Aims and objectives

1.      To assess the maternal outcome of pregnancies complicated by heart disease.

2.      To assess the foetal outcome of pregnancies complicated by heart disease.

Study Design: It was a prospective, observational study conducted at department of obstetrics and gynaecology in a tertiary care hospital over a period of two years.

Materials and methods: The study was approved by the Institutional ethical committee. All patients who have cardiac disease in pregnancies admitted in obstetrics and gynaecology department of our institute and were willing to participate in the study were enrolled. Those patients who were admitted in our institute in postpartum period and those who were not willing to participate in this study were excluded from the study. Women enrolled in this study were examined during antenatal or peripartum period (depending upon when they first visit our institute) and classified on the basis of New York heart association (NYHA) functional classification. In admitted patients indication of admission, complications associated with heart disease and shift of NYHA class, if any, were noted. Routine tests and special tests like ECG and 2DECHO were done. Fetal well being was also assessed. Mode of delivery and neonatal outcome was recorded according to the proforma. During postnatal period all patients were followed up to discharge from hospital for any obstetrical, cardiac and neonatal complications. Details of maternal and neonatal morbidity and mortality were noted.

Results: in this study the incidence of heart disease was found to be 0.69%. Mean age at presentation was found to be 24 +/- 3.4 years. Maximum patients belonged to age group 21-25 years. Majority of the patients (77%) were primigravida. Most of the patients (31.46%) were admitted in hospital during 34-37 weeks of gestation. The most common complaints for which the patients were admitted was breathlessness (58.87%) and labour pains (22.58%). A NYHA based classification revealed that most of the patients (70.96%) were NYHA grade I while grade II, III and IV were 13.7% ,11.31% and 4.03% respectively. Most common etiology of heart disease in studied subject was found to be rheumatic (66.94%) in origin followed by congenital (24.19%) and peripartum cardiomyopathy (5.66%). In patients having rheumatic valvular heart disease most common isolated valvular involvement was seen in the form of mitral stenosis (14.5%) followed by mitral regurgitation (6.45%) and tricuspid regurgitation (5.64%). Rest of the patients had multiple valvular lesions involving mitral,tricuspid and aortic valves. In patients who had congenital heart disease most common lesion was Atrial septal defect followed by cardiomyopathy, ventricular septal defect and mitral valve prolapse. 12 patients had undergone surgical correction of valvular lesions. Most common maternal complications seen were Anemia followed by pulmonary hypertension and pulmonary edema. There were total 4 (3.23%) maternal deaths during study period.Causes of maternal mortality included dilated cardiomyopathy, pulmonary edema, infective endocarditis and congestive cardiac failure. Maternal mortality associated with heart diseases was found in 3.39% patients of overall maternal mortality during study period. Out of 124 patients 71 (57.26%) underwent normal vaginal delivery while caesarian section was done in 32 (25.81%) cases. Most common indication for LSCS was foetal distress (8.87%).Analysis of neonatal outcome revealed that 92 (44.19%) babies were born full term while 32 (25.81%) were premature. 47 (37.89%) babies were born with birth weight of more than 2.5 kg while 61 (49.53%) were low birth weight babies. Perinatal mortality in patients with rheumatic valvular heart disease was 12.90%. The most common causes of neonatal mortality in these patients were prematurity with birth asphyxia which was seen in 4 (3.22%) neonates.

Conclusion: The management of pregnant woman with heart disease requires a multidisciplinary team work for optimal maternal and fetal outcome. Early diagnosis, good antenatal care and early recognition and treatment of complications will have a favorable impact on maternal and neonatal outcome. Being the commonest cause of heart disease during pregnancy rheumatic heart disease must be treated according to standard protocol. Fetal outcome is affected by NYHA functional classification and is better in grade I and II. In patients with heart disease normal delivery is preferable and caesarian section should only be considered for obstetric indications.

Keywords: Heart disease in pregnancy, New York Heart association, Rheumatic heart disease, multidisciplinary approach.