Managing heart disease during pregnancy -
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Managing heart disease during pregnancy

Managing heart disease during pregnancy

by: Dr. Monica Agarwal
Sr. Consultant Obstetrics & Gynecology - Paras Bliss, Panchkula

Cardiac disease in pregnancy can be a challenge to manage as both the mother and baby are at risk. Even an uncomplicated normal pregnancy has many physiological changes which pose risk to cardiovascular system. Cardiac disease is a very common cause of maternal mortality in pregnancy.

Physiological changes

  • Peripheral vasodilation
  • Increase in cardiac output
  • Increase in plasma volume
  • Increased pulse rate
  • Labour – There is a sudden, increased cardiac output in second stage of labour due to auto transfusion of 300-500 ml of blood back in circulation and sympathetic stimulation by pain and anxiety. This is very dangerous for the mother and can make her prone to cardiac failure.

They can cause pulmonary edema at the time of delivery and post partum leading to cardiovascular compromise. This can be aggravated if excessive IV fluids are given or she has pre eclampsia.

Conditions where pregnancy is contraindicated

  • Marfan’s syndrome with dilated aortic root
  • Pulmonary hypertension
  • Moderate to severe left ventricular outflow tract obstruction
  • LVEF < 0.3
  • Mortality in these conditions is nearly 50%. So termination should be advised.

Guidelines for management

Prosthetic heart valves– Anticoagulation has to be given. If patient is on warfarin, then we need to change to a safe drug as warfarin causes embryopathy. We need to shift to low molecular weight heparin or unfractionated heparin. Aspirin is also given. Patient has to be under multidisciplinary team of obstetrician, cardiologist, anaesthetist, intensivist and neonatologist.

Mitrial valve stenosis is very common congenital heart disease which can cause pulmonary oedema at time of delivery.

Peri partum cardiomyopathy is another dangerous condition defined as dilated cardiomyopathy with congestive heart failure in the last month of pregnancy or within 5 months of delivery. Treatment is similar to that of heart failure patients.

Aim

  • Early detection
  • Optimisation
  • Monitoring for deterioration
  • Plan of delivery
  • Post partum surveillance

Management

  • Preconceptional counselling by a multidisciplinary team
  • Plan of management of labour and delivery
  • Minimise cardiovascular load during delivery or post partum period
  • Drugs given are diuretics, digoxin, hydralazine, nitrates to decrease load on left ventricle
  • Mode of delivery- Vaginal delivery is preferred with effective pain relief with low dose regional analgesia. Cutting down the second stage by vacuum or forceps application is preferred to minimise load on heart.
  • Oxytocin should not be given as bolus but as slow infusion
  • Fluids should be given very slowly
  • Methergin should be avoided
  • Carboprost is not recommended
  • Post partum very intensive monitoring is done as patient can suddenly collapse due to sudden fluid changes. Infection should be quickly treated.

So to conclude we can say that pregnancy with heart disease is a serious condition and should be carefully seen by a team and with this approach, outcome can be favorable.

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