cardiac diseases with pregnancy - a study of maternal and fetal outcome

Cardiac diseases with pregnancy

International Archives of Integrated Medicine, Vol.

Copy right © 2015, IAIM, All Rights Reserved.

Original Research Article


maternal and fetal outcome

Tushar M Shah1, Keeranmayee Mishra

1Assistant Professor, Department of Obstetrics and

2Resident, Department of Obstetrics and

*Corresponding author email:

How to cite this article: Tushar M Shah

diseases with pregnancy - A study of maternal and fetal outcome

Available online at

Received on: 04-11-2014

Abstract

Background: Total 0.2% to 4% of all

countries, rheumatic heart diseases (

diseases only 9-19%.

Aim and objectives: To review all obstetric patients

tertiary care center over a period of one year and

maternal and perinatal morbidity and mortality.

Material and methods: A retrospective,

delivered over a period of January 20

representation of the data was done.

their severity, NYHA category, type of pathology,

and maternal mortality and perinatal mortal

Conclusion: Total 69% cardiac lesions in pre

high risk category while 13.1% were NYHA type IV.

Epidural analgesia preferred in LSCS

observed to increase with increase in NYHA class.

Key words

Cardiac diseases, Rheumatic, Obstetric.

diseases with pregnancy

International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015.

, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy - A study of


, Keeranmayee Mishra2*

, Pallavi Ninama

Parikh1

, Department of Obstetrics and Gynecology, B J Medical College,

India

Resident, Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad

*Corresponding author email: [email protected]

Tushar M Shah, Keeranmayee Mishra, Pallavi Ninama, Chirag Parikh

A study of maternal and fetal outcome. IAIM, 2015; 2(1

Available online at www.iaimjournal.com

2014 Accepted on:

4% of all pregnancies are complicated by cardiac diseases

rheumatic heart diseases (RHD) constitute 56-89% of the cases and c

To review all obstetric patients with co-existing cardiac diseases admitted to a

tertiary care center over a period of one year and ascertain the causes of admissions and the

maternal and perinatal morbidity and mortality.

A retrospective, analytical study of all patients with cardiac diseases who

over a period of January 2013 to December 2013 was cond

representation of the data was done. The various cardiac diseases were categorized according to

type of pathology, the maternal and perinatal outcome was assessed

and maternal mortality and perinatal mortality was recorded.

69% cardiac lesions in pregnancy were rheumatic in origin and

13.1% were NYHA type IV. Total 69% deliveries were

LSCS of cardiac patients. Perinatal and maternal complications were

observed to increase with increase in NYHA class.

Obstetric.

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Page 22

A study of


, Pallavi Ninama1, Chirag

B J Medical College, Ahmedabad,

Ahmedabad, India

Chirag Parikh. Cardiac

5; 2(1): 22-29.

Accepted on: 17-12-2014

diseases. In non western

f the cases and congenital heart

existing cardiac diseases admitted to a

ascertain the causes of admissions and the

cardiac diseases who

December 2013 was conducted. A tabulated

The various cardiac diseases were categorized according to

the maternal and perinatal outcome was assessed

gnancy were rheumatic in origin and 15% belonged to

Total 69% deliveries were by vaginal route.

Perinatal and maternal complications were




Introduction

Total 0.2% to 4% of all pregnancies

complicated by cardiac diseases

western countries, rheumatic heart diseases

(RHD) constitute 56-89% of the cases and

congenital heart diseases only 9

Total 2.7 deaths per 1000 pregnancies are

reported in pregnancies complicated

diseases [4].

Aim and objectives

• To study the incidence,

through parity and the

various cardiac diseases in pregnancy.

• To classify those into three risk

categories i.e. low, moderate,

• To study the maternal

outcomes in each case.

Material and methods

A retrospective, analytical study of all patients

with cardiac diseases who delivered

period of January 2013 to December 2013 was

conducted. A tabulated representation of the

data was done. The various cardiac diseases

were categorized according to their severity,

NYHA category, type of pathology,

and perinatal outcome was assessed and

maternal mortality and perinatal mortality

recorded. Total 59 cases out of 7053 deliveries

were studied.

Results and Discussion

Incidence of cardiac diseases was

deliveries. The number of booked cases was

(57.6%). Most patients were primi para (n=22,

37%). The majority belonged to an age group of

20 years to 25 years (53%). According

type of cardiac disease, valvular heart diseases




pregnancies are

diseases [1]. In non

rheumatic heart diseases

f the cases and

ongenital heart diseases only 9-19% [2, 3].

