DOI: 10.18410/jebmh/2015/608
REVIEW ARTICLE
CARDIAC DISEASE IN PREGNANCY AND ITS OUTCOME: A
RETROSPECTIVE STUDY
Sudha H. C1
HOW TO CITE THIS ARTICLE:
Sudha H. C. ”Cardiac Disease in Pregnancy and its Outcome: A Retrospective Study”. Journal of Evidence
based Medicine and Healthcare; Volume 2, Issue 29, July 20, 2015; Page: 4296-4307,
DOI: 10.18410/jebmh/2015/608
ABSTRACT: The incidence of Cardio Vascular Disease in pregnancy has remained stable for
many years since the significant decrease in RHD is compensated by increase in CHD in pregnant
women. Population based studies have reported incidence of CVD in pregnancy varies between
0.1 to 4%.
KEYWORDS: Cardiac disease in pregnancy and its outcome.
The objectives of the study:
1. To study the complications during antenatal, intrapartum and postnatal period in pregnancy
with cardiac disease.
2. To study the maternal and perinatal outcome in cardiac diseases complicating pregnancy.
METHODS: It is a retrospective observational study conducted on pregnant women with
cardiovascular disease >28 wks gestation admitted for labour to VVH attached to BMCRI,
Bangalore between the period of Jan 2009 to Dec 2013. The essential information of the patients
studied was gathered and recorded in the detailed proforma. The maternal complications, related
to the cardiac disease and obstetric complications, the perinatal outcome of the cases were
analysed.
RESULTS: Out of 165 cases in the study Cardiac Disease was found to complicate 0.22% of
pregnancy, RHD complicated about 73.33% and CHD: 20%, with isolated MS: 42%, ASD: being
the predominant lesion. The mean duration of onset of Cardiac Disease was 3.5 years, 64% of
patients belong to NYHA class II and 16% belong to IV class NYHA 1.32% of patients had
undergone Cardiac Intervention before pregnancy. Mean gest. Age of delivery was 38 wks. (78%)
and 82% of them had spontaneous onset of labour and 18% of them had induction of labour.
67.2% had spontaneous vaginal delivery and 13.9% had C. Section with 4.2% instrumental
delivery. CCF and Pulmonary HTN were the two main complications with 14% and 10%
respectively. 10% of patients had PPH, the main obstetrical complication. The incidence of preterm delivery was 18.2% and term delivery 80%, and 40% of babies weighed 1.5-2.5kg, live
birth rate: 96%, still birth: 4%, NICU admission: 18%, 4% of PNM was seen.
INTERPRETATION AND CONCLUSION: Majority of women with Cardiac Disease in pregnancy
can have a safe pregnancy and delivery provided proper medical care is given. The maternal and
perinatal outcome in these patients depends mainly on the functional cardiac status of the
mother at the time of pregnancy. Surgical correction of the cardiac disease before pregnancy has
a better maternal and perinatal outcome and they can tolerate pregnancy well.
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INTRODUCTION: Maternal heart disease complicates 0.4% to 4% of pregnancy and it is the
third major non-obstetric cause of maternal death during pregnancy and accounts for 10% of
maternal mortality.(1) There is a significant alteration in the type of cardiac lesion encountered
now, compared to 2-3 decades earlier, the estimated ratio of RHD to CHD has changed from 20:1
to 2:1, this is due to better medical management and early detection of CHD and surgical
correction prior to pregnancy and widespread use of antibiotics effective against the streptococcal
infection.
The likelyhood of favourable maternal and perinatal outcome depends on the (1) The
functional cardiac capacity; (2) Type of cardiac lesion; (3) Other associated complications; (4)
Quality of medical care provided. Optimum care of these potentially complicated pregnancies can
only be managed by a combined approach by the cardiologist and obstetrician in specialist center
with an understanding of the obstetric and cardiac complications that can arise.
OBJECTIVES:
1. To study the complications during the antenatal period, intrapartum period and postnatal
period in pregnancy with cardiovascular disease.
