2. Content of lecture:
Significance of heart disease in
pregnancy?
Physiology adaptation
Preconception care.
Antenatal care with cardiac problem
Specific heart problems
Anticoagulation therapy
General advice for Medical Officers
3. How significant is heart disease
in pregnancy?
Accounts for 12% of maternal death in
1996.
Commonest cause of indirect maternal
death in Malaysia
In Sarawak there were a total of 9
maternal deaths from heart diseases in
the 3 years period between 2010-2012
4. How common?
•Coronary artery disease is uncommon in pre-
menopausal women of child-bearing age.
•Majority of cardiac conditions encountered during
pregnancy will be either congenital heart disease or
rheumatic valvular heart disease.
•Cardiac complications result from hemodynamic
changes that occur during pregnancy.
5. CVS adaptation to pregnancy
Cardiac output Increased by 45%
Stroke volume increased
Heart rate Increase by10-20 bpm
Blood pressure Reduced in the 1st
& 2nd
trimester.
CVP static
SVR & PVR Reduced 25-30%
sr,.colloid oncotic
pressure
Reduced 10-15%
10. Preconception counselling:
Counseling plays an important role!!!
Should be referred by cardiologist or
physician to the PPC Clinic, if the patient is
keen to embark on a pregnancy
Estimate the risk during pregnancy
Any optimization needed?
Contraception necessary if advised not to
conceive
11. Contraception:
Surgical: vasectomy
BTL
-Best, low failure rate (LFR)
-Laparoscopic/minilap
Barrier method: condom,
spermicides
Compliance issues,
High failure rate (HFR).
COCP:
POP: /Implanon NXT
Avoid in IHD, valvular heart
disease and Pulmonary
hypertension
Very useful
IUCD/LNG-IUS (Mirena) LFR, contraindicated in
prosthatic valve, endocarditis.
12. High Risk Heart Diseases
Women with the following conditions are usually
advised to avoid pregnancy.
Pulmonary hypertension (>60% systemic pressure)
Dilated cardiomyopathy, ejection fraction <40%
Symptomatic obstructive lesions (delay pregnancy
until the obstruction has been corrected)
Aortic stenosis
Mitral stenosis
Pulmonary stenosis
Coarctation of the aorta
Marfan syndrome with aortic root >40 mm diameter
Cyanotic lesions
16. Antenatal care:
Combined clinic
Precipitating factor of heart failure
Watch out for dangerous periods
Dental care
Rest/ diet/ smoke
Contraception
Planning of delivery (mode) always get
anesthetic review/opinion
Multidisciplinary Team approach maybe
necessary in high risk patients
COMPLIANCE to follow up is important
17. CVS drugs safety profile in pregnancy:
Beta-blockers safe
Digoxin safe
Diuretics Use judiciously
Ace-i unsafe
Calcium antagonist Use judiciously
Adenosine safe
Lidocaine safe
Procainamide safe
Quinidine Safe
Amiodarone unsafe
18. Mode of Delivery
• Formostpatients,vaginaldeliveryfeasibleandpreferable.
• Caesareansectionindicatedonlyforobstetricreasons,exceptthefollowing.
o Patientanticoagulatedwithwarfarin
o Patientwithdilatedunstableaorta(e.g.,Marfansyndrome)
o Severepulmonaryhypertension
o Severeobstructivelesionsuchasaorticstenosis
• High-riskpatientsshouldbedeliveredincenterwithexpertisetomonitor
hemodynamicchangesandintervenewhennecessary.
• Noconsensusregardingantibioticprophylaxisattimeofdelivery,butmany
institutionsroutinelygive.
19. Hemodynamic changes during labour and
delivery
• Hemodynamic changes often abrupt.
• With uterine contraction, up to 500 mL of blood may be released into circulation, causing
rapid increase in cardiac output and blood pressure.
• Cardiac output often 50% above baseline during 2nd
stage of labour and may be even
higher at time of delivery.
• During normal vaginal delivery, about 400 ml of blood is lost.
• With caesarean section, about 800 ml of blood is lost.
• After delivery of baby, abrupt increase in venous return (autotransfusion from uterus &
baby no longer compresses inferior vena cava).
• Autotransfusion of blood continues for up to 24 to 72 hours after delivery, and this is
when pulmonary oedema may occur.
20. Intra-partum:
Delivery in specialist hospitals
Fluid management important
Lateral position if symptmatic
Ensure good analgesia
Oxygen maybe necessary
CCU maybe required post delivery
Use syntocinon and avoid syntometrine
Shortened second stage in some cases
21. Intra-partum:
IOL and Mode of delivery generally follow
obstetric indication
SBE prophylaxis: IV Ampicillin 1 g &
gentamicin 1.5 mg/Kg (max 120mg)
followed by ampicillin 500mg 6 hourly till
delivery.