2.7 deaths per 1000 pregnancies are

reported in pregnancies complicated by cardiac

To study the incidence, distribution

through parity and the prevalence of

various cardiac diseases in pregnancy.

To classify those into three risk

moderate, high [5].

To study the maternal and fetal

analytical study of all patients

cardiac diseases who delivered over a

December 2013 was

A tabulated representation of the

various cardiac diseases

were categorized according to their severity,

type of pathology, the maternal

and perinatal outcome was assessed and

maternal mortality and perinatal mortality was

Total 59 cases out of 7053 deliveries

Incidence of cardiac diseases was 8.36/1000

ooked cases was 34

Most patients were primi para (n=22,

The majority belonged to an age group of

According to the

valvular heart diseases

constituted the majority of

cases) of which (41/43 cases)

origin. Out of 41 cases, isolated

(MS) constituted 85% of cases,

valvular diseases 14.6% of cases and mitral valve

prolapse 4.8% of cases. Total

had undergone balloon mitral valvoplasty

preconceptionally, 30.23% (

secondary pulmonary hypertension.

of rheumatic origin were on Inj

intramuscularly (IM) every 21 days.

There were cases of congeni

that was nearly 15% (n=9)

be further classified as cyanotic

cases), all of which were atrial septal defects

which could further be classified into osteum

secundum type (n=4) (majority

venosus type (n=1). Total 37.5%

congenital heart diseases were acyanotic in

nature. Two of these were cases of Ebstein

Anomaly and one was Tetralogy of

patients out of 9 with congenital heart diseases

(25%), had undergone mitral valve replacement

(MVR).

Total 19 patients (32%)

secondary pulmonary hypertension which could

further be divided into mild

(n=6) and severe (n=3)

Eisenmenger Syndrome. There were 11%

cases with cardiomyopathies of which two were

of dilated cardiomyopathies and five cases were

of peripartum cardiomyopathies.

The various maternal complications could be

classified into obstetric and cardiac types.

Coming to the fetal outcome we observed that

there was higher incidence of preterm delivery

(19%) and a higher incidence

weight neonates.

Total 69% cardiac lesions in pre

rheumatic in origin and 15%

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3

constituted the majority of cases (95.3%, n=41

(41/43 cases) were rheumatic in

isolated mitral stenosis

85% of cases, combined

cases and mitral valve

Total 11.6% (5 cases)

had undergone balloon mitral valvoplasty

(13 cases) developed

secondary pulmonary hypertension. All lesions

in were on Injection Penidura

every 21 days.

cases of congenital heart diseases

of total. They could

be further classified as cyanotic (62.5%, n=5

of which were atrial septal defects

hich could further be classified into osteum

majority) and sinus

37.5% (n=3) cases of

congenital heart diseases were acyanotic in

Two of these were cases of Ebstein

Anomaly and one was Tetralogy of Falot. Total 2

patients out of 9 with congenital heart diseases

had undergone mitral valve replacement

Total 19 patients (32%) had developed

pulmonary hypertension which could

further be divided into mild (n=9), moderate

and one case of

There were 11% (n=7)

cases with cardiomyopathies of which two were

of dilated cardiomyopathies and five cases were

of peripartum cardiomyopathies.

The various maternal complications could be

to obstetric and cardiac types.

Coming to the fetal outcome we observed that

incidence of preterm delivery

and a higher incidence (17%) of low birth

69% cardiac lesions in pregnancy were

15% belonged to high




risk category and 13.1% were

Total 69% deliveries were by vaginal route.

Epidural analgesia preferred in

cesarean section (LSCS). Perinatal and maternal

complications increased with increase in NYHA

class. Infective endocarditis prophylaxis

given in all cases empirically.

was offered in two cases with prior mitral valve

replacement. The rate of both preterm birth and

perinatal mortality was high. (Chart 1 to 9)

Conclusion

Cardiac diseases take a heavy toll on both

maternal and fetal health. A multi

approach is ideal in dealing with and preventing

complications. Counselling for contraception

and family planning and follow up during

subsequent pregnancies is mandatory.

References

1. B M Weiss, et al. Outcome of

cardiovascular surgery and pregnancy

Am J Obst And Gyn, 1998;

1653.

2. Stangl V, Schad J, Gossing G

Baumann G, Stangl K.

disease and pregnancy outcome: a

single-centre experience.

