2. Incidence and types of heart diseases in
pregnancy
0 Incidence of heart disease in pregnancy is around
1%
0 These can be congenital or acquired
0 Of these, acquired heart diseases are more common
in developing countries. These include:
RHD, cardiomyopathies and ischemic heart disease

3. 0 Congenital heart diseases can be:
left to right shunts, stenotic lesions, right to left
shunts
0 Most common cardiac lesion in pregnancy is MS
0 Most common arrhythmia in pregnancy is SVT
0 Most common acyanotic heart disease in pregnancy
is ASD(ostium secundum )
0 Most common cyanotic heart disease- TOF

4. HEMODYNAMIC CHANGES DURING
PREGNANCY
0 Cardiac output:
increase in CO starts at ~5wk POG, reaches a
maximum at 30-34 wk ( 40% increase over the
prepregnant value) and remains elevated till term.
During labour, it increases by ~20% with uterine
contractions. Immediately following delivery CO
increases further by~15-20%
return to pre labour value= 1 hr after delivery
return to pre pregnant value= 4 wk after delivery

5. 0 Mechanism for increase CO
increase Stroke volume = 27%
increase heart rate = 17%
increase in intravascular volume
0 Intravascular volume (IVV)
increase in blood volume starts around 6 wk and
gradually reaches a peak of ~30-40% by 32 wk
plasma volume~ 40-50%
RBC volume~ 20-30%
IVV expansion is marked by systolic ejection
murmur .

6. 0 Systemic vascular resistance falls by 21%
0 Pulmonary vascular resistance falls by 34%
0 Colloid osmotic pressure falls by 14%
0 Aortic root – increase in size and compliance
0 Venous pressure-
femoral vein pressure:20cm of water (lying
down)
and 80 – 100 cm of water on standing.
0 BP: mid trimester, fall in MAP of 10 -15 mm of Hg, reaching
a nadir ~ 24-28 wk
0 No change in CVP
PCWP

7. NORMAL CARDIAC FINDINGS
0 Raised JVP with prominent pulsations
0 Brisk and diffuse apex impulse
0 Loud s1
0 Loud s2 and widely split
0 Occasional s3
0 Aortic or pulmonary flow murmurs
0 Venous hum
0 Mammary souffle

8. ABNORMAL CARDIAC FINDINGS
0 Progressive dyspnea or orthopnea
0 Nocturnal cough
0 Hemoptysis
0 Syncope
0 Chest pain
0 Cyanosis
0 Clubbing
0 Persistent neck vein distension
0 Systolic murmur grade 3 or above

9. 0 Diastolic murmur
0 Cardiomegaly
0 Persistent arrhythmia
0 Persistent split s2

10. PERIODS DURING PREGNANCY WHEN
DANGER OF CARDIAC DECOMPENSATION IS
HIGH
0 12-16 WK- hemodynamic changes of pregnancy
begin
0 28-32 wk- hemodynamic changes peak
0 During labour and delivery
0 Immediately following delivery of baby and
placental separation( max chances)
0 4-5 days following delivery

11. NYHA FUNCTIONAL CALSSIFICATION OF
CARDIAC DISEASE
0 I No symptoms and no limitation in ordinary physical
activity, e.g. shortness of breath when walking, climbing
stairs etc.
0 IIMild symptoms (mild shortness of breath and/or
angina) and slight limitation during ordinary activity.
0 III
Marked limitation in activity due to symptoms,
even during less-than-ordinary activity, e.g. walking
short distances (20-100 m).Comfortable only at rest.
0 IV
Severe limitations. Experiences symptoms even
while at rest. Mostly bedbound patients.

12. RISK OF MATERNAL MORTALITY AND
MORBIDITY WITH HEART DISEASE
0 Group1( minimal risk) 0-1%
ASD
VSD
PDA
Corrected TOF
Corrected congenital heart disease without
residual cardiac dysfunction
MVP
NYHA class 1,2

13. 0 Group 2( moderate risk) 5-15%
 AS
Marfan’s syndrome with normal aorta
Uncorrected TOF
Previous MI
Artificial valve
H/o peripartum cardiomyopathy with no residual
ventricular dysfunction
NYHA class 3,4

14. 0 Group3 (major) 25-50%
Pulmonary hypertension
Marfan’s syndrome with aortic valve involvement
Cardiomyopathy
Complicated coarctation of aorta

15. PERIPARTUM
CARDIOMYOPATHY
0 Incidence: 1 in 4000 pregnancies
0 More common after age 30
0 Can result in severe CHF
0 Clinically present by 3rd trimester
0 Close hemodynamic monitoring and early delivery
maybe necessary
0 Cardiomyopathy may persist even after delivery
0 High rate of recurrence so birth control
recommended

16. Diagnostic criteria
0 Diagnosis of exclusion
0 Cardiac failure within last month of pregnancy or
within 5 months postpartum
0 No determinable cause for failure
0 Absence of previous heart disease
0 Left ventricular dysfunction evidenced on echoejection fraction < 45 % & left ventricular end
diastolic dimension > 2.7cm/m2

17. Etiology
0 Unknown
0 Myocarditis
0 Viruses-Epstein-Barr ,Parvovirus B19, CMV
0 Genetic causes
0 Inflammation
0 Preeclampsia

18. Presentation
0 Progressive dyspnea or Orthopnea
0 Palpitations
0 Cough
0 Chest pain
0 Dizziness
0 Decrease exercise tolerance

19. Presentation
0 Often presents with major event
0Heart failure
0 Respiratory failure
0Stroke
0 Physical Exam
0Loud S2
0Pulmonary rales
0Elevated JVP
096% pulmonic systolic ejection murmur
0Increasing peripheral edema ( suddenly at end of
pregnancy)

20. Differential Diagnosis
0 Aortic Stenosis
0 Cardiomyopathy, other types
0 Hypertension
0 Mitral Stenosis
0 Pulmonary Disease
0 Pulmonary Edema

21. Workup
0 Echocardiogram
0 Chest X-ray
0 Stress testing

22. Treatment
Bed rest
0 Digoxin
0 Loop diuretics
0 Afterload reduction with hydralazine
0 Beta- blockers
0 Heparin when EF< 30%
0 Consider tertiary center

23. Treatment
Route of delivery
0 Vaginal preferred
0 Less incidence PE
0 Epidural anesthesia ideal

24. Prognosis
0
30% patients return to baseline ventricular
function within 6 months
0 50% of patients have significant improvement
0 Mortality 3% to 9.6%, ( 16% for African
American)
0 Progressive heart failure
0 Arrhythmia,
0 Thromboembolism. Up to 30%