Heart Diseases in Pregnancy

Regarding heart diseases in pregnancy answer the following questions:

1. Which cardiovascular change is not physiological in pregnancy:
a. Split 1st heart sound
b. Mid diastolic murmur
c. Shift of apex beat to 4th ICS and outwards
d. Decreased peripheral vascular Resistance.

Answer: b. Mid diastolic murmur

2. Indication for cesarean section in pregnancy is:
a. Mitral stenosis
b. Aortic aneurysm
c. PDA
d. Transposition of great vessels

Answer: b. Aortic aneurysm

3. Surgery for mitral stenosis during pregnancy is done at:
a. 8 wks
b. 10 wks
c. 14 wks
d. 22 wks

Answer: c. 14 wks

4. Which of the following disease has worst prognosis during pregnancy:
a. Pulmonary stenosis
b. Mitral stenosis
c. VSD
d. ASD

Answer: b. Mitral stenosis

5. All of the following are predictors of cardiac event during pregnancy except:
a. NYHA class>3
b. Obstructive lesion of the heart (mitral valve and aortic valve <1 cm2
c. Previous H/O heart failure
d. Ejection fraction <40%.

Answer: a. NYHA class>3

Discussion:

Heart Disease in Pregnancy

Normal findings in CVS during pregnancy:
• Pulse Rate increases
• Diastolic B.P decreases
• First heart sound is prominent and split
• Second heart sound–normal
• Third heart sound–normally not heard but in pregnancy it is prominent
• Murmurs-ejection systolic murmur heard normally in aortic or
pulmonary area at 10–12 weeks due to expanded intravenous volume.
• Continous murmur heard normally over the tricuspid area in left 2–3rd intercostal space.
• Apex beat is heard in the fourth ICS 2.5 cms left to midclavicular line
• Slight cardiomegaly
• Ecg- left axis deviation

Indicators of Heart Disease during Pregnancy:
• Systolic murmur greater than grade 3
• Diastolic murmur
• Marked Cardiomegaly
• Sustained arrhythmia
• Persistent split second heart sound

Predictors of Cardiac Event during Pregnancy
Potential for an adverse cardiac event in a pregnant female as pulmonary edema, sustained arrhythmia, stroke, cardiac arrest or cardiac death can be estimated by following parameters.

• N New York Heart Association (NYHA) class >2
• O Obstructive lesions of the left heart (Mitral valve or aortic valve area <1 cm2).
• P Prior cardiac event before pregnancy—Heart failure, arrhythmia, transient ischemic attack, stroke
• E Ejection fraction <40%

The risk of cardiac complications is 3%, 30% and 60% when none, one or more than one of these complications are present.

NYHA classification (revised 1979)
• Class I: No limitation of physical activity
• Class II: Slight limitation of physical activity
• Class III: Marked limitation of physical activity

Heart disease where vaginal delivery is contraindicated /Ceasrean section should be done are all those diseases where Aorta is involved (because in a patient with involved aorta, bearing down can lead to aortic rupture).
– Coarctation of aorta
– Aortic Aneurysm
– Marfans syndrome with aortic involvement.
– A patient who is fully anticoagulated with warfarin at the time of labor needs to be counseled for cesarean section because the baby is also anticoagulated and vaginal delivery carries increase risk to the fetus of intracranial hemorrhage

It is recommended that Infective Endocarditis prophylaxis may be given during labor in the following subgroups of patients:
• Prosthetic cardiac valve
• Previous IE
• Unrepaired congenital heart disease (including palliative shunts and conduits)
• Completely repaired congenital heart defect with prosthetic material or device, during the first 6 months after the procedure.
• Repaired congenital heart disease with residual defects at the site or adjacent to the site of aprosthetic patch or device.
• Cardiac transplantation recipients who develop cardiac valvulopathy.