Cardiac diseases with pregnancy - A study of maternal and fetal outcome by International Archives of Integrated Medicine

Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Original Research Article

Cardiac diseases with pregnancy - A study of maternal and fetal outcome Tushar M Shah1, Keeranmayee Mishra2*, Pallavi Ninama1, Chirag Parikh1 1

Assistant Professor,, Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad, India 2 Resident, Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad, Ahmedabad India *Corresponding author email: keeran.subham@gmail.com

How to cite this article: Tushar M Shah, Shah Keeranmayee Mishra, Pallavi Ninama, Chirag Parikh. Parikh Cardiac diseases with pregnancy - A study of maternal and fetal outcome. outcome IAIM, 2015; 5; 2(1): 2(1 22-29.

Available online at www.iaimjournal.com Received on: 04-11-2014 2014

Accepted on: 17-12-2014

Abstract Background: Total 0.2% to 4% of all pregnancies are complicated by cardiac diseases. diseases In non western countries, rheumatic heart diseases (RHD) ( constitute 56-89% off the cases and congenital c heart diseases only 9-19%. existing cardiac diseases admitted to a Aim and objectives: To review all obstetric patients with co-existing tertiary care center over a period of one year and ascertain the causes of admissions and the maternal and perinatal morbidity and mortality. Material and methods: A retrospective, analytical study of all patients with cardiac diseases who delivered over a period of January 2013 20 to December 2013 was conducted. cond A tabulated representation of the data was done. The various cardiac diseases were categorized according to their severity, NYHA category, type of pathology, the maternal and perinatal outcome was assessed and maternal mortality and perinatal mortality mortal was recorded. Conclusion: Total 69% cardiac lesions in pregnancy pregnancy were rheumatic in origin and 15% belonged to high risk category while 13.1% were NYHA type IV. Total 69% deliveries were by vaginal route. Epidural analgesia preferred in LSCS of cardiac patients. Perinatal and maternal complications were observed to increase with increase in NYHA class.

Key words Cardiac diseases, Rheumatic, Obstetric.

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Cardiac diseases with pregnancy

Introduction Total 0.2% to 4% of all pregnancies are complicated by cardiac diseases [1]. In non western countries, rheumatic heart diseases (RHD) constitute 56-89% off the cases and congenital ongenital heart diseases only 9-19% 9 [2, 3]. Total 2.7 deaths per 1000 pregnancies are reported in pregnancies complicated by cardiac diseases [4].

Aim and objectives •

• •

To study the incidence, distribution through parity and the prevalence of various cardiac diseases in pregnancy. To classify those into three risk categories i.e. low, moderate, high [5]. To study the maternal and fetal outcomes in each case.

Material and methods A retrospective, analytical study of all patients with cardiac diseases who delivered over a 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, the maternal and perinatal outcome was assessed and maternal mortality and perinatal mortality was recorded. Total 59 cases out of 7053 deliveries were studied.

Results and Discussion Incidence of cardiac diseases was 8.36/1000 deliveries. The number of booked ooked cases was 34 (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 to the type of cardiac disease, valvular heart diseases

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) constituted the majority of cases (95.3%, n=41 cases) of which (41/43 cases) were rheumatic in origin. Out of 41 cases, isolated mitral stenosis (MS) constituted 85% of cases, combined valvular diseases 14.6% of cases and mitral valve prolapse 4.8% of cases. Total 11.6% (5 cases) had undergone balloon mitral valvoplasty preconceptionally, 30.23% (13 ( cases) developed secondary pulmonary hypertension. All lesions of rheumatic origin in were on Injection Inj Penidura intramuscularly (IM) every 21 days. There were cases of congenital congeni heart diseases that was nearly 15% (n=9) of total. They could be further classified as cyanotic (62.5%, n=5 cases), all of which were atrial septal defects which hich could further be classified into osteum secundum type (n=4) (majority majority) and sinus venosus type (n=1). Total 37.5% (n=3) cases of congenital heart diseases were acyanotic in nature. Two of these were cases of Ebstein Anomaly and one was Tetralogy of Falot. Total 2 patients out of 9 with congenital heart diseases (25%), had undergone mitral valve replacement (MVR). Total 19 patients (32%) had developed secondary pulmonary hypertension which could further be divided into mild (n=9), moderate (n=6) and severe (n=3) and one case of Eisenmenger Syndrome. 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 classified into to obstetric and cardiac types. Coming to the fetal outcome we observed that there was higher incidence of preterm delivery (19%) and a higher incidence (17%) of low birth weight neonates. Total 69% cardiac lesions in pregnancy pre were rheumatic in origin and 15% belonged to high

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Cardiac diseases with pregnancy risk category and 13.1% were NYHA Type IV. Total 69% deliveries were by vaginal route. Epidural analgesia preferred in lower section cesarean section (LSCS). Perinatal and maternal complications increased with increase in NYHA class. Infective endocarditis prophylaxis was given in all cases empirically.. Anticoagulation 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 disciplinarian approach is ideal in dealing with and preventing complications. Counselling for contraception and family planning and follow up during subsequent pregnancies is mandatory. ndatory.

References 1. B M Weiss, et al. Outcome of cardiovascular surgery and pregnancy. pregnancy Am J Obst And Gyn, 1998; 179: 16431653. 2. Stangl V, Schad J, Gossing G, G Borges A, Baumann G, Stangl K. Maternal heart disease and pregnancy outcome: a single-centre centre experience. Eur J of Heart Fail, 2008; 10(9): 855-860. 860.

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) 3. Task Force Members, Celia Oakley, Anne Child, ild, Bernard Iung, Patricia Presbitero, et al. Expert consensus document on management of cardiovascular diseases during pregnancy. The task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology. Cardiology Eur Heart J, 2003; 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 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 ntions and the Society of Thoracic Surgeons. Circulation, 2006; 114: e84â&#x20AC;&#x201C;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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Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Chart – 1: Distribution istribution according to risk classification. classification

LOW RISK

• 31 CASES

MMR: <1% MODERATE RISK MMR: 5-15% HIGH RISK

• 19 CASES

• 9 CASES

MMR: 25-50%

Chart – 2: Distribution according to NYHA grading [4].

25 20 15 10 5 0 NYHA I

NYHA II

NYHA III

NYHA IV

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Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Chart – 3: Pregnancy regnancy outcome in each case. case

35 35 30 25 20 15 11 NORMAL OPERATIVE

10 6 5

5 3

VBAC OBSTETRIC CARDIAC

0 VAGINAL

LSCS

MTP

SUCTION

Chart – 4: Pregnancy outcome.

MTP 3% EM LSCS 9 CASES

EL LSCS 7 CASES

NORMAL 69%

43 CASES

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Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Chart – 5: Obstetric bstetric complications. complications

BLOOD TRANSFUSION, 6 6 PPH, 4 4 2

EPISIO HEMATOMA, 1

Chart – 6: Cardiac ardiac complications in course of pregnancy. pregnancy

8 8 6 4

3 2

2 0

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Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Chart – 7: Maturity aturity of newborn infants. infants

19%

full term delivery 81% pre-term delivery

Chart – 8: Distribution istribution of birth weight of neonates. neonates

2.10% 11.80% 10%

60.70%

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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Cardiac diseases with pregnancy

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Chart – 9: Perinatal outcome.

13 14 12 10 8 6 4 2 0

Source of support: Nil

6 4 2

Conflict of interest: None declared.

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