy
Indications:
- Mechanical heart valves
- Venous thromboemboolism
- Atrial fibrillation with structural
heart disease

49. Anticoagulation agents
Warfarin
- excellent anticoagulation
- generally avoided in first trimester
(risk of embryopathy esp. in doses >5mg dly
- avoided after 37 weeks
(risk of fetal bleeding in labour)
Heparin
- does not cross placenta
- in first trimester and after 37 weeks
- prob. of thrombocytopenia and osteopenia
Low Molecular Weight Heparin (LMWH)
- advantages over unfractionated
heparin (UFH)

50. Anticoagulation regimes
Fetal Complications
Maternal
Complications
Spont Abort
Cong AbN
TE
Death
Option I
Combined
heparin and
warfarin
24.8%
3.4%
9.2%
4.2%
Option II
Heparin
throughout
23.8%
0–
2.8%
33.3%
15%
Option III
Warfarin
throughout
24.7%
6.4%
3.9%
1.8%

51. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY

52. Labour & Delivery
• When, where, how – individualised
• Monitoring during labour and
postpartum
• Pain relief during labour
• Antibiotic prophylaxis

53. In summary…

54. Pre-pregnancy
• All women with heart disease should be
counselled on maternal and fetal risks
should they become pregnant
• Wherever indicated, significant cardiac
lesions should be corrected prior to
pregnancy

55. During pregnancy
• Pregnant patients with heart disease
should be risk stratified
• Low risk – Managed by primary care
doctors
• Moderate risk – Hospital with
Specialists
• High risk – Tertiary care centre

56. • Complications should be looked for and
treated
• Patients requiring anticoagulants should
be counseled on the available options

57. Labour and delivery
• Moderate and high risk – Labour and delivery
best managed by multidisciplinary team
• Timing and mode of delivery should be
individualised
• Adequate analgesia during labour is
important
• Antibiotic prophylaxis during labour in patients
susceptible to endocarditis

58. CONCLUSION
• Cardiovascular diseases are major
maternal mortality and morbidity
causes of
• An understanding of the physiology of the
cardiovascular adaptation in pregnancy and its
pathophysiology in disease states is crucial to
efficient management of these diseases in
pregnancy
• The importance of prevention of
pregnancy
cannot be overemphasized
in certain cardiac
diseases

59. Pregnancy is special,
lets make it safe.