If allergic to penicillin: IV vancomycin1g
over 2 hours.
SBE prophylaxis only necessary in some
cases
22. Postpartum:
HIGH RISK period!!!!
CCU care
Counseling for contraception needs
Encourage to limit number of pregnancy and
BTL
Breast feeding not contraindicated.
High Risk E-discharge and home visits
compulsory
PPC clinic appointment if still keen on future
pregnancy
Family planning clinic appointment
(encourage BTL)
24. Atrial Fibrillation
Usually associated with another underlying cause,
such as mitral stenosis, congenital heart disease,
or hyperthyroidism.
Antithrombotic therapy recommended.
Use heparin in 1st
trimester and last month of
pregnancy. Subcutaneous unfractionated
heparin 10,000 to 20,000 units every 12 hours,
adjusted to achieve APTT 1.5-2.0 times control.
Use oral anticoagulant during 2nd
trimester. Target
INR 2.0-3.0.
Control ventricular rate with digoxin, calcium
channel antagonist, or beta blocker.
25. Valvular heart Disease
Most can be managed with conservative
medical measures.
Symptomatic or severe valvular lesions
should be rectified before conception
and pregnancy whenever possible.
Drugs should be avoided when possible.
26. Mitral Stenosis
Mild to moderate mitral stenosis can be
managed with diuretics and cardio
selective beta blockers.
Severe mitral stenosis should undergo
PTMC before conception, if possible.
PTMC recommended if develop severe
symptoms during pregnancy.
27. Mitral Regurgitation
Can usually be managed medically with
diuretics.
If surgery is required, repair is preferred.
28. Aortic Stenosis
Mild stenosis and normal left ventricular
systolic function can be managed
conservatively.
Moderate to severe stenosis or symptomatic,
delay conception until aortic stenosis is
corrected.
Pregnant women with severe aortic stenosis
who develop symptoms may require either
early delivery or percutaneous balloon
valvotomy or surgery before delivery.
29. Aortic Regurgitation
Isolated aortic regurgitation can be
managed with diuretics and vasodilator
therapy.
Surgery during pregnancy only for control
of refractory symptoms.
30. Anticoagulation therapy
Low molecular weight heparin (LMWH)
and Factor Xa inhibitors should not be
used in pregnancy unless Factor Xa
activity can be measured
The anticoagulation therapy for patients
with mechanical valves is of critically
important and should be managed by
Cardiologists
31. Anticoagulation: 1st
trimester
If warfarin maintenance dose is ≥5
mg/day, risk of teratogenicity is 8-10%.
Convert warfarin to subcutaneous
unfractionated heparin (UFH) b.d.
Maintain APTT 1.5-2X control.
If warfarin dose is <5 mg/day, risk of
teratogenicity is 2%. Discuss risks with
patient and the options of changing to
UFH or continuing warfarin.
32. Anticoagulation: 2nd
& 3rd
trimester
Use warfarin. Maintain INR 2.0-3.0.
At 36 weeks, admit patient and convert
to i.v. UFH. Plan for delivery once INR <1.5.
Stop i.v. UFH 6 hours before delivery and
restart 6 hours after delivery if no
bleeding.
First dose of warfarin can be given Day 1
post-partum. Stop i.v. heparin once INR
>1.8.
33. Shared care:
It’s important to maintain good
communication between the
Cardiologists/Physicians and the
Obstetrician
These patients should be f/up in a
combine clinic setting but shared care
with health clinics is possible depending
on the severity of cases
34. General Advice for MOs
1. If a pregnant woman is suspected or known to have heart disease, she should be referred
to a physician or cardiologist as soon as she is found to be pregnant. In the referral letter,
request the specialist to state clearly in his/her reply letter:
a. The cardiac diagnosis
b. Whether the pregnancy is allowed to continue or whether termination is
recommended
c. The type of antenatal follow up required – polyclinic, district hospital, hospital
with specialist or cardiac centre
2. If unsure, always check the drug formulary (MIMS, MOH “blue book”, internet
resources, etc) to confirm that whatever medication prescribed is safe to use during
pregnancy.
3. The best guide to how well a patient with heart disease is tolerating pregnancy is her
functional status. If the patient is asymptomatic and able to do moderate or heavy work
without any difficulty, then most likely she will also tolerate the pregnancy.
4. Physical examination should be geared towards looking for signs of heart failure – basal
lung crackles, raised JVP, peripheral edema.
Multiple repeat echocardiograms usually not necessary as the cardiac lesions are “fixed” and
unlikely to change during the course of the pregnancy
35. Think: What can you do to
reduce the morbidity and
mortality of pregnant
mothers with heart
diseases?
