1. Prof. M.C. Bansal.
MBBS.MS. MICOG . FICOG .
Founder Principal & Controller.,
Jhalawar Medical College & Hospital ,
Jhalawar ( Raj.)
Ex. P&C .MGMC and hospital,. Sitapura Jaipur

2.  Breathlessness ( Dyspnoea ) / shortness of breath
/difficult, laboured , consciousness about taking breath
is a common symptom during pregnancy.
 May be related to physiological changes in cardio-
pulmonary, haemopoetic system , increase in weight
etc.
 Degree of breathlessness---
1. Orthopnoea-breathlessness when lying flat.
2. Paroxysmal Nocturnal Dyspnoea- sudden onset of
dyspnoea at night.
3. Dyspnoea on rest.
4. Dyspnoea-Mild , Moderate Extraneous.

3.  Breathlessness of cardiac origin—Cardio-
myopathies and congenital anomalies
(surgically corrected or uncorrected ).
 Breathlessness of Respiratory origin.
 Haematological---Anaemia.
 Drug induced—NFT , NSAIDs, Inhalers ,
Amiodarone .
 Psychological– anxiety , fear , Minor or major
illness.
 Metabolic—Acidosis / Alkalosis.

4. • Other Congenital ___2
• Unknown heart disease___2
• Endocarditis _____3
• Myocardiac infarction________5
• Aortic Dissection________5
• Peri Partum cardiomyopathy ______________7
• Pulmonary hypertension_________________8
• Myocarditis _____________________9
• T0tal______________________________41

5.  Cardiao-myopathies—
1. Peripartum cardiomyopathy.
2. Dilated cardiomyopathy.
3. Hypertrophic cardiomyopathy.
 Congenital heart Disease.
1. Surgically corrected.
2. non corrected.

6.  Breathlessness caused by cardiomyopaty in
pregnancy mainly comprises three types----
 1, Peripartum.,
 2, Dilated
 3, hypertrophic.
 Dilated and hypertrophic can effect any one and
at any time in pregnancy.
 Peripartum cardiomyopathy occurs mostly in
young women of Afro –Caribbean origin during last
trimester or in the 1st 6 weeks of postpartum.


7.  - occurring in 1 in 3000-15000 pregnancy.
 -Some form of viral myocarditis has been
postulated.
 -Maternal mortality is as high as 20% though foetal
outcome is good.
 -Management is to correct the impaired systolic
function of ventricles.
 -There is substantial risk of recurrence in future
pregnancy and permanent impairment of left
ventricular function.

8.  Condition is poorly tolerated in pregnancy.
 7% maternal mortality .
 There is elevated risk of heart failure., to be
managed on same line of treatment as that for non
pregnant women.
 Angiotensin converting enzyme inhibitors are
avoided as they cause renal agenesis in foetus.


9.  Patient with hypertrophic cardiomyopathy usually
tolerate the increased load in pregnancy ,. as left
ventricle adopts in a physiological way.
 Women with murmur and increased gradient across
the left ventricular flow may present with
breathlessness for the 1st time in pregnancy.
 There is no risk of sudden death and maternal
mortality.

10.  ECG, Ecogardiography trademill, genetic counselling
are done for diagnosis.
 Women with severe diastolic dysfunction develop
pulmonary congestion---leading to increased
breathlessness and even pulmonary edema.
 complete bed rest, B-blockers are continued and
diuretics are added.
 Atrial fibrillation is managed with low-molecular
 weight heparin and B- blockade . Cardioconversion
may be done after excluding thrombus in atrium by
trans oesophagial echocrdigraphy.
 prophylactic low forceps – vaginal delivery can be
managed in as usual way for other cardiac patients.,
less chances of prolonged labour and blood loss.


11.  Classification of congenital Heart disease----
 1. Low risk lesion.
 Ventricular septal defect .
 Atrial septal Defect ( unoperated)
 coarctation Of aorta
 Teratology of fallot repaired
 2. Moderate Risk lesion
 Mitral Stenosis
 Aortic Stenosis
 Fortan- type circulation
 3. High Risk Lesion
 Marfan Syndrome
 Eisenmanger Syndrome

14. Lesion Exclude before Potential risk Recomonded Rx
Pregnancy in preg &
puerperium
Low Risk Lesion
1.Ventrcular Pulmonary Arrhythmias Antibiotic
septal defe3ct arterial SABE Prophylaxis foe
hypertension SABE
2.Atrial septal Pulmonary Arrhythmia Thrombo
defect arterial prophylaxis if pt
(un operated ) hypertension Is on complete
Ventricular bed rest
dysfunction