2. To study the maternal and perinatal outcome in cardiac disease complicating pregnancy.
REVIEW OF LITERATURE: One of the greatest wonders of the nature is the growth of the
foetus within its mother, 'The growth and development of the baby is dependent upon the health
of the mother because she is the both seed as well as soil where the baby is nurtured'. Hence,
extensive studies are done with the aim of decreasing the morbidity and mortality in these high
risk cases of women with cardiac disease in pregnancy.
Epidemiology: The overall incidence of heart disease in pregnancy is 0.3 to 3.5% and accounts
for 10% of maternal mortality.(2) The prevalence of pregnancy complicated by RHD has decreased
in developed countries and the former ratio of 3:1 for RHD: CHD complicating pregnancy is now
essentially reversed(2) Haemodynamic changes in pregnancy Major haemodynamic changes occurs
during pregnancy, labour, delivery and in the postpartum period. These changes begins to take
place during the first 5-6 wks and reaches their peak late in the second trimester which correlates
with a preexisting cardiac lesion.(3)
Physiological changes: During labour and puerperium.
First Stage: Cardiac output increases by 15%. Uterine contractions increases venous return,
causing increase in cardiac output & can cause reflex bradycardia.
Second Stage: Increase in intra-abdominal pressure (valsalva’s) causes increase in venous
return and cardiac output.
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Third Stage: Normal blood loss during delivery (around 250-350 ml).
It leads to:
a. Decrease blood volume
b. Decrease cardiac output.
 Blood Volume - ↑ significantly at 6 wks and reaches peak at 32 wks (4700- 5200 ml),
increase is about 45% (1200-1600 ml).(4)
 Cardiac Output = stroke volume x heart rate, co ↑ by 50% during the I trimester and
peaks between 25-35 wks, in early pregnancy ↑ in co is due to stroke volume and in late
pregnancy it is due to ↑ heart rate(5)
 Heart rate - ↑as early as 5 wks gestation to maximum rate of 15-20 beats per minute by
32 wks and peaks at the IIIrd trimester.
 Blood Pressure - ↓ as early as 7 wks and reaches peak by mid pregnancy by 10-15 mm
hg, due to ↓ peripheral vascular resistance.
 Systemic Vascular Resistance - significantly ↓ with concomitant ↓ in diastolic BP, due to
oestrogen, progesterone, N2O and relaxin.(5)
Changes in the peurperium: Haemodynamic changes of pregnancy begin to reverse within 1-3
days after delivery and cardiac output falls to non-pregnant level in two weeks of peurperium.
The clinical features in a normal pregnancy which can mimic a cardiac disease are:
1. Dyspnea - due to hyperventilation, elevated diaphragm.
2. Pedal Edema
3. Cardiac impulse- Diffused and shifted laterally from elevated diaphragm.
4. Jugular veins may be distended and JVP raised.
5. Systolic ejection murmurs along the left sternal border occur in 96% of pregnant women
and are believed to be caused by increased flow across the aortic and pulmonary valves.
New York Heart Association (NYHA) Functional Classification:
NYHA Class Symptoms:
1. Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g.
shortness of breath when walking, climbing stairs etc.
2. Mild symptoms (mild shortness of breath and/or angina) and slight limitation during
ordinary activity.
3. Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g.
walking short distances (20–100 m). Comfortable only at rest.
4. Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.(6)
Criteria to diagnose cardiac disease during pregnancy:
1. Presence of diastolic murmurs.
2. Systolic murmurs of severe intensity (grade 3).
3. Unequivocal enlargement of heart (x-ray).
4. Presence of severe arrythmias, atrial fibrillation or flutter
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Contraindication to pregnancy:
1. Pul arterial HTN of any cause.
2. Marfan’s syndrome with dilated aortic root >40 mm.
3. Aortic dilatation > 50mm in aortic disease.
4. Severe left heart obstructive lesion (severe MS, severe AS, native severe COA of aorta).
5. Previous peripartum cardiomyopathy with any residual impairment of LV function.
Management of pregnancy in women with heart diseases:
1. Diagnosis:
 History taking -thorough cardiac history
 Functional class assessment
 Physical examination
 Ancillary tests - CBC, PT, APTT, INR, obstetric ultra sound
 ECG
 2D echo - it is safe, rapid and useful diagnostic tool. In case of patient with aortic
dilatation 2D echo is done at 6-8 wks interval throughout the pregnancy till 6 months
post-delivery.
 Imaging - CXR is done in indicated cases only.
2. Antepartum Care: After diagnosis is established, the disease process classified, outcome
estimated, if there is no indication for termination of pregnancy, and if patient wishes to continue
the pregnancy general plan for prenatal care is discussed with the patient. Frequency of antenatal
visits that is once/month up to 28-30 wks, and once/2 wks until 36 wks and once/wk till delivery.
 Delivery in tertiary care.
 Physical activity - all patients must be advised to limit their physical activity, bed rest, in
most compromised cases and in patients with CHD rest is important to maintained the
oxygen saturation.
 Folic acid - supplementation, iron and calcium supplementation is done in all cases.
 Anticoagulants in patients with prosthetic valves, LMWH in I & III trimester and warfarin
between 12-37 wks.
 A constant vigilance for prematurity, symptoms of cardiac failure is required.
 Admission in case of NYHA Class III & IV and in patient with signs of decompensation,
infection, anaemia, pulmonary hypertension.
3. Management of Delivery:
 Delivery team - timing and mode of delivery should be discussed in advance, with a
multidisciplinary team consisting of obstetrician, cardiologists and anesthetist.
 Timing of delivery - in symptomatic women in good condition spontaneous delivery can be
awaited.
 Induction of labour is relatively safe procedure with either prostaglandins, mechanical
methods and with oxytocin(4)
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4. Mode of Delivery: Depends mainly on obstetric indication and the maternal haemodynamic
condition. Vaginal delivery is preferred in women with adequate, cardiac output and carries low
risk and is therefore recommended.(4)
Advantages of vaginal delivery:
 Decreased blood loss
 More rapid recovery
 Absence of abdominal surgery(7)
 Decreased thrombogenic risk
 Adequate pain relief with analgesics, epidural anesthesia helps to attenuate the
haemodynamic changes of labour and delivery.
 It allows controlled foetal descent to the pelvic floor by suppressing bearing down efforts.
5. Assisted vaginal delivery: Vaccum, forceps, extraction is recommended when excessive
maternal efforts and prolonged labour is contraindicated.
6. Caesarean Section:
 It annihilates the haemodynamic changes associated with labour.
 It permits more appropriate invasive and non-invasive haemodynamic monitoring.
 It increases the risk of thrombo embolism, infection and PPH.
 Controlled regional anaesthesia is preferred.
 Intrapartum Care
 I/V fluids: All cardiac patients in labour should be kept on the dry side of labour. I/V fluid
restricted to 75 ml per hour.
 Continuous monitoring with pulse oximetry.
 Desaturation during labour that is not corrected by oxygen is suggestive of the
development of pulmonary oedema.
 Patient with congenital, acquired heart lesions and artificial valves prosthesis shunt have
antibiotics prophylaxis at the time of delivery in order to avoid sub-acute bacterial
endocarditis.(8)
Post-partum period:
 Haemodynamic monitoring is continued for 24 hrs following delivery.
 Slow I/v infusion <20/ml of oxytocin to prevent maternal haemorrhage.
 Anticoagulants are continued in indicated cases to prevent thromboembolism.
 In patients with low risk for heart failure, normal ventricular function, strict observation for
a period of 48 hrs is required.
Possible Contraceptive Option:
1. Barrier Methods: This safe method but has a high failure rate and hence not
recommended to women when the maternal risk of pregnancy related complications is high.
