Below is a **complete, exam-ready, concise-but-exhaustive reference** for **Heart Disease in Pregnancy** — covering definition, physiology, classification, clinical features, investigations, management (stepwise), drug details, labor/delivery planning, postpartum care, and contraindications.

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# **Heart Disease in Pregnancy – Complete Overview**




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## **1. Definition**

Heart disease in pregnancy refers to **pre-existing cardiac disorders** (congenital or acquired) or **pregnancy-induced cardiac dysfunction** (e.g., peripartum cardiomyopathy) that complicate pregnancy, labor, or postpartum period.

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## **2. Why Pregnancy Worsens Heart Disease (Physiological Changes)**

Pregnancy causes major hemodynamic changes that peak at **28–32 weeks**:

* **↑ Blood volume by 40–50%**
* **↑ Cardiac output by 30–50%**
* **↑ Heart rate by 10–20 bpm**
* **↓ Systemic vascular resistance**
* **Hypercoagulable state**
* **During labor:** CO ↑ 20–30% more
* **Immediately postpartum:** Autotransfusion ↑ CO up to 80%

These changes may **unmask latent heart disease** or **worsen existing cardiac failure**.

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## **3. Types of Heart Diseases Seen in Pregnancy**

### **A. Congenital Heart Disease (CHD)**

* Atrial septal defect (ASD)
* Ventricular septal defect (VSD)
* Patent ductus arteriosus (PDA)
* Tetralogy of Fallot (repaired/unrepaired)
* Eisenmenger syndrome (very high-risk)

### **B. Acquired Heart Disease**

* Rheumatic heart disease

* Mitral stenosis (most common serious lesion in pregnancy)
* Mitral regurgitation
* Aortic stenosis
* Cardiomyopathies

* **Peripartum cardiomyopathy**
* Ischemic heart disease
* Arrhythmias
* Hypertensive heart disease

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## **4. WHO Classification of Maternal Cardiovascular Risk**

### **WHO Class I – Low Risk**

* Small ASD/VSD
* PDA
* Mitral valve prolapse
* Successfully repaired simple CHD

### **WHO Class II – Moderate Risk**

* Unrepaired ASD/VSD
* Repaired TOF
* Mild LV dysfunction

### **WHO Class III – High Risk**

* Mechanical valves
* Cyanotic congenital heart disease
* Moderate LV dysfunction
* Previous peripartum cardiomyopathy with normal EF now

### **WHO Class IV – Extremely High Risk (Pregnancy Contraindicated)**

* **Pulmonary hypertension / Eisenmenger syndrome**
* **Severe LV dysfunction (EF < 30%)**
* **Severe mitral stenosis or aortic stenosis**
* **Marfan syndrome with aorta > 45 mm**
* **Previous peripartum cardiomyopathy with persistent dysfunction**

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## **5. Clinical Features**

### **Symptoms**

* Dyspnea (especially NYHA III–IV)
* Orthopnea / PND
* Fatigue
* Palpitations
* Chest pain
* Syncope

### **Warning Features of Cardiac Decompensation**

* Dyspnea at rest
* Hemoptysis
* Cyanosis
* Loud P2 / RV heave
* Basal crepitations
* New arrhythmias

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## **6. Investigations**

### **Basic**

* CBC
* ECG
* **Echocardiography – Most important**
* BNP (optional)

### **Advanced**

* Cardiac MRI (safe without gadolinium)
* Holter monitoring
* Exercise testing (pre-pregnancy only)

### **Avoid**

* CT angiography unless life-saving
* ACE inhibitors / ARBs history to be checked

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## **7. Complications**

* **Maternal:** Heart failure, arrhythmias, thromboembolism, endocarditis, cardiac arrest
* **Fetal:** IUGR, preterm birth, fetal hypoxia, congenital heart disease (3–5% risk)

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# **8. Management of Heart Disease in Pregnancy (Stepwise)**



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## **A. Preconception Counselling**

* Risk assessment + WHO classification
* Optimize cardiac status (e.g., balloon valvotomy for MS)
* Stop teratogenic drugs (ACE inhibitors, ARBs, statins, warfarin if possible)

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## **B. Antenatal Management**

### **1. Lifestyle**

* Adequate rest
* Left lateral position
* Avoid anemia (treat aggressively)
* Avoid excessive weight gain
* Salt restriction if HF symptoms