15. Lesion Exclude Potential Recomonded
Before hazards Rx in preg., 7
pregnancy PUERPARIUM
3.Coarctation Re-coarctation PIH Low dose Asprin
(reported) Aneurism Aortic therapy
formation at dilatation/
the site of dissection B-blockers to
operation. control BP
Associated C HF
Lesions—
Aortic Endocarditis Elective LSCS
bicuspid valve ( as soon as
with / with out foetal lung
stenosis / maturity
regurgitation , obtained
ascending Antibiotic
atropathy , prophylaxis.
Systemic BP

16. Lesion Exclude before Potential Risks Recommended
pregnancy treatment In
prig,
puerperium
4.Tetralogy of Severe Right Arrhythmias Pre term
Fallot Ventricular delivery if RVF
outflow tract develop
obstruction , RVF Antibiotics
severe
pulmonary Endocarditis
obstruction
,right
ventricular
dysfunction,
DiGeorge
Syndrom

17. Moderate Risk
Lesions
Lesion exclude Before Potential Recomonded
Pregnancy Hazards Treatment in
Preg ,
puerperium
1. Mitral Severe Stenosis Atrial Beta –Blockers
Stenosis Pulmonary Fibrillation
Venous Thrombi- Low dose
Hypertension embolic Aspirin
Phenomenon Hospitalization
Pulmonary in 3rd trimester
edema .
Thrmboprophyl
axisAntibiotics

18. Lesion Exclude before Potential Recommended
Pregnancy Hazards Treatment during
Pregnancy
2. Aortic stenos is Severe Stenosis ( Arrhythmia Hospitalization
peak pressure withThromboprop
gradient on USG > hylaxis
80 mmHg, ST
segment
depression Angina Balloon aortic
,symptoms) Valvotomy , Pre
Left Ventricular term LSCS By pass
dysfunction. surgery carries
20% risk of foetal
death.
Fontan –Type Ventricular Heart Failure Low molecular
circulation dysfunction, Arrhythmia , Heparine& aspirin
Arrhythmias , thromboembolic , in whole preg,
Heart failure Endocarditis Antibiotics

19. High Risk lesions
Lesions Exclude before Potential Risks Recomonded
Pregnancy Treatment in Preg,
puerperium
Marfan Syndrome Aortic Root Type A Dissection of Beta—blockers
dilatation >4 cm aorta Elective LSCS at 35
weeks .
Eisenmanger Ventricular 30-50 % risk of Therapuetic MTP.
syndrome dysfunction maternal death
Pulmonary arterial If pregnancy
Hypertension Arrhythmias Arrhythmia continues , CVs
Heart failure Monitoring,
Endocarditis hospitalization ,
pulmonary
vasodilators with O2
supplimentation.
Cntnue same in
puerperium

20.  1. Ventricular Septal defect----A small VSD
with normal right sided pressures
 Puts no added risk to pregnancy .
Prophylactic antibiotics and care full ANC is
that all needed. Paradoxical embolism ia not
common in VSD with large pressure gradient
across the defect . Large VSD with pulmonary
HTN & Eisenmenger complex need special
cardiac care.

21.  2.
Unoperated Atrial Septal Defect---
Unrepaired ASD are well tolerate pregnancy ,
when pulmonary resistance is normal. Pre
existing tendency to atrial fibrillation ---
hypercoagulable state of pregnancy and
potential right to left shunt increase the
chances of paradoxical embolism., more so
when intra thorasic pressure increases during
active labour. This accident can also occur in
cases of patent foramen ovale. There is
definite role of prophylactic antilcoaglant
therapy.

22.  3. Repaired Coarctation of Aorta----As majority
of pt get operated in childhood hence it puts no
risk in pregnancy as long as there is no
development of aneurism at the site of repair .
This can be confirmed by MRI.
 4. Repaired Teratology of Fallot ---Most common
cynotic congenital heart disease ., once
corrected one lives asymptomatic normal life .
Pregnancy is well tolerated by such women.
one need not to emphasise to asses such
patients thoroughly before planning pregnancy.
, torule out and treat any decompensation
before hand.

23.  5. Fontan Type Circulation—These patient are
not cynosed . , but experience long standing low
output circulation and risk of ventricular failure
and atrial arrhythmias. They need long term ore
warferin therapy and arte to be put on low
molecular Heparin therapy as soon as pregnancy
is planned or diagnosed. There is 30 % twice
more risk of abortion as compared to normal
pregnant women. Maternal outcome depends on
functional capacity of ventricle , it is better
when single ventricle is left. Advice to continue
the pregnancy is given when there is no
decompensation.

24.  6. Mitral Stenosis—
Commonest rheumatic valvular disease (
corrected / uncorrected –compensated or
decompensated )is diagnosed during ANC ,. More
common in developing, over populated ,localities
with poor sanitation, medical and health services.
it can remain silent till the 3rd decade., symptoms
often develop during pregnancy as cardiac load
increases . Congenital fusion of the commissures,
parchute mitral valve or left atrial mixoma are
other causes of mitral stenosis.

