Cardiac and pulmonary

diseases
in pregnancy

‫دكتورة‬
‫شيماء رؤوف الحسني‬
Hemodynamic changes in normal pregnancy
 The ECG changes in normal pregnancy
1. Atrial and ventricular extrasystoles
2. A ‘left shift’ in the QRS axis
3. Small Q wave and inverted T wave in lead III
4. ST segment depression
5. T wave inversion in the inferior and lateral leads.
Pregnancy changes mimic cardiac disease

Symptoms – breathlessness, weakness, oedema,

syncope and tachycardia

Signs :
•Splitting of 1st heart sound
•Murmur – systolic , breast bruit
•Displacement of apex beat – upwards to left
 Investigations
• ECG – cardiac arrhythmias, hypertrophy
• Echocardiography – cardiac status and structural
anomalies , an echocardiogram at the booking visit and at
around 28 GA is usual
• X-ray chest –AP and lateral view CXR
- lead apron shield
-cardiomegaly , vascular prominence
• Cardiovascular MR imaging
• Cardiac catheterization - It is safe to perform cardiac
catheterization with limited fluoroscopy time to minimize
radiation exposure
Stages of heart failure – New York Heart Association
(NYHA) classification
:Preconception counseling
It is important in the care for women with cardiac disease
and it should be performed before conception or, as
early as possible during pregnancy
• It should be multidisciplinary with both cardiac and
obstetric input, to enables women and their partners to
make a well-informed choice whether to continue
pregnancy or not.
• Counseling regarding the risk of pregnancy for the
mother and fetal.
• Optimizing the woman’s clinical condition by changes in
medications or surgical procedures before conception
Issues in prepregnancy counselling of women with
heart disease

1. Risk of maternal death.

2. Possible reduction of maternal life expectancy.
3. Effects of pregnancy on cardiac disease.
4. Mortality associated with high-risk conditions.
5. Risk of fetus developing congenital heart disease.
6. Risk of preterm labour and FGR.
7. Need for frequent hospital attendance and possible admission.
8. Intensive maternal and fetal monitoring during labour.
9. Other options – contraception, adoption, surrogacy.
10.Timing of pregnancy.
General considerations in pregnant women with
heart disease:
The outcome and safety of pregnancy are related to:
● presence and severity of pulmonary hypertension;
● presence of cyanosis;
● haemodynamic significance of the lesion;
● functional NYHA (New York Heart Association) class as determined by the
level of activity that leads to dyspnoea . Most women with pre‐existing
cardiac disease tolerate pregnancy well if they are asymptomatic or only
mildly symptomatic (NYHA class II or less) before the pregnancy, but
important exceptions are pulmonary hypertension, Marfan’s syndrome
with a dilated aortic root, and some women with mitral or aortic stenosis.
Women with cyanosis (oxygen saturation below 80–85%) have an increased
risk of fetal growth restriction, fetal loss, and thromboembolism secondary
to the reactive polycythaemia.
 Antenatal management
It is important to distinguish between ‘normal’
symptoms of pregnancy and an impending cardiac
failure, so ask the pregnant woman if :
• She has noted any breathlessness, specially at night.
• Any change in her HR or rhythm
• Any tiredness or a reduction in exercise tolerance.
Routine physical examination should include:
PR, BP, jugular venous pressure, heart sounds, ankle
and sacral oedema and presence of basal crepitations.
 Clinical Indicators of Heart Disease During Pregnancy

Symptoms Clinical Findings

• Progressive dyspnea • Cyanosis
or orthopnea • Clubbing of fingers
• Persistent neck vein distention
• Nocturnal cough
• Systolic murmur grade 3/6 or greater
• Hemoptysis • Diastolic murmur
• Syncope • Cardiomegaly
• Persistent tachycardia and/or
• Chest pain
arrhythmia
• Persistent split second sound
• Fourth heart sound
• Criteria for pulmonary hypertension
 Antenatal management
1. Counseling regarding the risk of pregnancy.
2. Correct any maternal complication (hypertension, anemia
arrhythmia).
3. Monitor signs of heart failure(clinically and with echo).
4. Monitor fetal growth (risk of IUGR)
5. Women should advice to reducing their normal physical activities.
6. Prophylactic antibiotics should be given to any women with a
structural heart defect to reduce the risk of bacterial
endocardites.
7. Anticoagulant is essential in patients with CHD who have pul. HT
or artificial valve replacement , and patients at risk of atrial
fibrillation
Anticoagulation with heparin is less hazardous for the fetus,
however, the risk of maternal thromboembolic complications
is much higher.
Warfarin is teratogenic and causes miscarriage, stillbirths, and
fetal malformations.
AHA estimate that the risk of embryopathy is dose dependent,
if the dose of warfarin is ≤5 mg/d the risk—< 3%
If the dosage is >5 mg/d, the risk > 8%
Four regimens is recommended.
1. Adjusted-dose LMWH is given twice daily, with a peak anti-Xa level
drawn 4 hours after dosing.
2. Adjusted UFH is dosed every 12 hours to keep the mid interval aPTT
twice control or anti Xa level between 0.35–0.70 U/mL.
3. LMWH or UFH is given as just described until 13 weeks, and then
warfarin is substituted until near delivery, at which time it is
replaced by LMWH or UFH.
4. Last, in women judged to carry a high risk of thrombosis and for
whom the efficacy and safety of heparins are concerns, warfarin is
suggested throughout pregnancy. Heparin is then substituted close
to delivery. In addition, aspirin, 75 to 100 mg, is given daily.

