Maternal & Fetal outcome among women with
Heart Diseases
Dr. Wafa Fageeh
Correspondence to:
Dr. Wafa Fageeh
Consultant
Department of Obstetrics and Gynecology
King Abdulazziz University Hospital
PO Box 6615, Jeddah 21452
Saudi Arabia
Abstract
Objective:
The main objective of the present study is to examine maternal & fetal outcome in patients
with heart disease among a hospital sample of pregnant women.
Setting:
King Abdul-Aziz University in Jeddah
Method:
Retrospective analysis of all patients recorded in the labor room registry as having heart
disease over a period of 20 years from Jan-1986 to Dec-2005. For each patients demographic
data, fetal and maternal outcome were recorded. In addition the clinical grading of the heart
disease as assessed by the NYHA(1) system during pregnancy and after delivery as well as
the etiological and pathological diagnosis of cardiac was noted.
Results:
During the study period a total of 56,082 deliveries had taken place in KAUH, 288 cases of
heart disease were identified. The majority were cases of rheumatic heart disease 198
patients (68.75%), followed by congenital heart disease 78 patients (27.08 %), next were
cases of coronary heart disease 6 patients (2.08%), then were cases of cardiomyopathy 4
patients (1.38%), 2(0.69%) were miscellaneous.
Clinical grading of heart disease during and after delivery showed that 9 out of 74 patients in
class I had deteriorated, five became in class II while four became in class III.
18 out of 154 patients in class II had deteriorated, 14 became in class III, while 4 became in
class IV. All patients in class III(11) had deteriorated to class IV. Out of 4 patients in class
IV, 3 patients died.
forty five patients who underwent heart surgery prior to pregnancy were evaluated
separately, all patients( 24 ) in class I remained in the same class post delivery. 12 patients
(66%) from class II were post delivery reallocated to class I, while the rest ( 6 ) remained in
the same class. One patient in class III remained in the same class, while the other one
improved. One patient in class IV died.
Introduction
Pregnancy is a state of progressive stress that is usually well tolerated by healthy women.
However patients with compromised cardiac functions run a serious risk of severe morbidity
or even mortality if pregnancy is allowed to continue. Therefore and despite all advances in
surgical and medical technology, heart diseases are among the recognized, albeit indirect,
causes of maternal mortality [2]. Data from western countries showed that in the United
Kingdom cardiac diseases ranked third after pulmonary embolism and hypertensive disorders
as a cause of maternal death [3]. In the United States cardiovascular diseases were among the
leading indirect causes of maternal deaths [4-5].
In a recently published report on maternal mortality in Saudi Arabia, the main focus was on
obstetric causes of maternal mortality [6]. Thus the proportion of maternal deaths due to
what is regarded as “indirect causes” of maternal mortality remains unknown. The main
objective of the present study is to examine maternal mortality, which is primarily due to
heart disease among a hospital sample of pregnant women. As far as we know this aspect of
maternal mortality has not been examined before.
Patients and Method
The labor room registries at King Abdul-Aziz University Hospital for the 20 years period
from January 1986 to December 2005 were retrospectively reviewed in order to indentify all
patients with heart disease who had delivered during this period. For each patient the medical
record was retrieved and examined for the following data:
Personal data: age, weight, height, parity, past obstetric history and any significant medical
disorder other than heart disease.
Pregnancy outcome: Mode of delivery whether spontaneous or induced, duration of labor,
birth weight, gestational age, Apgar score at 1 and 5 minutes, and the presence of any
obvious congenital abnormalities.
The severity of the heart disease and type of cardiac lesion: The severity of the heart disease
was based on the clinical evaluation of the patients according to the New York Heart
Association for grading of heart diseases in pregnancy (N.Y.H.A). In addition, definite
diagnosis of the type and extent of the cardiac lesion normally made by the treating
cardiologist was recorded.
Results:
During the twenty year studied period a total of 56,082 deliveries had taken place at KAUH,
out of those 288 patients were identified as cases of heart disease, giving a prevalence of
0.5% for heart disease among delivering young patients. The majority, 90.9% (262 patients)
were booked cases, while the rest were unbooked patients who presented directly through the
emergency room.
Table (1) gives patient’s demographic date including age, parity, body mass index, past
obstetric history and any significant medical complications, other than heart disease.
Only 216(75%) of those patients were Saudi. The mean age of patients was 30.22 +_ 5.66
years. 8 patients (2.77%) were <18 years old. The means of patient’s weight, height and
body mass index were 65.68 +_ 13.07 kg,153.36 +_ 6.32 cm, and 25.9 +_ 6.42 respectively.
