HEART DISEASE IN PREGNANCY

The number of women of childbearing age who have heart disease is diminishing as more
and more congenital heart anomalies are corrected in early infancy. The cardiovascular disease
which was once a major threat to pregnancy now complicates only approximately 1% of all
pregnancies.

The cardiovascular disorders that most commonly cause difficulty during pregnancy are
valve damage concerns caused by rheumatic fever or Kawasaki disease and congenital anomalies
such as atrial septal defect or uncorrected coarctation of the aorta. Aortic dilatation may occur
from Marfan syndrome and is also a concern.

CLASSIFICATION OF HEART DISEASE

Class Description
I Uncompromised. Ordinary physical activity causes no discomfort. No symptoms
of cardiac insufficiency and no anginal pain.
II Slightly compromised. Ordinary physical activity causes excessive fatigue,
palpitation, and dyspnea or anginal pain.
III Markedly compromised. During less than ordinary activity, woman experiences
excessive fatigue, palpitations, dyspnea, or angina pain.
IV Severely compromised. Woman is unable to carry out any physical activity without
experiencing discomfort. Even at rest, symptoms of cardiac insufficiency or angina
pain are present.

A woman with class I or II heart disease can expect to experience a normal pregnancy
and birth. Women with class III can complete a pregnancy by maintaining special interventions
such as bed rest. Women with class IV heart disease are usually advised to avoid pregnancy
because they are in cardiac failure even at rest and when they are not pregnant.

Risk Factors

Age
Heredity
Obesity
High cholesterol and blood pressure
Insulin resistance or diabetes

Left-sided Heart Failure

Left-sided heart failure occurs in conditions such as mitral stenosis, mitral

insufficiency, and aortic coarctation. In these instances, the left ventricle cannot move the large
volume of blood forward that it has received by the left atrium from the pulmonary circulation.
This causes back pressure the left side of the heart becomes distended, systemic blood pressure
decreases in the face of lowered and pulmonary hypertension occurs.

Manifestations

Pulmonary edema occurs when the pressure in the pulmonary vein reaches a point of
about 25 mmHg and fluid begins to pass from the pulmonary capillary membranes into
the interstitial spaces surrounding the lung alveoli and then to the alveoli themselves.
Shortness of breath it occurs because the pulmonary edema interferes with oxygen-
carbon dioxide exchange.
Productive cough with blood-speckled sputum it occurs when the pulmonary
capillaries rupture under the pressure and small amounts of blood leak into the alveoli.
Increase respiratory rate the chemoreceptors stimulate the respiratory center to
increase the respiratory rate when the oxygen saturation of the blood decreases from
dysfunction of the alveoli.
Increase heart rate
Increased fatigue, weakness and dizziness
Sleeplessness due to severe pulmonary edema
Paroxysmal nocturnal dyspnea it is the condition that when suddenly wakes at night
with shortness breath. Occurs because heart action is more effective when she is at rest.

Treatments

Anticoagulants to prevent thrombus formation if there is mitral stenosis.

Low molecular weight Heparin is the drug of choice for early pregnancy because
it does not cross the placenta and so does not have teratogenic effects.
Antihypertensives - to control blood pressure
Diuretics - to reduce blood volume
-blockes to improve ventricular filling

Right-Sided Heart Failure

Right-sided heart failure occurs when the right ventricle is overwhelmed by the amount
of blood received by the right atrium from the vena cava. It can caused by unrepaired congenital
heart defect such as pulmonary valve stenosis, but the anomaly most apt to cause right-sided
heart failure in women of reproductive age is Eisenmenger syndrome, a right-to-left atrial or
ventricular septal defect with an accompanying pulmonary valve stenosis.

Manifestations

Congestion of the systemic venous circulation

Decreased cardiac output to the lungs
Blood pressure decreases in the aorta because less blood is able to reach it
 Pressure is high in the vena cava from back pressure of the blood.
Evident jugular venous distention and increased portal circulation
Distended liver and spleen
Dyspnea and pain because of the extreme liver enlargement, as it pressed upward by
the enlarged uterus, puts extreme pressure in diaphragm.
Peripheral edema because the distention of abdominal and lower extremity vessels can
lead to exudate of fluid from the vessels into the peritoneal cavity.
Women who have an uncorrected anomaly of this type may be advised not to become
pregnant. If they do plan a pregnancy, because they need oxygen administration and
frequent arterial blood gas assessments to ensure fetal growth.

Peripartum Heart Disease

An extremely rare condition, peripartal cardiomyopathy can originate in pregnancy in

women with no previous history of heart disease. This apparently occurs because of the stress of
the pregnancy on the circulatory system. The mortality rate can be as high as 50%. It occurs most
often in African American multiparas in conjunction with gestational hypertension.