25. Heamodynamic changes in pregnant women with mitral
stenosis include
Elevated left atrial , pulmonary ( venous and arterial )
pressures which flow across the mitral valve.
Maternal complications include pulmonary edema,
pulmonary hypertension and right ventricular failure.
Tachycardia and dyspnoea may be precipitated by exertion
, anxiety , anaemia, fever.this may decrease diastolic left
ventricular filling time , further elevation of left atrial
pressure there by decreased cardiac output.
The end result is biventricular failure., atrial fibrillation
,pulmonary edema and embolic phenomenon

26.  Clinical
Presentation---
pregnant woman with MS may come in
state of failure of both left and right
ventricles depending upon the degree of
decompensation, duration and severity of
valvular disease.
Symptoms of left ventricular failure are
more common --- orthopnoea , paroxysmal
nocturnal / exertional dyspnoea, hamoptesis.
Symptoms of right ventricular failure
develop very late and include ascites and
edema feet .

27. careful cardiac examination specially for
opening snap and a diastolic rumbling
murmur with pre systolic accentuation in
mitral area.
Elevated jugular venous pressure ,
hepatomegaly , loud P2 , right ventricular
haeve in epigastric region support the
diagnosis of MS.
Transthorasic Echocardiography helps in
diagnosis as well as severity of cardiac
dysfunction ,important to assess the success
of percutaneous mitral valvuloplasty by
baloon. It can be done safely in such women.

28.  Symptomatic AS is less common than MS in
pregnancy.
Rheumatic AS is more common in developing
countries . Conge4nital AS secondary to
membrane on bicuspid valve may also be seen,
women is at risk of dissection of aorta related to
hormonal changes on connective tissue in
pregnancy.
Pressure gradient across aortic valve is responsible
for haemodynamic changes in AS.
Increase in left ventricular systolic pressure leads
to left ventricular hypertrophy and later on left
ventricular failure and diminished coronary flow.

29.  Increase in stroke volume and fall in peripheral
resistance in pregnancy are responsible for
increase in pressure gradient across Aortic valve.
Increase demand to increase Cardiac output in
late pregnancy and labour ---women with AS
develops symptoms of left ventricular failure.
 Clinical Presentation depends on degree of
stenosis .woman with aortic valve area > 1.0cm
tolerate pregnancy well. Women with more
severe stenosis will develop left ventricular
failure., manifesting as dyspnea and pulmonary
edema. Left ventricular impulse is sustained and
displaced laterally towards maxilla. A systolic
ejection murmur is heard along right boarder of
sternum and radiates to neck in carotid area.

30.  A systolic ejection click may be heard. 4th heart
sound may be present indicating abnormal
diastolic function too.
 Presence of slow rising pulse and narrow pulse
pressure (difference between systolic and
diastolic pressure indicates significant aortic
Stenosis.
 Diagnosis can be confirmed by echocardiography
and aortic gradient and area of aortic valve can
be calculated by dopller flow study. Patient with
< 55% ejection flow are at risk of left ventricular
failure . fetus of mother with congenital AS is at
risk (15%) of developing same cardiac anomaly.

31.  Pregnant women carries 1% risk of type A
aortic dissection.
 But it is ten time more when Aortic root
diameter is > 4cm. Its repair carries 22%
maternal mortality., such women should be
advise against going for pregnancy.
 Women who become pregnant and want to
continue it , should be kept on B –blockers
and under go elective LSCS on fetal maturity.
 Patients should also be aware of the 50%
recurrence rate.
.

32.  Pulmonary hypertension of any reason carries a
high maternal risk.
Patient with Eisenmenger complex carries > 50%
mortality.
Women should be advised not to become
pregnant.
In the event of pregnancy MTP in early weeks (6-
10 ) is indicated .
Male partner should be vasectomies / laparoscopic
sterilization can be done with explained risk.
The progesterone sub dermal implant
contraceptive is as effective as sterilization and
safe also.

33.  ANC Such women once become pregnant or
as soon as heart disease is diagnosed for the 1st
time in ANC should be referred to tertiary care
centre with 24hrs available facility of
cardiologist, high risk pregnancy care , cardiac
anesthetist , parental medicine , and well
equipped premature NICU.
 Patient and her husband should be involved in
decision making and let them understand the
‘minimal risk approach’
 Generous approach to hospitalization as and
when needed and more so in last trimester.
Patient confined to bed rest should receive Low
molecule Heparin as prophylaxis against risk of
thrombi embolism.

34.  Pregnant women with congenital heart disease ,
Atrial arrhyhmias , prolonged bed rest Are at 6
fold increased risk of thromboembolism in
pregnancy and 11fold more in
puerperium.Therefore achieving thorough
anticoagulation is more important in such cases.
 Anti coagulation therapy also carries maternal
fetal complications. Warfare crosses the
placenta and carries more risk to fetus hence not
recommended.
 Heparin does not cross the placenta hence safe .
 Strict monitoring of dose and regular laboratory
test must bed done .