CARDIAC DISEASE IN PREGNANCY

In sub Saharan Africa, this is often of rheumatic heart disease origin.

Clinical Features

History of;
  • Rheumatic fever in childhood, or known rheumatic heart disease
  • Dyspnoea
  • Palpitations
  • Body oedema
  • Cough
  • Easy fatigability
  • Evidence of heart enlargement
  • Murmurs
  • Thrills
  • Left parasternal heave
  • Prominent neck veins, and tachycardia.

There may also be hepatomegaly, ascites, and basal crepitations.

Investigations

  • Shielded chest x-ray in early pregnancy
  • Electrocardiogram
  • Routine antenatal profile (haemoglobin, VDRL, blood group, urinalysis)
  • Urine C&S, blood culture, urea and electrolytes

Management

  • This depends on functional classification of the New York Heart Association:
    • Class I Asymptomatic
    • Class II Symptomatic with heavy work
    • Class III Symptomatic with light work or exercise
    • Class IV Symptomatic at rest
  • Class I and II are managed as outpatients until 34–36 weeks when they are admitted for bed rest and observation in hospital level 4–6.
  • Class III and IV are admitted on first visit at any gestation for entire duration of pregnancy.

Management – Supportive

  • Bed rest
  • Haematinic supplementation: Ferrous sulphate 200mg TDS + folic acid 5mg OD combination.
  • Treat intercurrent infections: Dependent on organisms identified and site of infection.
  • Avoid undue physical and emotional stress.
  • Regular urine analysis and culture.
  • Ensure dental hygiene.
  • Regular urea and electrolyte determination.

Management – Pharmacological

  • Digitalization is indicated in imminent and overt cardiac failure, if not previously on digoxin. Consult cardiologist on medication regimes.
  • Rapid digitalization by mouth, 1–1.5mg in divided doses over 24 hours, less urgent digitalization 250–500mcg daily (higher dose may be divided).
  • Continue maintenance therapy with digoxin 0.25mg, frusemide 40–80mg.
  • Continue prophylactic IM benzathine penicillin 2.4 mega units monthly.

Labour and Delivery

  • Spontaneous labour and delivery are preferred.
  • Prop up.
  • Keep oxygen and emergency tray available.
  • Start antibiotics PO amoxicillin 2g + IV gentamicin 160mg STAT then PO amoxicillin 1g 8 hourly and IV gentamicin 80mg 8 hourly for 2 weeks.
  • Adequate analgesia with morphine 10mg IM STAT at 4–6cm cervical dilatation.
  • Avoid lithotomy position.
  • Assisted vacuum delivery in second stage.
  • Massage uterus after delivery of placenta to achieve uterine contraction.
  • Give oxytocin 10 IU IM if needed to achieve uterine contraction or to control postpartum haemorrhage.
  • Give frusemide 80mg IV STAT after 3rd stage of labour
  • Observe closely for evidence of cardiac failure
  • Keep in hospital for 2 weeks. Continue antibiotics for entire period. Discharge through the cardiac clinic.

Patient Education

  • Advise on family planning. Cardiac patients should have small families of 1 or 2 children or none. Suitable methods include minilaparotomy tubal ligation under local anaesthesia, vasectomy, barrier methods, progesterone-only
    agents pills or implants. Oestrogen containing methods are contraindicated such patients.