Only 42 (14.58%) patients were primigravidas. 59 patients (20.48%) were grandmultiparous
(>5 gravida), seven patients were para 13.
Additional medical complications were found in nineteen patients, ten had diabetes mellitus,
eight patients had chronic hypertension and twelve had anemia (hemoglobin less than 8.5
g/dl). One patient developed renal failure during the second trimester of pregnancy
secondary to heart failure.
Types of heart lesions: 198 patients (68.75%) were cases of rheumatic heart diseases, 78
patients (27.08 %) had congenital heart lesions, 6 cases (2.08%) were diagnosed as coronary
heart disease and the remaining 4 cases (1.38 %) were diagnosed as cardiomyopathy.
2(0.69%) were miscellaneous. Thirty five patients had undergone open-heart surgery before
pregnancy. (Table 2)
In the rheumatic heart group the majority were cases of mitral stenosis (99 patients) followed
by combined mitral valve disease (mitral stenosis + mitral regurgitation) 30 patients), then
mitral regurgitation (24 patients). Aortic stenosis (AS) and aortic regurgitation each occurred
in eight patients. 45 patients has miscellanies combinations of valvular diseases.
In the congenital heart group, the most common lesion was mitral valve prolapsed (50
patients), followed by ventricular and atrial spetal defects in 5 and 3 patients respectively.
In the relevant medications used during pregnancy the following were noted; 5 patients were
on anticoagulant treatment, 32 were on digitalis, 54 were on diuretics, 15 were on Beta
blocker, 25 were on aspirin, 27 were receiving antibiotics ( 6 on long acting penicillin, 2 on
erythromycin because of allergy to penicillin), and 1 patient was on persantin.
Clinical grading of heart disease according to ‘NYHA’ during pregnancy:
During pregnancy; 74 patients were graded as class I, 154 patients as class II, 11 patients as
class III and 4 patients as class IV.
Clinical grading of heart disease according to ‘NYHA’ after delivery:
Of class I patients, 41(55.4%) remained asymptomatic i.e. in the same class, however 9 (12.5
%) patients were reallocated because of worsening symptoms, 5 (6.9%) patient became class
II and 4 (5.55%) patients became class III. One(1.38%) of the latter was admitted to ICU
(intensive care unit) in the last trimester because of pulmonary edema. 12 patients did not
show up after delivery.
Of class II patients, 6 patients (3.89%) have improved i.e became asymptomatic after
delivery, and thus were reallocated to class I, while 118 patients (51.8%) remained in class
II. However 15 patients (9.74%) showed worsening symptoms, 11 patients (7.14%) were
reallocated to class III and 3 patients (1.94%) to class IV,4 (2.59%) patients did not show up
after delivery.
All patients in class III showed worsening symptoms and were reallocated to class IV. One
patient, a 30 year old with cardiomyopathy, had spontaneous vaginal delivery at 28 weeks of
gestation. Subsequently she was admitted to the ICU in acute heart failure and died one
month later.
Of the five patients in class IV, 4 patients died. One patient was a case of Eisenmenger’s
syndrome. She was 29 years old, para 0+2, delivered at 32 weeks of gestation by elective
cesarean section because of deterioration of her heart condition. Post delivery she developed
acute pulmonary edema, was admitted to the ICU for intensive treatment but eventually died.
The second patient was 26 years old, para 3, who was pregnant with twins and had double
mitral valve lesion. In her first trimester she was advised to have a termination of pregnancy,
but she refused. At 26 weeks of gestation she developed symptoms of premature labor and
was admitted to the hospital for rest where she stayed about 3 weeks before she was
discharged when her condition has improved. However few days later she was readmitted
with acute heart failure. She was immediately transferred to the ICU. Unfortunately, her
condition continued to deteriorate until she died.
The third patient para 0+2 presented to the emergency room in acute heart failure and an
intrauterine fetal death at 38 weeks of gestation. She delivered spontaneously and
immediately arrested. She was resuscitated and transferred to the ICU but died 48 hours
later.
The fourth case, 32 year old para 3+2 patient was a known case of cardiomyopathy who had
been operated on 2 years prior to her pregnancy. Despite initial improvement, her cardiac
condition subsequently deteriorated. At the time when she conceived she was already class
IV. At 32 weeks of gestation she had premature rupture of membrane and was delivered by
cesarean section. Post delivery she developed septicemia and acute heart failure. She died 3
days later despite intensive care management.
