Cardiac Disease

The cardiac illness affects about 1% of all pregnancies and is the leading cause of maternal death among mothers. Rheumatic heart disease was once 8-9 times more frequent than congenital heart disease.

Physiological Changes in the Cardiovascular System During Pregnancy

The circulatory dynamics of a normal pregnancy change to match the increased needs of the fetoplacental unit. This considerably increases the workload on the heart. The following are the major cardiac changes:

• 40% increase in cardiac output
• An increase in blood volume of 35%
• Total peripheral resistance decreases
• The blood pressure drops in the first and second trimesters and then returns to normal in the third trimester. The pulse pressure has increased.

During labor, cardiac output increases during contractions and decreases between them. After birth, blood returns to circulation from the placental bed, pelvis, and lower limbs as a result of the uterus being relieved of pressure by emptying.

A healthy heart can easily adapt to this alteration. This increased blood volume and cardiac output in a patient with heart disease make the condition serious and difficult.

Types of Cardiac Disease

Acquired heart disease (90%)

• Rheumatic heart disease (80 %)
• Mitral stenosis
• Mitral regurgitation
• Aortic stenosis
• Aortic regurgitation
  1. Cardiomyopathy
  2. Coronary artery disease

Congenital heart disease (10%)

• Atrial septal defect
• Ventricular septal defect
• Patent ductus arteriosus
• Tetralogy of Fallot
• Coarctation of aorta

Classifications

The NYHA (New York Heart Association) classification ranks the severity of heart disease based on the patient's functional impairment.

Class 1:

• There are no restrictions on physical exercise.
• Normal physical exercise does not result in excessive weariness, dyspnea, palpitation, or anginal pain.

Class 2:

• Physical activity is restricted slightly.
• Patients are at ease while resting.
• Physical exercise causes tiredness, palpitation, dyspnea, and anginal discomfort.

Class 3:

• Physical exercise is severely restricted.
• At rest, patients are at ease.
• Excessive physical exertion causes tiredness, palpitation, dyspnoea, and anginal discomfort.

Class 4:

• Inability to engage in physical activities without pain
• Even at rest, symptoms of heart insufficiency or angina may be present.

Class 1 and 2 women generally do well throughout pregnancy; nevertheless, additional cardiovascular stress arises as a result of various complications such as PIH, anemia, hemorrhage, and infection.

Effects of Cardiac Disease

• Maternal
• The majority of deaths are caused by heart failure, and the majority of deaths occur shortly after birth. Pulmonary edema, pulmonary embolism, active rheumatic carditis, subacute bacterial endocarditis, and rupture of a coronal aneurysm in coarctation of the aorta are the causes of death.
• Acute cardiac failure may occur. Anemia, respiratory infection, intense exercise, any febrile sickness, emotional upset, and so forth all increase this condition.
• Fetal: An increase in the number of spontaneous abortions
• Premature labor is a risk.
• IUGR
• Stillbirth
• Congenital malformation risk is increased.

Diagnosis of Cardiac Disease in Pregnancy

• Taking a history of rheumatic fever, syphilis, congenital lesion, coronary lesion, coronary insufficiency, and so forth.
• Inquire about your symptoms in detail.
• Consider your previous medical history as well as your family's medical history.
• Inspection, palpation, percussion, auscultation, vital signs, investigation, O2 saturation, urine output, CVP line, and other relevant procedures are performed on the patient.
• Symptom-based functional classification

Management

• Early diagnosis and evaluation of case functional grading
• To prevent, detect, and implement effective heart failure therapy.
• To avoid and manage the added complication.
• Hospital delivery is required.

Management During the Antenatal Period

The fundamental goal of antenatal treatment is to minimize situations that can cause tachycardia, such as activity, stress, anemia, infection, and so on, thus patients with cardiac disease should be cared for from start to finish in a referral hospital.

• The patient should be handled collaboratively by an obstetrician and a cardiologist.
• Adequate rest: the patient should sleep for 10 hours at night and relax for 2 hours at midday.
• Limit your activities and avoid excitement and tension.
• The diet should be low in salt. Reduce carbohydrate and fat intake while increasing protein intake; avoid high-calorie or spicy diets.
• Anemia should be treated with the proper medication.
• Because infection and febrile sickness are harmful, maintain infection preventive measures such as avoiding crowded locations and taking prophylactic antibiotics.
• Encourage the patient to have regular antenatal check-ups to detect any anomalies early on.
• Adequate dental care should be recommended to avoid potential infection sources.
• Suggest an elective admission for a labor patient.
  • Class 1: at least 2 weeks prior to labor
  • Class 2: At 28th weeks especially in cases of unfavorable social surroundings.
  • Class 3 and 4: As soon as pregnancy is diagnosed. The patient should be kept in the hospital throughout pregnancy.
• Continuously monitor mother and fetal well-being in the event of another negative pregnancy condition.
• The patient should be a nurse in a propped-up position, begging for rest.

Management During Labor

Induction and cesarean sections are not permitted. The patient must be permitted to give birth spontaneously.

During the first stage of labor:

• Maintain total bed rest and a left lateral position to reduce aorta canal pressure caused by the gravid uterus.
• Oxygen should be maintained nearby and supplied as needed.
• The patient should be kept quiet by administering analgesics, the best of which is epidural analgesia.
• Giving I/V fluids should be done with caution. To avoid pulmonary edema and cardiac overload, the amount should not exceed 75ml/hr.
• Every 12 - 1 hour, carefully monitor vital signs and perform a cardiovascular assessment.
• Antibiotics can be provided as a preventive measure to avoid endocarditis. Ampicillin 2gm IV, gentamycin 60-80 mg, and so on.

During the second stage of labor:

• To reduce the additional pressure on the heart caused by bearing down, the second stage can be shortened with the use of outlet forceps or a vacuum.
• Frusemide 40 mg I/V must be given shortly after the baby is born.
• Methergine is not recommended.
• As needed, O2 treatment.

During the third stage of labor:

• The third stage of labor will be managed using conventional management as active management. A small amount of blood loss is helpful, but if it is excessive, oxytocin can be administered by infusion.

Management During Puerperium:

• For the next 24 hours, the patient should be closely monitored.
• She should be placed on complete bed rest in a position that is comfortable for her.
• To promote sleep and repose, 15mg of intramuscular morphine is administered as follows.
• O2 is supplied continuously or intermittently as needed.
• Hourly pulse, respiration, and blood pressure readings should be taken.
• The patient should be admitted to the hospital for two weeks. She should be restricted to bed for the first week and allowed to move her limbs. If everything is normal after one week. She might be allowed to get out of bed.
• The temperature is checked daily, and antibiotics are continued.
• Lactation is permitted unless a cardiovascular problem exists.