### **2. Drugs Used**

Below are the major drug classes **with indications, mechanism, dosing, adverse effects, contraindications, interactions, and counselling.**

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## **i. Diuretics (Furosemide)**

**Indication:** Heart failure, pulmonary edema
**MOA:** Loop diuretic → inhibits Na-K-2Cl in loop of Henle
**Dose:** 20–40 mg PO/IV, repeat as required
**PK:** Rapid onset, renal excretion
**AEs:** Hypokalemia, dehydration
**Contra:** Severe electrolyte imbalance
**Interactions:** Digoxin ↑ toxicity if hypokalemia
**Counselling:** Monitor weight, urine output, electrolytes

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## **ii. Beta-blockers (Metoprolol preferred)**

**Indication:** Rate control, arrhythmias, ischemic heart disease
**MOA:** Blocks β1 receptors → ↓ HR & contractility
**Dose:** 25–100 mg/day
**AEs:** IUGR (minimal), bradycardia
**Contra:** Severe asthma
**Interactions:** Calcium channel blockers → heart block risk
**Counselling:** Do not stop suddenly

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## **iii. Anticoagulants**

### **a. LMWH (Enoxaparin) – Preferred**

**Indication:** Mechanical valves, AF, thromboembolism
**MOA:** Enhances antithrombin III → inhibits Xa
**Dose:** 1 mg/kg twice daily
**Monitoring:** Anti-Xa levels
**AEs:** Bleeding
**Contra:** Active bleeding

### **b. Warfarin – Teratogenic (avoid 6–12 weeks)**

Used only when valve thrombosis risk is very high.

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## **iv. Vasodilators (Hydralazine, Nitrates)**

**Indication:** HF with hypertension
**AEs:** Headache, hypotension

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## **v. Digoxin**

**Indication:** HF with atrial fibrillation
**MOA:** Na-K ATPase inhibition → ↑ Ca → ↑ contractility
**Dose:** 0.125–0.25 mg daily
**AEs:** Toxicity (nausea, vision changes)
**Monitor:** Serum levels

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## **Drugs Contraindicated in Pregnancy**

* **ACE inhibitors / ARBs** → renal failure, skull defects
* **Amiodarone** → fetal thyroid dysfunction
* **Warfarin (first trimester)** unless essential
* **Statins**

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## **C. Follow-up Schedule**

* Monthly (WHO I–II)
* Fortnightly (WHO III)
* Weekly (WHO IV — pregnancy discouraged)

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# **9. Labor and Delivery Management**



### **Preferred Mode:** **Vaginal delivery with epidural anesthesia**

### **Indications for Caesarean Section**

* Severe aortic stenosis
* Marfan with aortic root dilation
* Eisenmenger
* Severe HF
* Anticoagulation not stopped

### **Intrapartum Measures**

* Continuous ECG + pulse oximetry
* Avoid fluid overload
* Slow, assisted second stage (forceps/vacuum)

### **Anesthesia**

* Epidural preferred
* Avoid general anesthesia (↑ cardiac stress)

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# **10. Postpartum Care**

* Highest risk of heart failure in **first 24–72 hours**
* Gradual mobilization
* Restart anticoagulation after 6 hours (if needed)
* Contraception counselling

* **Avoid estrogen pills**
* Prefer: IUCD, progestin-only methods

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# **11. High-Risk Specific Conditions**

## **A. Mitral Stenosis**

* Most dangerous RHD lesion in pregnancy
* Tachycardia → ↑ LA pressure → pulmonary edema
* Management: β-blockers + diuretics
* Balloon valvotomy if severe

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## **B. Eisenmenger Syndrome**

* **Pregnancy contraindicated (WHO IV)**
* Maternal mortality 30–50%
* No effective treatment → counselling for termination

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## **C. Peripartum Cardiomyopathy**

* Heart failure in last month of pregnancy or 5 months postpartum
* EF < 45%
* Treatment:

* Diuretics
* Beta-blockers
* Bromocriptine (stops prolactin → improves function)
* Avoid future pregnancy if EF not normalized

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# **12. Fetal Risks**

* Prematurity
* Growth restriction
* Neonatal asphyxia
* Congenital heart disease (if mother has CHD)

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# **13. Key Prevention Strategies**

* Early diagnosis
* Control anemia
* Avoid excessive fluids
* Use cardiac medications judiciously
* Multidisciplinary care (obstetrician + cardiologist)

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