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Heart disease

Extracted from Mayes' Midwifery 14th edition (2011) Sue Macdonald, Julia Magill-Cuerden (Eds). London; Baillre Tindall: 2011. Courtesy Elsevier

Heart disease is the leading non-obstetric cause of maternal death in the UK. The most common cardiac cause of maternal death is myocardial infarction. The total incidence of cardiac disease in pregnancy is 0.5% - 2%. Signs and symptoms of cardiac disease include:

  • Dyspnoea
  • Chest pain
  • Limitation of activity
  • Palpitations, arrhythmias, dysrhythmias
  • Cyanosis
  • Heart sound changes

During pregnancy, women with pre-existing heart disease may experience a worsening of symptoms due to physiological changes of pregnancy - increase in circulating blood volume, increased resting oxygen consumption, decreased peripheral vascular resistance, increase in stroke volume and slight increase in resting heart rate. These changes influence haemodynamics, increasing strain on the heart, which is further compromised during labour. Maternal heart disease may be congenital or acquired.

The fetus is at increased risk of

  • Congenital cardiac defects
  • Intrauterine hypoxia
  • Intrauterine death
  • Effects of maternal medication

Antenatal care

Pre-pregnancy counselling and then care in a dedicated antenatal cardiac clinic are required, with input from an obstetrician, cardiologist, anaesthetist and midwife. The aims of antenatal care are to detect heart failure and disturbances of cardiac rhythm. A high protein, low salt diet is recommended; weight control is important. Infections (including dental infections) should be treated with antibiotics to reduce the risk of bacterial endocarditis. Major antenatal complications are acute pulmonary oedema and congestive cardiac failure. Symptoms of a worsening of the condition (dyspnoea, cough or chest pain) indicate the need for immediate hospital admission.

Care in labour

Depending on the condition and progress of the pregnancy, labour may be spontaneous, induced, or an elective caesarean section may be carried out. Prophylactic antibiotics may be given to reduce the risk of bacterial endocarditis. Epidural analgesia is recommended but with caution in respect of hypotension, and is contraindicated in women on anticoagulant therapy.

In addition to usual midwifery observations, the following are important:

  • Colour in case of cyanosis
  • Respiratory rate - should remain below 24 per minute
  • Degree of dyspnoea
  • Radial and apical pulses - should remain below 110 per minute
  • ECG may be continuous throughout labour
  • Fluid balance to prevent overload
  • Continuous electronic fetal monitoring

There is no reason for instrumental delivery if birth is progressing well, but excessive pushing should be avoided. Strong uterine contraction in the third stage may alter circulation and compromise an impaired heart: ergometrine and syntometrine are not used, and syntocinon used with caution (contraindicated in heart failure).

Postnatal care

Continue close observation of vital signs as heart failure or peripartum cardiomyopathy may occur in the first few days postnatally. Women require rest but not immobilisation. Physiotherapy may reduce the risk of thromboembolic disorders. There is usually no contraindication to breastfeeding. Careful examination of the baby to exclude congenital heart disease (increased risk) is required.

Further reading

European Society of Cardiology (2011). ESC Guidelines on the management of cardiovascular diseases during pregnancy. European Heart Journal (2011) 32, 3147-3197. Doi:10.1093/eurheartj/ehr218. Available at: https://www.escardio.org/static_file/Escardio/Guidelines/publications/PREGN%20Guidelines-Pregnancy-FT.pdf

Royal College of Obstetricians & Gynaecologists (2011) Cardiac disease and pregnancy. Good Practice No 13. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/goodpractice13cardiacdiseaseandpregnancy.pdf

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