Heart Disease complicating pregnancy

Heart disease in pregnancy is the most common cause of death in pregnancy in the United Kingdom. Heart disease can present for the first time in pregnancy and many women are unaware of it. It could be because of undetected underline heart abnormality which might get aggravated due to pregnancy.A strong family history and sudden death in families can be considered for risk of heart disease in pregnancy. Also, pre-existing heart conditions may worsen during pregnancy, putting additional strain on the compramised heart

Heart changes during pregnancy:

During pregnancy a woman's body undergoes various changes to provide nutrition and care to the growing fetus. The pregnant heartbeat increased by 10-15% per mins . Due to relaxation of muscles of blood vessels Blood Pressure falls by 10 mm hg. Also to compensate for the increased need of blood flow to growing fetus , blood volume increases by 30-40 % , but Red Blood Cells increase 20% compared to blood volume. This causes pregnancy as a physiological state of anemia. These changes start as early as 8 weeks and plateau by 32 weeks. A growing womb also increases the pressure on the chest and shifts the apex of the heart towards the left. All these changes lead to some pregnancy specific changes in heart trace i.e Electrocardiogram (ECG) which make it difficult to identify diseased hearts.

Symptoms of heart disease :

The heart changes in pregnancy make women get fatigue easily, she may experience shortness of breath and lightheadedness. These are also the symptoms of heart disease so making diagnosis of heart disease in pregnancy difficult. But few symptoms are alarming or a red flags.🚩 Chest pain, severe shortness of breath, air hunger in lying down position are few of alarming symptoms. One should not neglect it, and seek urgent medical attention.

Risk Factors:

If you are planning a pregnancy, one should be aware of various risk factors for heart disease. If you are having any of the below risks, visit your Doctor and take specialist opinion whenever possible. Age above 35 years High blood pressure/ diabetic mellitus Obesity BMI > 30 Previous pregnancy complicated by BP or Diabetes of pregnancy like preeclampsia, gestational diabetic mellitus. Family history of heart disease Heavy Alcohol intake

Pre-existing heart lesions in pregnancy.

Acquired:

● Infections: these are caused by viruses and bacteria, less seen in pregnant women in the developed world compared to the developing world. Few of the bacterias can cause Rheumatic heart disease which mainly affects valves of hearts. Cardiomyopathy is a condition where muscles of the heart get malfunctioned and pump less effectively.
● Heart attack: also known as Coronary artery disease , the blood vessel which supplies to heart muscle gets clogged by fat plug and causes muscle death of the portion.
● Autoimmune: the antibodies formed against our own cells specially heart and make it weak.
● Cardiomyopathy: weak heart to pump blood effectively.
● Arrhythmia and heart block: abnormal rhythm of heart.

Congenital:

● Cyanotic heart diseases: these are a group of conditions where the impure blood mixes with pure blood and circulates in the body. This causes less oxygen supply to tissues and can turn life threatening . surgical treatment is required for correction of such heart conditions.
● Acyanotic heart disease: Group of heart conditions which are caused by developmental abnormalities, are compatible with life.
For some women pregnancy with heart conditions can be life threatening, in such situations pregnancies are contraindicated.
● Pulmonary Hypertension
● Aortic Root dilatation ( Marfan’s syndrome, Turner’s syndrome)
● Severe aortic valve stenosis
● Severe mitral valve stenosis
● Cardiomyopathy with impaired heart function
● Heart failure

Risk of heart disease during pregnancy:

Mother:

● Blood clot formation
● Abnormal heart rhythm
● Heart failure
● Pre-eclampsia
● Frequent admission to hospital

Baby :

● If the mother is having congenital heart disease then there is a small possibility of having congenital heart disease in the baby.
● Miscarriages
● Prematurity
● Smaller birth weight
● Needing admission to special care

How to manage heart disease in pregnancy? Pre-pregnancy:

Women with pre-existing heart disease should be seen by a team of specialist doctors preferably prior to conception to check upon functionality of the heart. Electrocardiogram, Heart trace and 2D ECHO are the primary investigations. With this appropriate drug review needs to be done to assess the risk of teratogenicity of drugs on growing fetuses. Folic Acid 400microgram to be started at least 3 months prior.

Pregnancy:

During the first three month, women with heart disease will be seen in conjunction with cardiologist , consultant obstetrician at tertiary care where all facilities including intensive heart care units will be available. These patients are at increased risk of miscarriages. First trimester symptoms of pregnancy like nausea vomiting can precipitate symptoms of heart disease. So one should seek early intervention. As pregnancy advances women with heart disease need frequent follow up and a low threshold for admission. Heart functions will be assessed from time to time by doing ECG and 2D-ECHo. We also need fetal heart assessment by experts to check upon congenital heart disease in the fetus. Drug review and need for blood thinner should be assessed from time to time. Red flags are the symptoms when women should seek urgent assistance from healthcare professionals. Sudden breathlessness Palpitations or awareness of heart beats and pounding heart Acute pain in chest Frothy sputum from mouth Shortness of breath when lying down Care during labour and Delivery: Most of the women with heart disease deliver vaginally without posing any risk. Labour care plans will be discussed with women well in advance in relation to patients' heart condition by obstetrician and heart specialists. In labour we need to assess heart condition, oxygen saturation and fluid balance. To minimize the pain of labour epidural pain relief is offered to women in labour . Since women with heart disease may face challenges at the time of birth of baby , instrumental delivery is offered to lessen the strain on weak heart. For few conditions like pulmonary hypertension planned cesarean section is recommended. Baby’s heart beats will be monitored on a machine continuously and women will be encouraged to keep herself motivated , active and supportive. Once the baby is born baby will be assessed by neonatologist

Post Delivery:

After delivery , heart changes started reverting back to normal. This may pose more stress to a weak heart. To minimize the risk after delivery Diuretics , a medication to remove excess fluid from your body will be given through drip. Certain routine medications like Methergine, which minimize the bleeding after the delivery is contraindicated and not offered to women with heart disease. Women are encouraged to breastfeed their baby as early as possible to enjoy the joy of motherhood.

Contraception:

Need for effective contraception should be discussed with women after the birth. Hormone containing contraceptives might not be suitable for all the patients . Take an expert opinion , who will help you to choose the best options available.

After Care :

Women with modifiable risk factors can be encouraged to follow a healthy lifestyle like exercise, dietary habits and healthy BMI. Women should see the heart Doctor after delivery and restart her pre pregnancy medication. Take good care of your heart !

Take Home message:

With good pre pregnancy planning and an effective care by multidisciplinary team of specialists, many women with heart disease achieve the dream of motherhood.