3-30% failure rate but decreases the risk of STD.
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2. Hormonal Contraception:
a. Combined ON and PN contraception: Oestrogen compound is associated with risk of
both artery and venous thrombosis. It has got a good efficacy, but it should be used
with caution in women with mechanical valves and in patients with previous thrombo
embolic events are un operated ASD, Cyanotic CHD, it affects the metabolism of
warfarin.
b. Progesterone only pill i. Low dose progesterone is safer
ii. Mini pill can be used
iii. Depoprovera I/M
iv. Subdermal Implants
v. IUS (Mirena) Ideal for women with heart disease.
3. IUCD → Copper T device → IUS (Mirena)
Infective endocarditis prophylaxis has to be given. Insertion of the device has to be done
under S/A, E/A to prevent Vasovagal shock (9,10)
4. Sterilization:
i. Laparoscopic sterilization - Minimal CO2 is used, risk of air embolism is one of the
disadvantage.
ii. Mini laparotomy - Safest method if done under combined S/A or E/A in a tertiary centre.
METHODOLOGY: Source of Data: In the present study 165 cases of pregnant women with
cardiac disease more than 28 weeks gestation who are being admitted for delivery to Vani Vilas
Hospital affiliated to Bangalore Medical College and Research Institute (BMCRI), Bangalore in the
period from Jan 2009 to Dec 2013.
Method of Collection of Data: Pregnant women with cardiac disease with gestation period
>28 wks admitted to Vani Vilas Hospital was included in the sample. The previous records of the
patients were studied, to know the type of cardiac lesions, type of cardiac surgery undergone and
the treatment received earlier. Proper history of the patient is taken, after clinical examination a
clinical diagnosis was made in consultation with the cardiologist.
The following details of patients were noted and were analyzed as follows:
 Age of the patients
 Socio-economic status
 Whether the patient were booked at our tertiary centre, or elsewhere or unbooked.
 Whether the patients were referred from periphery or rural area, urban area in view of
cardiac disease.
 Obstetric index - gravida, parity, living issues, previous abortions, IUD's, still birth.
 History related to cardiac disease in detail.
 Age of onset of cardiac disease.
 Duration of the disease.
 Onset of exertional dyspnea.
 Paroxysmal nocturnal dyspnea.
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Palpitation, haemoptypsis, cough with expectoration.
Pedal oedema, syncopal attack.
Obstetric history in detail.
H/o CCF in previous pregnancy and the period of gestation of CCF.
Contraceptives used.
H/o rheumatic fever, recurrent sore throat, fleeting joint pain.
H/o cardiac surgery, CVA, thrombo embolism.
H/o medications, anticoagulants etc. for the cardiac disease.
General physical examination.
Built of the patient, nutritional status, height, weight was recorded.
Other signs of oedema, cyanosis, clubbing, teeth, gums, breast, spine and thyroid were
examined.
Examination of the cardiovascular system.
Pulse - rate, rhythm, volume character and peripheral pulses.
Neck was examined for presence of distended veins, excessive pulsations of the carotid
vessels, any thyroid swelling noted.
Blood pressure checked in all cases.
Jugular venous pulse.
Inspection of the chest wall for any precordial bulge, apical impulse and for any scar of
previous cardiac surgery.
Chest was auscultated for heart rate, heart sounds, murmurs and its characters, locations
and time of occurrence.
Respiratory system - examined for rhonchi, crepititons, breath sounds.
Patients were classified into different classes based on the NYHA classification based on
their symptoms.
Abdominal examination.
Careful p/v examination is done in indicated cases at the onset of labour pains.
ECG, 2D echo was done and cardiologists opinion was sought regarding further
management of the cardiac disease.
Patient was given intra partum, infective endocarditis prophylaxis as per the cardiologists
advice in indicated cases and antibiotic prophylaxis was given to all cases to prevent
infective endocarditis.
Prophylactic forceps, vaccum extraction were used in three cases to cut short second
stage of labour.
