Managing heart disease during pregnancy

Pregnancy has a profound effect on the mother’s body and especially the heart. Most of these changes start in the first three months and peak during the second trimester, and plateau during the third trimester

Managing heart disease during pregnancy
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Increased occurrences of heart disease have been found in pregnant women, this constitutes a substantial amount of high-risk pregnancies. Changes that occur in maternal circulation have the potential to affect both maternal and unborn baby’s health.

Health records show that 4% of pregnancies may have heart issues, with no prior known existence. It is a two-way relation, i.e. the disease can influence pregnancy and vice-versa.

Some changes that occur in the heart and related system during pregnancy are:

  • The pulse rate increases.
  • The cardiac output (blood pumped out by the heart) increases.
  • Certain changes occur in the ECG.

A patient’s medical history is important to assess the possible risks at hand and should comprise of evidence on the baseline functional status and previous cardiac events as these are strong interpreters of cardiac issues that occur during pregnancy.

  • Previous cardiac occurrence
  • Left-sided heart obstruction – valve disease or thickened heart muscles
  • Low pumping power of heart
  • Diabetes and high blood pressure during pregnancy
  • Physiological changes during pregnancy and after delivery

Many of the normal symptoms of pregnancy, such as breathlessness on exertion or lying flat, swelling of the body, and feeling one’s own heartbeat are also symptoms of associated heart disease. Physical signs commonly seen with pregnancy are clearly swollen visible neck veins, extra heart sounds, exaggerated heart sounds and swelling of feet.

Types

Rheumatic heart disease: 90 per cent of heart disease problems in pregnancy are of this type. Mitral stenosis (narrowing of mitral valve) is the most common. In all these types of heart diseases, the risk of heart failure is high, followed by risk of foetal loss. The others that fall in the same group are aortic stenosis (narrowing of aortic valve) and mitral insufficiency (the valve does not close properly when the heart pumps out blood).

The second type of heart disease that is seen during pregnancy is the congenital type. This can exist already but are asymptomatic and can show symptoms for the first time during pregnancy.

A few of them are Atrial Septal Defect (ASD) and Ventricular Septal Defect (VSD), which are septal defects (hole in the heart), Tetralogy of Fallots (a rare condition caused by a combination of four heart defects that are present at birth), Pulmonary Hypertension (high blood pressure that affects the arteries in your lungs and the right side of your Heart) and cyanotic heart disease.

Pulmonary hypertension and cyanotic heart disease pose the biggest problem during pregnancy and the mortality rate can significantly increase.

Cardiac arrhythmias (problems with rhythmic beating of the heart) are managed more or less in the same way in pregnant and non- pregnant patients.

Cardiomyopathies are not common during pregnancy. They are seen towards the last part of pregnancy or early post-partum period. The exact cause of this is not known but these women may be hypertensive or malnourished during pregnancy.

Management

Management of these pregnancies is based on a multidisciplinary approach, by both an obstetrician and cardiologist who play an important role. For milder heart diseases, frequent consultations with time to time hospital admissions are the accepted methods of management.

Women with heart disease are at risk of cardiac complications during pregnancy and delivery. Risk assessment should be performed in these women, and the management of pregnancy and delivery should be planned accordingly.

Basic guidelines to be followed are as follows:

  • Avoid excess weight gain
  • Consume low sodium diet
  • Rest in left lateral position
  • Get adequate sleep
  • Strenuous activity and anaemia increase the work load on the heart and also interfere with placental circulation (blood supply to the baby), and are hence best avoided
  • Labored breathing and difficultly in doing routine work is to be looked for. Especially during labour and immediate post-delivery period.
  • Use of epidural anaesthesia to reduce pain during labour.
  • Prophylactic antibiotics to reduce chances of infection.
  • Delivery to be done at a tertiary care hospital.
  • Vaginal delivery is advisable unless there is an obstetrical indication.
  • Other routine obstetrical care and fetal monitoring for growth etc. is managed as in any other pregnancy.
  • Electrocardiography or echocardiogram should be promptly done in case of any doubts.
  • Diagnosis of the problem at its earliest.

Dr Manjiri Mehta is a consultant Gynaecologist, Obstetrician and Laparoscopic surgeon at Hiranandani Hospital, Vashi

Dr Brajesh Kumar Kunwar, Interventional Cardiologist at Hiranandani Hospital, Vashi