|Year : 2015 | Volume
| Issue : 2 | Page : 120-123
Maternal heart disease and pregnancy outcome: Findings from a retrospective cohort in a tertiary care government hospital in Haldwani, Nainital
Godawari Joshi1, Subhash C Joshi2, Sanjay K Jha3, Yatendra Singh2, Arun Joshi2
1 Department of Obstetrics and Gynaecology, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Medicine, Government Medical College, Haldwani, Uttarakhand, India
3 Department of Community Medicine, Government Medical College, Haldwani, Uttarakhand, India
|Date of Web Publication||30-Jul-2015|
2/411, Sheesh Mahal, Post Office Kathgodam, Nainital - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: Heart disease in pregnancy is a potentially serious medical complication in pregnancy. Limited studies have been conducted in India to assess heart disease in pregnancy.
Objective: To determine the type of cardiac lesions and to assess the maternal and fetal outcomes in patients with heart disease in pregnancy.
Materials and Methods: In this retrospective study, 42 pregnant women with known or newly diagnosed heart disease were followed from January 2012 to December 2013. The data analysis was done using statistical software Systat 12.
Results: Out of total 42 subjects selected for the study, maximum 13 (30.9%) were in the age group of 26-30 years. Majority of the women 30 (71.4%) were primigravida. Mostly 26 (61.9%) patients belonged to New York Heart Association (NYHA) class I andII. In total, 30 (71.4%) women presented with rheumatic heart disease and 6 (14.3%), with congenital heart disease. Majority 22 (52.4%) had spontaneous vaginal deliveryand only 8 (19.0%) required induction of labor. Most common maternal complication was heart failure (16.7%) and maternal deaths were 4.8%. The live birth was recorded in 38 cases (90.5%) of them 16 (42.1%) were preterm babies. Intrauterine death occurred in four cases while five babies died in neonatal period.
Conclusion: The study results conclude that the rheumatic heart disease is still a predominant lesion and heart disease in pregnancy is associated with increased maternal and fetal risk.
Keywords: Heart disease, outcome, pregnancy, retrospective cohort
|How to cite this article:|
Joshi G, Joshi SC, Jha SK, Singh Y, Joshi A. Maternal heart disease and pregnancy outcome: Findings from a retrospective cohort in a tertiary care government hospital in Haldwani, Nainital. Nig J Cardiol 2015;12:120-3
|How to cite this URL:|
Joshi G, Joshi SC, Jha SK, Singh Y, Joshi A. Maternal heart disease and pregnancy outcome: Findings from a retrospective cohort in a tertiary care government hospital in Haldwani, Nainital. Nig J Cardiol [serial online] 2015 [cited 2020 Jun 1];12:120-3. Available from: http://www.nigjcardiol.org/text.asp?2015/12/2/120/152027
| Introduction|| |
Heart disease in pregnancy is an uncommon problem with an overall prevalence of less than 1%.  Heart disease in pregnancy is a potentially serious medical complication in pregnancy. Treatment of heart disease is pregnancy is still a difficult task, because the impact of pre-existing cardiac disease on the mother and foetus are profound. Pregnancy and the peripartum period are associated with important cardio circulatory changes that can lead to marked clinical deterioration in the women with heart disease.  Maternal outcome is determined by the nature of the cardiac disease, surgical repair, myocardial dysfunction, history of arrhythmias and prior cardiac events. There are limited studies conducted in India to focus particularly on heart disease in pregnancy. With this background the present study was planned to determine the type of cardiac lesions and to assess the maternal and fetal outcomes in patients with heart disease in pregnancy.
| Materials and methods|| |
This retrospective cohort study was conducted in the department of Obstetrics and Gynaecology at Dr. Susheela Tewari Hospital and Govt. Medical College Haldwani, Nainital. The study population consisted of 42 pregnant women with known or newly diagnosed heart disease, who were admitted in obstetric ward and intensive coronary care unit from January 2012 to December 2013.
Baseline data recorded including age, parity, gestational age, New York Heart Association (NYHA) functional class. Detail history and investigation included ECG, Echocardiography, X-ray chest, patients were followed throughout the pregnancy, peripartum and postpartum period. All patients were assessed for the mode of delivery. Vaginal delivery was the aim; caesarean section was done only for obstetric indication. Maternal outcome recorded in terms of termination of Pregnancy, hemorrhage, maternal death. Fetal outcome recorded in terms of birth weight, prematurity and fetal cardiac lesion.