Most of caesarean section done for obstetric indication only.
Injection methergine was withheld in all most many of the cases.
Patients were kept in labour room for intensive monitoring for a period of 5-7 days after
delivery and then shifted to postnatal ward.
Antibiotics were given for a total period of 7-10 days following delivery.
Breast feeding - patients were advised breast feeding except in cases with severe
maternal CCF/pulmonary oedema treated in ICU.(12)
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All babies born to mother with CHD cardiac evaluation was done for CHD of new born and
two babies were found to have CHD in our study.
Patients were discharged after 10 days following delivery and were advised to continue
necessary medications and follow up with the cardiologists regularly for further treatment
and corrective surgery.
Maternal outcome was analyzed in terms of
 Type of delivery - spontaneous / induced (methods of induction)
 Gestational period - preterm / term
 Mode of delivery - vaginal, LSCS, instrumental delivery methods
 Obstetric complications - sepsis, postpartum haemorrhage, respiratory tract
 infection,
 Cardiac complications - CCF, AF, pulmonary edema, arrhythmias, IE were analysed.
Foetal outcome in terms of
 Term / preterm / IUGR / still birth / IUD
 Babies admitted to NICU in indicated cases in view of birth asphyxia, respiratory distress.
(13)
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Babies were followed up post natally and neonates were examined and evaluated for
congenital heart disease of new born in mother with CHD.
Sample size: Study includes 165 pregnant women with cardiac disease >28 wks gestation
admitted for delivery.
Inclusion Criteria:
1. Patients who are willing to give informed consent for the study.
2. All antenatal women with cardiac disease admitted to VVH and Bowring and Lady Curzon
hospital.
3. Antenatal cases with gestational age above 28 weeks gestation with cardiac disease.
4. Antenatal cases with previous cardiac surgical repair or operations on the cardia.
5. Cases treated earlier or untreated for cardiac disease, booked, un booked and referred
cases of antenatal women with cardiac disease will be enrolled for the study.
Exclusion Criteria:
1. All antenatal women with cardiac diseases with <28 wks gestation.
2. Pregnancy with cardiac diseases associated with risk factors like gestational diabetes, preeclampsia, anaemia, thyroid disease will be excluded.
3. Non consented antenatal women with cardiac disease >28 wks will be excluded (not
willing to give consent for the study)
Study Design: Prospective observational study conducted on pregnant women with cardiac
disease >28 wks gestation admitted for delivery.
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Study Period: Jan 2009 to Dec 2013.
Statistical Method: Descriptive and inferential statistical analysis has been carried out. Results
on continuous measurements are presented on mean±SD (mini - max) and results on categorical
measurements are presented in numbers (%)
Statistical Software: SPSS version 20 used for the analysis of the data. Microsoft word and
excel has been used to generate graphs, tables etc.
RESULTS:
Study Design: An retrospective clinical study.
Study Period: Jan 2009 to Dec 2013 165 pregnant women with cardiovascular disease >28 wks
gestation admitted for labour in Vani Vilas Hospital attached to BMCRI between Jan 2009 to Dec
2013 were studied.
The above table depicts the region wise distribution of the cases studied and it shows that
42% of the cases were from rural areas and 58% of the patients were from urban area.
The table 24 depicts the classification of study group by gravida status, it is evident from
the findings that the majority of the study groups were PrimiGravida constituting 58%, followed
by Gravida 3 is 20%, Gravida2 is 18% >Gravida 3 is 4%.
The table 27 depicts the type of the cardiac lesions seen in our study, MS was the
predominant lesion in RHD- 20%, ASD was the predominant lesion in CHD constituting 20% with
one case of Lutenbachers syndrome and 10% of cardiomyopathy cases (PPCM).(14)
DISCUSSION: This observational study was conducted between Jan 2009 to Dec 2013 in VVH
attached to BMCRI, in this study 165 pregnant women with cardiac disease admitted to VVH for
delivery was studied. The incidence in the present study is 0.22%.
