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Rheumatic Heart Disease In Pregnancy

worldwide the incidence of heart disease with pregnancy is between 0.2 and 3.7%.   

The worldwide maternal mortality rate in pregnant cardiac patients is 10%  

In Egypt 8% of all maternal deaths and 28% of all indirect obstetric deaths are caused by heart disease. The maternal mortality ratio for cardiac diseases is 12/100,000  (Ntional Maternal Mortality Study,1992-93,Minisry of Health/child Survival Project,cairo,1994)  

Worldwide, the most common rheumatic heart disease is rheumatic mitral stenosis. Other conditions that must be considered when caring for pregnant women are mitral regurgitation and aortic valve lesions

Hemodynamic changes during Pregnancy

 

·       Cardiac output increases by as much as 40% starting as early as the 10th.  week , peaks by 28th. Week, and remains elevated until the end of pregnancy.

·       Blood volume increases by as much as 50%

·       Heart work increases by 30-40%

·       Peripheral resistance decrease.

 

In healthy pregnant women the functional capacity of the heart can deal effectively with these physiological demands. However, patients with cardiac disease have a limited cardiac functional  capacity and their hearts may fail to compensate for these changes.

Serious consequences may arise, such as:

·       Congestive heart failure

·       Acute pulmonary edema

·       Sudden death

·       Increased incidence of preterm labor

·       Increased incidence of IUGR and fetal demise

 

Diagnosis of heart Disease

 

-        Consult with Cardiologist

-        Ask patient: Most pregnant patients with rheumatic heart disease know that they have this problem beforehand

-        A minority of cases are discovered during pregnancy and the diagnosis may be difficult to make because:

·       the cardinal signs and symptoms of heart disease---easy fatigability, shortness of breath, orthopnea…etc—may be present with normal pregnancy

·       Ascultatory findings, such as murmurs, are commonly heard during pregnancy without having an organic cause

·       ECG changes seen can result from normal pregnancy, making even this diagnostic tool not adequately sensitive to investigate a cardiac problem

 

Symptoms include: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitation, easy fatigability.

 

Grades of dyspnea:

-        Grade I: No limitation of activity

-        GradeII: Shortness of breath with extraordinary activity

-        GradeIII: Dyspnea with ordinary efforts

-        Grade IV: Dyspnea at rest

 

Pregnancy usually deteriorates dyspnea by one grade so that 50% of women who develop heart failure during 28-32 weeks gestation actually started pregnancy at Grade I and II

 

Signs include: caynosis, clubbing of fingers, marked parasternal pulsation, marked congestion of neck veins

 

NB. Adequate history taking will provide valuable information that may be the first clue to making an accurate diagnosis

 

Prognostic Criteria

 

·       The degree of organic lesion, its type, and the degree of dyspnea at the start of pregnancy

·       Performance in previous pregnancies

·       Cardiac enlargement

·       Auricular fibrillation (AF)

·       Any associated problem such as hypertension or anemia

 

Antenatal care

-        Combined cardiac and obstetric care

-        More frequent visits (every two weeks) specially of there is history of previous heart failure

-        Encourage adequate rest and sleep of not less than 8 hours/day

-        Warn against excessive weight gain

-        Restrict salt in diet

-        Suggest diet rich in proteins and low in fats and carbohydrates

-        Treat anemia

-        It is important to rule out presence of any septic focus

-        Use prophylactic long-acting penicillin, 1.200.000 IU every 15-30 days

-        Treat any chest infection as an emergency

-        Advise patient to avoid factors that cause tachycardia

-        Order rest and decreased physical efforts starting from 28 weeks

 

Indications for hospitalization/referral during antenatal period

 

·       Patients with Grade II dyspnea or higher should be admitted a week before their expected date of delivery

·       Grade III should not leave until reaching Grade I

·       Grade IV should not leave hospital at anytime until after delivery

·       Severely anemic patients should remain in hospital until their condition is corrected

·       Respiratory tract infection patients should remain in hospital until they are adequately treated

·       Hypertensive patients should remain in hospital until their condition is adequately controlled

·       Edematous patients should remain in hospital until the cause of their condition is investigated and successfully treated

 

Digitalization

 

Should be carried out in the presence of cardiologist in hospital whenever possible. It is recommended for patients with:

-        Grade II or more

-        Cardiac enlargement

-        AF with rheumatic fever

-        Heart failure

 

NB- start digoxin with loading dose 1-1.5mg/24hours. Maintenance dose is usually 0.25mg/day

-        If there is any need for diuretics in a cardiac patient , the safest approach is to start with chlorothiazede.

-        Furosemide should not be used unless it is necessary for life-threatening conditions

 

Obstetric Management

 

·       Observe strict use of aseptic technique

·       Avoid prolonged exhaustion

·       There is no indication for induction of labor or cesarean delivery for cardiac disease unless there are other indications

·       Provide adequate analgesia and oxygen during labor

·       Deliver fetus with patient in the semi-seated position

·       Provide antibiotic coverage during labor(parenteral 2gm ampicillin+80mg gentamicin) depending on timing of the woman's labor:

-        2hours before delivery and 8 hours postpartum

-        After membrane ruptures and a second dose 8 hours later , or

-        After clamping of the cord and 8 hours later

·       Avoid having the patient strain in the second stage; cut it short

·       Restrict fluid intake to not more than 75m/hour

·       Avoid the routine use of ergometrine

 

Important Considerations

 

·       There is no contraindication to breast feeding for mothers with rheumatic heart disease if they are not in failure

·       Early ambulation is very important to avoid possible postpartum embolization

·       Postpartum observation in hospital for not less than 48 hours is mandatory

-         

 

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03/17/2007