Heparin is discontinued just before delivery , warfarin or heparin may

be restarted 6 hours following vaginal delivery and 6-12 h after c/s
 Management of labour and delivery
1. Avoid induction of labour if possible.
C/S should only be performed in situations where the maternal
condition is considered too unstable to tolerate the physiological
demands of labourn these are :
(1) dilated aortic root >4 cm or aortic aneurysm
(2) acute severe congestive heart failure
(3) recent myocardial infarction
(4) severe symptomatic aortic stenosis
(5) warfarin administration within 2 weeks of delivery
(6) need for emergency valve replacement immediately after delivery
2. One to one care
3. Continous fetal heart monitoring
4. Epidural anaesthesia is often recommended
5.Prophylactic antibiotics should be given to any woman with
a structural heart defect
6. O2 saturation and continuous arterial blood pressure
monitoring.Keep the second stage short. This reduces
7. effort and the requirement for increased cardiac output
8. Ensure fluid balance.
9. Avoid the supine position.
10. Active management of the third stage is usually with
Syntocinon. (vasodilator and therefore should be given
slowly to patients with significant heart disease, with low-
dose infusions preferable. )
 PULMONARY HYPERTENSION
The current clinical classification system, shown in Table five groups of
disorders that cause pulmonary hypertension. In pregnant women, group 2
disorders are the most common. These are secondary to pulmonary venous
hypertension caused by left-sided atrial, ventricular, or valvular disorders. A
typical example is mitral stenosis . In contrast, groups 3 through 5 are seen
infrequently in young healthy women.
Pul. HT cause maternal mortality in 25-40%
The danger of pul. HT relates to fixed pulmonary vascular resistance that
cannot fall in response to pregnancy, and a consequent inability to increase
pulmonary blood flow with refractory hypoxaemia.
Management: Specific treatments shown to improve symptoms and survival
include endothelin blockers, Ex. bosentan, and phosphodiesterase
inhibitors such as sildenafil.
In women who choose to continue their pregnancy, targeted pulmonary
vascular therapy is an option, with timely admission to hospital and
delivery according to the progress of the woman and fetal condition.
 Risk factors for the development of heart failure in
pregnancy
1. Respiratory or urinary infections.
2. Anaemia.
3. Obesity.
4. Corticosteroids.
5. Tocolytics.
6. Multiple gestation.
7. Hypertension.
8. Arrhythmias.
9. Pain-related stress.
10.Fluid overload
CAUSION:
bosentan, can reduce the effectiveness of most hormonal contraception,
including Cerazette and Nexplanon, so additional contraception should be used
if you need to take bosentan.
 Mitral stenosis
• It is a well-recognized risk factor for maternal morbidity and
mortality, as it result in an inability to increase cardiac output
to meet the demands of pregnancy , MS usually is rheumatic
in origin. The normal mitral valve surface area is 4.0 cm2, and
when stenosis narrows this to <2.5 cm2 symptoms usually
develop.
Women may deteriorate secondary to tachycardia, arrhythmias
or the increased cardiac output such as in 3rd stage of labour .
The commonest complication is pulmonary oedema, This risk
is increased with severe mitral stenosis, moderate or severe
symptoms prior to pregnancy
Management
 Women with severe mitral stenosis should be advised to delay
pregnancy until after balloon mitral valvotomy or mitral valve
replacement.
 Beta-blockers decrease heart rate and the risk of pulmonary
oedema but if medical therapy fails or for those with severe
mitral stenosis, balloon mitral valvotomy may be safely and
successfully used in pregnancy
 Avoid supine and lithotomy positions as much as possible for
labour and delivery.
 Avoid Fluid overload
 Pulmonary oedema should be treated in the usual way with
oxygen and diuretics.
 PERIPARTUM CARDIOMYOPATHY
This pregnancy-specific condition is defined as heart failure secondary to left
ventricular (LV) systolic dysfunction towards the end of pregnancy or in the
months following delivery, where no other cause of heart failure is found. It
is a diagnosis of exclusion. The LV may not be dilated but the EF is always
reduced < 45%
Risk factors include multiple pregnancy, hypertension, multiparity,
increased age and African–Caribbean race