Forty five Patients who underwent heart surgery prior to pregnancy were evaluated
separately. Table 4 demonstrates the progress of their conditions post delivery.
All 24 patients in class I remained in the same class post delivery. 12 patients (66 %) from
class II were reallocated post delivery to class I, while the rest ( 6 ) remained in the same
class. One patient in class III remained in the same class, while the other one improved and
reallocated to class I.
One patient in class IV (the cardiomyopathy case) died 3 days post cesarean section delivery.
Table 3 gives previous and present obstetric data for the studied population. Labor occurred
spontaneously at term in 213 patients, while in 11 patients (3.8%) the primary indication for
induction of labor was their heart disease.
The mean gestational age at delivery was 38.14 +_ 3.07 weeks. Twenty eight patients went
in spontaneous preterm labor in addition to 1 who was delivered at 32 weeks because of her
cardiac condition. Cesarean section was performed in 27 cases, 9 for obstetric indication and
three because of deterioration in maternal cardiac condition. Instrumental vaginal delivery
was applied in 9 cases (3 forceps and 6 vacuum extractions).
The mean fetal birth weight was 3.343 kg. Low birth weight (<2500g) occurred in 15(5.2%)
cases. There were 7 (2.47%)cases of perinatal mortality all were stillbirths, there was no
neonatal deaths and no observed congenital anomalies.
Discussion:
Heart disease is one of the most common medical disorders encountered in pregnancy. In a
report of maternal deaths from 2000 to 2002 in the United Kingdom, cardiac disease
was the second most common cause[7]. Its incidence varies between 1 to 1.5%. However
there is a wide variation, not only in its overall prevalence rate but also, in the pattern of
distribution of the different types of cardiac lesions among different population. In the
present study only 0.5% of all deliveries which had taken place at KAUH over the twenty
years period from Jan-1986 to Dec-2005 were registered as having heart disease. It must be
emphasized that this figure does not necessarily reflect the true incidence of heart disease
among pregnant women, not only because of the inherent problems of retrospective studies,
but also because pregnancies which might have ended in abortions, were not included.
Nevertheless the results depict the pattern of distribution of cardiac lesions in developing
societies where rheumatic heart lesions constitute more than 70% of the cases[8-9]. This is in
contrary to the situation in developed societies where corrected congenital heart lesions
constitute the overwhelming majority of cases of heart diseases in pregnancy.
However the major objective of the present study is to examine maternal outcome among
patients with heart disease. The findings should be alarming to both obstetricians and
cardiologists alike. It shows that maternal mortality among patients with heart diseases is
probably higher than with any other medical disorder. Furthermore it highlights some
potentially avoidable factors.
The clinical grading of patient’s cardiac status using the NYHC classification is an important
predictor for both the course and outcome of pregnancy. Earlier publications showed that, by
and large, women in classes I and II have good prognosis [10]. However a major drawback
of the NYHC classification is the fact that it is based on subjective assessment of patients’
clinical symptoms ignoring both the type and the extent of the cardiac lesion. Under such
circumstances a potential problem of ‘false recurrence’ may develop particularly for patients
clinically categorized as class I or II and who might continue to have very mild symptoms as
long as they are not exposed to a real hemodynamic challenges[11]. Hemodynamic stress is
known to increase as pregnancy progresses reaching a peak during labor, patients would then
be at a serious risk of development of acute cardiac decompensation. In the present study
eight patients in class I (five were cases of mitral stenosis three were cases of mitral stenosis
and regurgitation ) became class II after delivery, one of the cases of double mitral had to be
admitted to the ICU during the third trimester because of acute pulmonary edema which is a
well known possible complication[12-13] Similarly fourteen patient in class II were
reallocated to class III after delivery, while four become in class 1V.
Patients in more advanced classes are at higher risk of serious morbidity or even mortality.
In this study almost all patients in class III were reallocated to class IV after delivery. The
highest mortality rates were among class IV patients (4 out of 5 patients died).
One of the mortality cases was a patient with Eisenmenger's syndrome, a recognized fatal
anomaly [14,15,16,17]. The only chance of treating such cases is by heart lung transplant
operation. Without surgical correction maternal mortality can be as high as 80%.
Based on this knowledge, patients with Eisenmenger's syndrome, who had no surgical
treatment, should be counseled for tubal ligation or termination of pregnancy.