Manifestations

Shortness of breath
Chest pain
Non-dependent edema
Heart increase in size

Treatment

Advise to sharply reduce her physical activity

Diuretic
An arrhythmia agent to maintain heart function
Digitalis therapy
Low molecular weight Heparin to decrease the risk of thromboembolism
Immunosuppressive therapy

Diagnostic Procedure for Heart Disease in Pregnancy

History and clinical investigation a thorough physical examination considering the

physiological changes that occur during pregnancy is mandatory, including auscultation
for new murmurs, changes in murmurs, and looking for signs of heart failure. Oximetry
should be performed in patients with congenital heart disease.
Electrocardiography
 Echocardiography because echocardiography does not involve exposure to radiation,
is easy to perform, and can be repeated as often as needed, it has become an important
tool during pregnancy and is the preferred screening method to assess cardiac function.
Transoesophageal echocardiography Multiplane transducers have made
transoesophageal echocardiography a very useful echocardiographic method in the
assessment of adults with, for example, complex congenital heart disease.
Transoesophageal echocardiography, although rarely required, is relatively safe during
pregnancy. The presence of stomach contents, risk of vomiting and aspiration, and
sudden increases in intra-abdominal pressure should be taken into account, and fetal
monitoring performed if sedation is used.
Exercise testing it is useful to assess objectively the functional capacity, chronotropic
and BP response, as well as exercise-induced arrhythmias. It has become an integral part
of the follow-up of grown up congenital heart disease patients as well as patients with
asymptomatic valvular heart disease. It should be performed in patients with known heart
disease, preferably prior to pregnancy to assist in risk assessment.
Radiation exposure the effects of radiation on the fetus depend on the radiation dose
and the gestational age at which exposure occurs. If possible, procedures should be
delayed until at least the completion of the period of major organogenesis (.12 weeks
after menses). There is no evidence of an increased fetal risk of congenital
malformations, intellectual disability, growth restriction, or pregnancy loss at doses of
radiation to the pregnant woman.
Chest radiograph the radiograph should only be obtained if other methods fail to
clarify the cause of dyspnea, cough, or other symptoms. If the required diagnostic
information can be obtained with an imaging modality that does not use ionizing
radiation, it should be used as a first-line test. If a study that uses ionizing radiation has to
be performed, the radiation dose to the fetus should be kept as low as possible.
Magnetic resonance imaging and computed tomography Magnetic resonance
imaging (MRI) may be useful in diagnosing complex heart disease or pathology of the
aorta. It should only be performed if other diagnostic measures, including transthoracic
and transoesophageal echocardiography, are not sufficient for complete diagnosis.
Limited data during organogenesis are available, but MRI is probably safe, especially
after the first trimester. Computed tomography (CT) is usually not necessary to diagnose
CVD during pregnancy and, because of the radiation dose involved, is therefore not
recommended. One exception is that it may be required for the accurate diagnosis or
definite exclusion of pulmonary embolism.

Medical management

Percutaneous therapy
Aspirin is relatively safe, and its use can prevent pre-eclampsia inhigh risk women.
 Clopidogrel no teratogenic effects in animal studies, serious complications have
not been documented in case reports.
Diuretics can be used during pregnancy, if used before pregnancy and whenever is
necessary. Not indicated in pre-eclampsia; there is some concern that their use might
promote the occurrence of pre-eclampsia.
Beta-blockers have been used extensively during pregnancy with good safety
profile and no teratogenic effects. Monitoring of fetal growth is recommended as fetal
growth retardation has been described. Can be used during breastfeeding, avoiding
nursing infants at the time of peak beta-blocker plasma levels, usually occurring 3 to
4 hours after a dose.
Calcium channel blockers
Digoxin is considered safe through pregnancy when not exceeding
therapeutic levels. Has been considered the drug of choice in treating fetal
arrhythmias.
Adenosine treatment of choice for supraventricular tachycardia during
pregnancy; short half-life.
Procainamide can be used with relative safety to treat a variety of maternal
and fetal arrhythmias. Chronic therapy is not recommended during pregnancy
because of lupus like effects.
Lidocaine has been used as local anesthetic during pregnancy and is
relatively safe.
Flecainide has become the treatment of choice for fetal supraventricular
tachycardia. It is especially useful in treating cases refractory to digoxin and
in those complicated by hydrops fetalis.

Chamaidi, A. & Gatzoulis, M. (2006). Heart disease and pregnancy. Retrieved from
http://www.hellenicjcardiol.com/archive/full_text/2006/5/2006_5_275.pdf

Pilliteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing
family. Philippines: Lippincott Wiliams & Wilkins.