The study was started after taking permission from the Institutional Ethical Committee. The data analysis was done using statistical software Systat 12.
| Results|| |
A total of 42 pregnant women with heart disease were included in the study. Baseline characteristics of all pregnancies are shown in [Table 1]. Out of total 42 subjects selected for the study, maximum 13 (30.9%) were in the age group of 26−30 years followed by 12 (28.6%), 10 (23.8%) and 7 (16.7%) in 21−25 years, 31−35 years and more than 35 years of age group, respectively. Majority of the women30 (71.4%) were primigravida. Most patients were in NYHA classes I and II (61.9%), while 38.1% of the patients were in NYHA classes III and IV.
The cardiaclesions are depicted in [Table 2]. In total, 30 (71.4%) women presented with rheumatic heart disease and6 (14.3%), with congenital heart disease. Six (14.3%) pregnant patients had history of cardiomyopathy, prior mitral valve replacement, and priormitral valvoplasty. Among the rheumatic heart disease, mitral stenosis was the most common cause (40%). In congenital lesions, atrial septal defect was present in three cases (50%). In miscellaneous group, the most common (50%) cause was cardiomyopathy.
[Table 3] shows that nearly half 22 (52.4%) had spontaneous vaginal delivery and only eight (19.0%) required induction of labor (PGE2gel). Two cases delivered by instrumental delivery (outlet forceps) because of prolonged second stage of labor. Ten (23.8%) women delivered by Cesarean section.
Out of total 42 women with heart disease, 26 (61.9%) developed severe maternal complications [Table 3]. Most common (16.7%) complication was heart failure followed by PIH, PPH and anemia in 11.9%, 11.9% and 7.1%, respectively. There were two maternal deaths (4.8%). Cause of death in one patient was cardiac failure after vaginal delivery and another patient died after Cesarean section because of cardiac arrest.
The fetal outcomes are shown in [Table 3]. In our study, the live birth was recorded in 38 cases (90.5%) and intrauterine death occurred in four cases (9.5%). Out of total 38 live births, 16 (42.1%) were preterm babies, 22 (57.9%) babies were ≥2.5 kg and five babies died in neonatal period. No baby had congenital heart disease.
| Discussion|| |
In the present study we determined the type of cardiac lesion and assessed the maternal and fetal outcomes in pregnant women with heart disease. Nearly 60% of the patients with heart disease were young (less than 30 years). Pregnancy produces significant cardiovascular and hemodynamic changes, which in patients with heart disease, may lead to obstetric and neonatal complications. Heart disease in pregnancy encompasses a wide spectrum of disorder. In India, maternal death from valvular heart disease is increasing and often occurs in patients with no history of heart disease and it is responsible for 10 to 20% of maternal death. , Rheumatic heart disease continues to be the predominant cardiac lesion in pregnancy in India.  In this study, RHD was about five times more common (71.5%) than the congenital heart disease (14.3%) as shown in [Table 2], and mitral stenosis was the predominant valvular lesion. These observations are similar to other Indian studies. ,,, This may be due tolack of preventive treatment and inadequate use of secondary antibiotic prophylaxis against the streptococcal infections in India.
Murmurs are commonly heard during pregnancy due to the hemodynamic changes. Echocardiography is rarely necessary in pregnant women with murmurs.  However, in our study, echocardiography was done routinely and was very helpful for early and accurate assessment of cardiac status.
Nearly half 22 (52.4%) of the women with heart disease in pregnancy had spontaneous vaginal delivery and only 8 (19.0%) required induction of labor with PGE2 gel, which was found safe and effective in this study. Konar et al. in their study also reported that most of the women with heart disease in pregnancy went into spontaneous labor and delivered vaginally.  In our study, the use of Cesarean delivery was also found to be higher (23.8%) among the study subjects.
