Cardiac diseases with pregnancy - A study of maternal and fetal outcome

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O)Cardiac diseases with pregnancy - A study of maternal and fetal outcomeTushar M Shah1, Keeranmayee Mishra2*, Pallavi Ninama1, Chirag Parikh11Assistant Professor, Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad, India2Resident, Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad, India *Corresponding author email: [email protected] to cite this article: Tushar M Shah, Keeranmayee Mishra, Pallavi Ninama, Chirag Parikh. Cardiacdiseases with pregnancy - A study of maternal and fetal outcome. IAIM, 2015; 2(1): 22-29. Available online at www.iaimjournal.comReceived on: 04-11-2014 Accepted on: 17-12-2014AbstractBackground: Total 0.2% to 4% of all pregnancies are complicated by cardiac diseases. In non westerncountries, rheumatic heart diseases (RHD) constitute 56-89% of the cases and congenital heartdiseases only 9-19%.Aim and objectives: To review all obstetric patients with co-existing cardiac diseases admitted to atertiary care center over a period of one year and ascertain the causes of admissions and thematernal and perinatal morbidity and mortality.Material and methods: A retrospective, analytical study of all patients with cardiac diseases whodelivered over a period of January 2013 to December 2013 was conducted. A tabulatedrepresentation of the data was done. The various cardiac diseases were categorized according totheir severity, NYHA category, type of pathology, the maternal and perinatal outcome was assessedand maternal mortality and perinatal mortality was recorded.Conclusion: Total 69% cardiac lesions in pregnancy were rheumatic in origin and 15% belonged tohigh 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 wereobserved to increase with increase in NYHA class.Key wordsCardiac diseases, Rheumatic, Obstetric.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 22Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Introduction constituted the majority of cases (95.3%, n=41 cases) of which (41/43 cases) were rheumatic inTotal 0.2% to 4% of all pregnancies are origin. Out of 41 cases, isolated mitral stenosiscomplicated by cardiac diseases [1]. In non (MS) constituted 85% of cases, combinedwestern countries, rheumatic heart diseases valvular diseases 14.6% of cases and mitral valve(RHD) constitute 56-89% of the cases and prolapse 4.8% of cases. Total 11.6% (5 cases)congenital heart diseases only 9-19% [2, 3]. had undergone balloon mitral valvoplastyTotal 2.7 deaths per 1000 pregnancies are preconceptionally, 30.23% (13 cases) developedreported in pregnancies complicated by cardiac secondary pulmonary hypertension. All lesionsdiseases [4]. of rheumatic origin were on Injection Penidura intramuscularly (IM) every 21 days.Aim and objectives There were cases of congenital heart diseases that was nearly 15% (n=9) of total. They could • To study the incidence, distribution be further classified as cyanotic (62.5%, n=5 through parity and the prevalence of cases), all of which were atrial septal defects various cardiac diseases in pregnancy. which could further be classified into osteum secundum type (n=4) (majority) and sinus • To classify those into three risk venosus type (n=1). Total 37.5% (n=3) cases of categories i.e. low, moderate, high [5]. congenital heart diseases were acyanotic in nature. Two of these were cases of Ebstein • To study the maternal and fetal Anomaly and one was Tetralogy of Falot. Total 2 outcomes in each case. patients out of 9 with congenital heart diseases (25%), had undergone mitral valve replacementMaterial and methods (MVR).A retrospective, analytical study of all patients Total 19 patients (32%) had developedwith cardiac diseases who delivered over a secondary pulmonary hypertension which couldperiod of January 2013 to December 2013 was further be divided into mild (n=9), moderateconducted. A tabulated representation of the (n=6) and severe (n=3) and one case ofdata was done. The various cardiac diseases Eisenmenger Syndrome. There were 11% (n=7)were categorized according to their severity, cases with cardiomyopathies of which two wereNYHA category, type of pathology, the maternal of dilated cardiomyopathies and five cases wereand perinatal outcome