Incidence: In my present study the incidence of cardiac disease complicating pregnancy is
0.22%.
CONCLUSION: Majority of women with cardiac disease in pregnancy can have safe pregnancy
and child birth provided the disease is diagnosed and evaluated before pregnancy and treatment
started at the right time and patient delivers in a tertiary care centre. Incidence of pregnancy
with cardiac disease admitted for labour in our study was 0.22%. PNM was 4%, with one case of
maternal death. RHD still predominant but incidence of RHD in developing countries has been
reduced by wide spread use of antibiotics effective against the streptococal bacterium which
causes Rheumatic fever. Early detection of CHD and surgical correction prior to pregnancy was
associated with better pregnancy outcome. Patients with CHD can have better maternal and
perinatal outcome if early detection, prompt treatment, meticulous antenatal, and postnatal care
is given to the patient at the tertiary level. It is not merely about the statistics it is about
extending the rapidly expanding frontier of cardio vascular medicine to a small yet very special
population where each successful pregnancy will serve not one but at least two precious lives.
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SUMMARY:
1. Number of pregnant women with cardio vascular disease studied from Jan 2009 to Dec
2013 – 165 cases.
2. Incidence is 0.22% in the present study.
3. Peak incidence is found in the age group between 20-25.
4. Majority of women were in the Socio Economic group of low Socio Economic status.
5. Most of the women were referred cases of 80% and 90% cases were booked cases.
6. Most of the women were primigravida about 43%.
7. Majority of the women had the duration of illness of 1-5 years (38%).
8. 73.3% of the heart disease was RHD and 20% had CHD with 6% PPCM in the present
study.
9. Among RHD 50% of patients had mitral stenosis and among CHD 20% had ASD which was
the predominant lesion.
10. 64% of the patients belong to NYHA class II and 16 % belong to class I according to NYHA
classification.
11. 14% and 6% of cases belong to class III and class IV respectively according to NYHA
classification.
12. 50% of cases were on medications before pregnancy for the cardiac disease and 2% had
undergone cardiac intervention before pregnancy.
13. 16% of patients had undergone PTMC before pregnancy, 6% had mitral valve repair with
mechanical valves and was on anti-coagulants.
14. About 76% of the patients delivered at term between 37-40 weeks gestation and 4%
delivered between 40-42 weeks, 20% were pre term deliveries.
15. Majority of women had spontaneous onset of labour with 82% and 18% of them had
induced delivery.
16. About 67.2% of patients had spontaneous vaginal delivery, 13.9% of patient had
undergone LSCS for obstetric indication, forceps applications in 0% and ventouse in 4%.
17. 24% of the patients had PPIUCD insertion and 6% of the cases underwent tubectomy
(concurrent).
18. CCF and pulmonary HTN was the most common cardiac complications in the present study.
19. Foetal Outcome.
 80% of term babies and 20% preterm babies.
 40% of babies weight between 1.6 - 2.6 kgs. and 60% of babies weight between
2.6 - 3.5 kgs.
 Live birth rate was 96%.
 MTP- 2 cases
 Low birth weight - 40%.
 12% of babies had NICU admission belonging to NYHA class III and IV and 6% of
babies had NICU admission belonging to NYHA class I and II.
 Two early neonatal deaths due to extreme pre-maturity and one case due to severe
birth asphyxia.
 PNM - 20%.
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AUTHORS:
1. Sudha H. C.
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of
Obstetrics and Gynaecology,
Bangalore Medical College and
Research Institute.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Sudha H. C,
Assistant Professor,
#936, 21st Main Road,
J. P. Nagar IInd Phase,
Bangalore – 78.
E-mail: drsudha69@gmail.com
Date
Date
Date
Date
of
of
of
of
Submission: 13/07/2015.
Peer Review: 14/07/2015.
Acceptance: 19/07/2015.
Publishing: 20/07/2015.
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