Two patients had mitral valvuloplasty and one patient had mitral valve replacement before pregnancy [Table 2] and all of them received anticoagulant, low dose warfarin (3−4 mg per day), throughout the pregnancy. A dose of more than 5 mg is associated with the increased risk of teratogenesis, miscarriage and still birth.  Majority (61.9%) developed severe maternal complication in pregnancy and the cardiac failure was a major complication [Table 3]. In this study, majority of pregnancies had a favorable outcome for both the mother and the baby. There were two (4.8%) maternal deaths among complicated pregnancies, which is comparatively higher than the other studies in India because of the of late arrival and delay in referral to our hospital. In our study, favorable baseline NYHA class is likely to have contributed to the relatively favorable outcomes. Similar findings were seen in other studies. , Hsieh et al. in their study reported that out of the total maternal deaths 75% were in patients with NYHA classes III and IV. 
Perinatal outcome were usually seen in the form of preterm birth and low birth weight babies and these neonates also run the risk of inheriting congenital heart disease. Overall, the risk of such inheritance is 3.5% compared to 1% in general population.  In our study there were no such inherited cardiac lesions in new born babies.
Despite the potential for significant maternal morbidity in most patient with cardiac disease a satisfactory outcome can be expected with careful antenatal, intrapartum and postpartum management. 
| Conclusions|| |
This study results conclude that the rheumatic heart disease is still a predominant lesion and heart disease in pregnancy is associated with increased maternal and fetal risk. We need to monitor cardiac patient for early detection and management of heart failure throughout the course of pregnancy labor and puerperium. Thus cardiac disease in pregnancy remains an important cause of maternal mortality and is potentially avoidable with optimal care and also early referral to a good critical care center, which is well equipped with a team of cardiologist and obstetrician who are trained to deal with such kind of complicated cases.
| References|| |
Sugrue D, Blake S, MacDonald D. Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Ireland, 1969 to 1978. Am J Obstet Gynecol 1981;139:1-6.
Hsuth WA, Luetscher JA, Carlson EJ, Grislis G, Fraze E, et al
. Changes in active and inactive renin throughout pregnancy. J Clin Endocrinol Metab 1982;54:1010-6.
Enein M, Zima AA, Kassem M, el-Tabbakh G. Echocardiography of the pericardium in pregnancy. Obstet Gynaecol 1987;69:851-3.
de Swiet M. Heart disease in pregnancy. In: deSwiet M, editor. Medical disorders in obstetric practice. Oxford: Blackwell; 1984. p. 483-504.
Devabhaktuni P, Devinenik K, Vemuri U. Pregnancy outcome in chronic rheumatic heart diseae. J Obstet Gynaecol India 2009;59:41-6.
Puri S, Bharti A, Puri S, Mohan B, Bindal V, Verma S. Maternal heart disease and pregnancy outcomes. JK Sci 2013;15:7-10.
Konar H, Chaudhari S. Pregnancy complicated by maternal heart disease: A review of 281 women. J Obtet Gynaecol India 2012;62:301-6.
Ashwini M, Gyatri Devi J. Maternal and fetal outcome in cardiac disease complicating pregnancy at a tertiary care centre in a rural area. Int J Biomed Res 2014;5:200-303.
Mishra M, Chambers JB, Jackson G. Murmurs in pregnancy: An audit of echocardiography. BMJ 1992;304:1413-4.
Chong MK, Harvey D, de Swiet M. Follow up study of children where mothers were treated with warfarin during pregnancy. Br J Obstet Gynaecol 1984;91:1070-3.
Vasu S, Stergiopoulos K. Valvular heart disease in pregnancy. Hellenic J Cardiol 2009;50:498-510.
Bhatla N, Lal S, Behra G, Kriplani A, Mittal S, Agarwal N, et al
. Cardiac disease in pregnancy. Int J Gynaecol Obset 2003;82:153-9.
Hsieh TT, Chen KC, Soong JH. Outcome of pregnancy in patients with organic heart disease in Taiwan. Asia Oceania J Obstet Gynaecol 1993;19:21-7.
Gelson E, Mank J, Gatzoulis M. Cardiac disease in pregnancy. Obstet Gynaecol 2007;9:83-7.
Siu S, Sermer M, Colman JM, Alvarez AN, Mercier LA, Mortan BC, et al.
Cardiac Disease in Pregnancy (CARPREG) Investigators. Prospective multicenter study of pregnancy outcome in women with heart disease. Circulation 2001;104:515-21.
[Table 1], [Table 2], [Table 3]