Fail, 2008; 10(9): 855-860.




13.1% were NYHA Type IV.

by vaginal route.

Epidural analgesia preferred in lower section

Perinatal and maternal

complications increased with increase in NYHA

Infective endocarditis prophylaxis was

. Anticoagulation

was offered in two cases with prior mitral valve

The rate of both preterm birth and

(Chart 1 to 9)

take a heavy toll on both

A multi disciplinarian

ideal in dealing with and preventing

Counselling for contraception

and family planning and follow up during

ndatory.

B M Weiss, et al. Outcome of

cardiovascular surgery and pregnancy.

1998; 179: 1643-

Gossing G, Borges A,

Maternal heart

disease and pregnancy outcome: a

centre experience. Eur J of Heart

860.

3. Task Force Members, Celia Oakley, Anne

Child, Bernard Iung, Patricia Presbitero,

et al. Expert consensus document on

management of cardiovascular diseases

during pregnancy. The task force on the


during pregnancy

Society of Cardiology

24: 761-781.

4. Bonow RO, Carabello BA, Kanu C, et al.

ACC/AHA 2006 guidelines for the

management of patients with valvular

heart disease: a report of the American

College of Cardiology/American Heart

Association Task Force on Practice

Guidelines (writing committee to revise

the 1998 Guidelines for the

Management of Patients With Valvular

Heart Disease): developed in

collaboration with the Society of

Cardiovascular Anesthesiologists:

endorsed by the Society for

Cardiovascular Angiography and

Interventions and the Society of

Thoracic Surgeons.

114: e84–e231.

5. Mazghar, et al. Maternal cardiac

complications in women with cardiac

diseases. J Coll. Phy Surg Part I, 2005;

5(8): 476-480.

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Page 24

Task Force Members, Celia Oakley, Anne

ild, Bernard Iung, Patricia Presbitero,

et al. Expert consensus document on


The task force on the


during pregnancy of the European

Society of Cardiology. Eur Heart J, 2003;

Bonow RO, Carabello BA, Kanu C, et al.

ACC/AHA 2006 guidelines for the

management of patients with valvular

heart disease: a report of the American

College of Cardiology/American Heart

Association Task Force on Practice

writing committee to revise

the 1998 Guidelines for the

Management of Patients With Valvular

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collaboration with the Society of

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Chart – 1: Distribution according to risk classification

Chart – 2: Distribution according to NYHA

LOW RISK

MMR: <1%

MODERATE RISK

MMR: 5-15%

HIGH RISK

MMR: 25-50%

0

5

10

15

20

25

NYHA I NYHA II




istribution according to risk classification.

Distribution according to NYHA grading [4].

• 31 CASES

• 19 CASES

• 9 CASES

NYHA II NYHA III NYHA IV

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Chart – 3: Pregnancy outcome in each case

Chart – 4: Pregnancy outcome.

0

5

10

15

20

25

30

35

VAGINAL LSCS

35

6

2

EL LSCS

7 CASES

EM LSCS

9 CASES




regnancy outcome in each case.

LSCS MTP

11

53

MTP

3%

43 CASES

NORMAL

69%

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NORMAL

OPERATIVE

VBAC

OBSTETRIC

CARDIAC

SUCTION




Chart – 5: Obstetric complications

Chart – 6: Cardiac complications in course of pregnancy

0

2

4

6

EPISIO

HEMATOMA, 1

0

2

4

6

8

2




bstetric complications.

ardiac complications in course of pregnancy.

EPISIO

HEMATOMA, 1

PPH, 4

BLOOD

TRANSFUSION, 6

8

2

3

2

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2




Chart – 7: Maturity of newborn infants

Chart – 8: Distribution of birth weight of neonates

19%

60.70%




aturity of newborn infants.

istribution of birth weight of neonates.

81%full term delivery

pre-term delivery

2.10%

11.80%

10%

16.90%

<1 kg

1.1 to 1.5 kg

1.6 to 2 kg

2.1 to 2.5 kg

> 2.5 kg

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Chart – 9: Perinatal outcome.

Source of support: Nil

02468

101214

9




Nil Conflict of interest:

13

2 2

6

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Conflict of interest: None declared.

4

cardiac diseases with pregnancy - a study of maternal and fetal outcome

Documents

various cardiac diseases

cardiac lesions

coexisting cardiac diseases

pregnancy maternal

maternal mortality

maternal complications

perinatal outcome

perinatal mortality