was assessed and of peripartum cardiomyopathies.maternal mortality and perinatal mortality wasrecorded. Total 59 cases out of 7053 deliverieswere studied.Results and Discussion The various maternal complications could be classified into obstetric and cardiac types.Incidence of cardiac diseases was 8.36/1000 Coming to the fetal outcome we observed thatdeliveries. The number of booked cases was 34 there was higher incidence of preterm delivery(57.6%). Most patients were primi para (n=22, (19%) and a higher incidence (17%) of low birth37%). The majority belonged to an age group of weight neonates.20 years to 25 years (53%). According to thetype of cardiac disease, valvular heart diseases Total 69% cardiac lesions in pregnancy were rheumatic in origin and 15% belonged to highInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 23Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)risk category and 13.1% were NYHA Type IV. ISSN: 2394-0034 (O)Total 69% deliveries were by vaginal route. 3. Task Force Members, Celia Oakley, AnneEpidural analgesia preferred in lower sectioncesarean section (LSCS). Perinatal and maternal Child, Bernard Iung, Patricia Presbitero,complications increased with increase in NYHAclass. Infective endocarditis prophylaxis was et al. Expert consensus document ongiven in all cases empirically. Anticoagulationwas offered in two cases with prior mitral valve management of cardiovascular diseasesreplacement. The rate of both preterm birth andperinatal mortality was high. (Chart 1 to 9) during pregnancy. The task force on theConclusion management of cardiovascular diseasesCardiac diseases take a heavy toll on both during pregnancy of the Europeanmaternal and fetal health. A multi disciplinarianapproach is ideal in dealing with and preventing Society of Cardiology. Eur Heart J, 2003;complications. Counselling for contraceptionand family planning and follow up during 24: 761-781.subsequent pregnancies is mandatory. 4. Bonow RO, Carabello BA, Kanu C, et al.References ACC/AHA 2006 guidelines for the 1. B M Weiss, et al. Outcome of cardiovascular surgery and pregnancy. management of patients with valvular Am J Obst And Gyn, 1998; 179: 1643- 1653. heart disease: a report of the American 2. Stangl V, Schad J, Gossing G, Borges A, College of Cardiology/American Heart Baumann G, Stangl K. Maternal heart disease and pregnancy outcome: a Association Task Force on Practice single-centre experience. Eur J of Heart Fail, 2008; 10(9): 855-860. 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. Circulation, 2006; 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.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 24Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Chart – 1: Distribution according to risk classification. ISSN: 2394-0034 (O) LOW RISK • 31 CASES MMR: <1% • 19 CASES • 9 CASES MODERATE RISK MMR: 5-15% HIGH RISK MMR: 25-50%Chart – 2: Distribution according to NYHA grading [4].2520151050 NYHA II NYHA III NYHA IV NYHA IInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 25Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Chart – 3: Pregnancy outcome in each case. ISSN: 2394-0034 (O) 35 NORMAL35 OPERATIVE VBAC30 OBSTETRIC CARDIAC25 SUCTION2015 11 3 5 MTP10 6 LSCS 52 0 VAGINALChart – 4: Pregnancy outcome. MTP 3% EM LSCS 9 CASES EL LSCS NORMAL 7 CASES 69% 43 CASESInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 26Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Chart – 5: Obstetric complications. ISSN: 2394-0034 (O) 6 BLOOD TRANSFUSION, 6 4 EPISIO PPH, 4 2 HEMATOMA, 1 0Chart – 6: Cardiac complications in course of pregnancy. 8864 3 2 2 2220International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 27Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Chart – 7: Maturity of newborn infants. ISSN: 2394-0034 (O) 19% full term delivery 81% pre-term deliveryChart – 8: Distribution of birth weight of 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 kgInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 28Copy right © 2015, IAIM, All Rights Reserved.

Cardiac diseases with pregnancy ISSN: 2394-0026 (P)Chart – 9: Perinatal outcome. ISSN: 2394-0034 (O) 131412 910 6 8 4 6 4 2220Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 29Copy right © 2015, IAIM, All Rights Reserved.