Diagnosis should be suspected in puerperal women or those in late

pregnancy with breathlessness and signs of heart failure. It is confirmed with
• echocardiography showing LV dysfunction EF <45%; and often dilatation of
all four chambers of the heart , shortening fraction<30 % , left ventricular
end- diastolic dimension >2.7cm/m2(n=3.9-53 cm/m2)
• CXR shows an enlarged heart with pulmonary congestion or oedema and
often bilateral pleural effusions
:The differential diagnosis
• pre-existing dilated cardiomyopathy
• pulmonary thromboembolism
• amniotic fluid embolism
• myocardial infarction
• pulmonary oedema related to pre-eclampsia or β2-agonist therapy for
preterm labour.
Treatment
• As for other causes of heart failure, with oxygen, diuretics, vasodilators,
• Anticoagulation prophylaxis with unfractionated heparin should be started
• inotropes if required.
After delivery add diuretics to reduce cardiac work and switch to ACE inhibitors,
And LMWH to warfarin
• Prognosis and recurrence depend on the normalization of LV size and
function within 6 months of delivery
 Pulmonary disorders
Asthma is the most common pul. disorder which affects up to 4% of
women. It is chronic disease that inflammed and narrows airways due
to increase responsiveness of tracheobronchial tree to multiple
stimuli . patient present with cough, shortness of breath, wheezing.
It is common in young women and therefore is seen frequently during
pregnancy it has no effect on pregnancy , only poorly controlled
asthma may be associated with low birth weight and preterm labour.
Effect of pregnancy on asthma.
1/3 show no change.
1/3 improve.
1/3 deteriorate ( most episodes occur bet 24 and 36 wk)
 Management
1. Multidisplinary team.
2. Treatment should be continued during pregnancy.
3. Measure expiratory flow rate.
4. Follow up of blood sugar because of increase risk of gestational
DM in women on long term oral steroid.
5. Asthma attack may occur during labour . if women on long term
oral steroid give her IV hydrocortisone during labour because of risk
of collapse.
6. Avoid prostagladin f2 alpha.
7. Encourge breast feeding because it decrease risk of allergy later
in life.
 Pneumonia
IT is an inflammatory condition of the lung affecting primarily
the alveoli it can be caused by bacteria , viruses , fungi , or
due to autoimmune disease, its incidence is about 1/1000.
Clinical featurese include: cough, SOB ,fever,fatigue.
Diagnosis usually based on clinical findings, CXR may be
needed.
Treatment include physiotherapy ,adequate oxygenation,
hydration and appropriate antibiotics (ampicillin,
cephalosporin or erythromicin).
Complications include PTL and LBW
A Aortic dissection E Hypertrophic cardiomyopathy
B Aortic stenosis F Mitral valve prolapse
C Coarctation of the aorta G Peripartum cardiomyopathy
D Eisenmenger syndrom H Rheumatic heart disease
I Tricuspid regurgitation

A ) A 42-year-old Bangladeshi woman presents to the emergency department at

32 weeks of gestation with distension of the abdomen. An abdominal scan
reveals a congested liver and minimal ascites. An echocardiogram shows LV
dilatation with an ejection fraction of 15%. Clinical examination reveals a
respiratory rate of 26 breaths/minute and an oxygen saturation of 95%. She is
para 10 with all normal vaginal deliveries. She speaks no English.
B ) A 28-year-old woman is brought to the emergency department at
25 weeks of gestation with acute severe chest pain radiating to the back. She
has a lifelong history of Marfan syndrome but has remained well for the last
18 years. She is hypertensive and currently on methyldopa 250 mg three
times a day. General examination reveals a blood pressure of 180/80 mmHg,
pulse 120 beats/minute and respiratory rate 22 breaths/minute.

C) A 42-year-old Asian woman presents to the emergency department 4 weeks

post delivery with increasing shortness of breath while lying flat. On CV
examination the apical impulse is diffuse and displaced downwards. A CxR
shows cardiomegaly and a respiratory system examination reveals vesicular
breath sounds with fine basal crepitations.

D) A 35-year-old woman, para 1, presents with syncope at 20 weeks of

gestation. A cardiovascular examination reveals an ejection systolic murmur,
double apical pulsation and arrhythmia. She was started on beta-blockers
following which her symptoms improved gradually. She gives a history of the
sudden death of her cousin who was 18 years old.