Several reports have shown significant improvement in maternal and fetal outcome if
surgical correction of cardiac lesions were undertaken prior to pregnancy [18,19]. The result
of the present study reflects similar findings. However for such conclusion to be qualified
appropriate post operative evaluation and counseling should be performed by both
cardiologists and obstetrician. In the present study the maternal mortality which had taken
place among patients in this group i.e. patients who had previous cardiac surgery, was a case
of cardiomyopathy. Almost a year following her cardiac surgery she developed serious
complication so that at the time when she conceived she was already in class III. Whether or
not she was advised to have a termination of pregnancy is not known. Cardiomyopathy is
another fatal heart disease which is associated with a mortality of up to 50 during pregnancy
[20,21].
The demographic data of the studied group reflects a wide spectrum as far as age and parity
is concerned. eight primigravidae patients were below the age 18. It is possible that if those
young girls had had adequate counseling prior to pregnancy, some of them would have had
the benefit of surgical correction of their heart lesions prior to pregnancy. At the other end of
the spectrum are the grand multiparous patients (59 patients were multiparous, 7 of them
were para 13 and one was para 15). Obviously none of those patients had considered any
form of family planning. However it is difficult from such reviews to decide whether the
patients had refused medical advice or that none had been given in the first place.
The perinatal mortality (PNM) was seven times higher than the average PNM in this
hospital, (3.47%) . This was mainly due to the poor outcome in class III and class IV patients
i.e. extreme prematurity (<26 weeks) in 15 babies and 2 stillbirths associated with maternal
death.
In conclusion, it is obvious that heart diseases are serious and life threatening disorders
which progressively deteriorate with repeated pregnancies. The present study shows that
both patients and health care providers need to be aware of the seriousness of this problem.
Obstetric reports tends to put more emphasis on direct causes of maternal mortality leaving
out ‘indirect ones’ such as heart disease being more relevant to other medical specialties. It
must be emphasized that in developing countries pregnancy might be the only encounter that
women will have with any form of health care, Hence obstetricians have dual responsibility
of patients counseling for both the immediate and long term seriousness of her problem in
addition to obstetric care. With development in cardiac surgery obstetricians are expected not
only to see more cases but also to deal with women with corrected heart lesions who
previously were not expected to reach a stage of reproduction.
Table 1. Shows the patient's demographic data including age, parity, body mass
index, past obstetric history and any significant medical problems other than heart
diseases.
Saudi Patients
Mean Age
Patients less than 18
Mean Weight
Mean Height
Mean Body Mass Index
Primigravidas
Grandmultiparous
Para 13
Patients with Diabetes
Mellitus
Patients with Chronic
Hypertension
Patients with Anemia
(less than 8g/dl)
Patients with Renal
Failure
216 (72%)
30.22 ± 5.66
8 (2.77%)
65.68 ± 13.07 kg
153.36 ± 6.32 cm
25.9 ± 6.42
42 (14.58%)
59 (20.48%)
7 (2.43%)
10( 3.47%)
8(2.77%)
9(3.12%)
1(0.34%)
Table 2 shows the different types of heart lesions in the patients during their
pregnancy.
Rheumatic Heart Disease
Congenital Heart Lesions
Coronary Heart Disease
Cardiomyopathy
miscellaneous
Open Heart Surgery Before
Pregnancy
198 (68.7%)
78 (27.77%)
6 (2.08%)
4 (1.38%)
2 (0.69%)
45
Table
Spontaneous Labor
213 Patients
Induction of labor due to
heart disease
11(3.8%)
Mean gestational age at
delivery
38.14 ± 3.07 weeks
Spontaneous
labor
28 (9.72%)
preterm
Ceasarian Section
Instrumental
Delivery
27 (9.3%)
Vaginal
9 ( 3.01%)
3.343 kg
Mean fetal birth weight
Low
birth
weights
(<2500g)
15 (5.2%)
Perinatal Mortality
7 (2.47%)
3.
Gives
previous
and
present
obstetric
history for the
studied
population.
Table 4. Demonstrates the progress of the patients (45 )who underwent heart surgery
prior to pregnancy post delivery.
Improve reallocated in class I
(12)class II (1) class III
Remained in the same Class
(24) class I ( 6 )class II( 1 )class III
Deaths in Class IV
1
Acknowledgement
I would like to convey my deep thanks and appreciation to all who contribute in
this article, namely Dr Hanyah Abdulhadi Alkhify, Dr Amro Yossef Elias, Dr
Badr Saleh Saadawi and to the Medical Student Enas and Anas Rafa .who helps
in collecting data.
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