Heart disease in pregnancy are congenital or acquired anatomical abnormalities of the heart valves, orifices, intracardial septa, aorta and pulmonary artery, the course of which may become complicated during gestation or worsen its prognosis. They manifest weakness, fatigue, drowsiness, heaviness in the legs, shortness of breath, palpitations, peripheral edema, dry cough. They are diagnosed using echocardiography, ECG, phonocardiography. Antibiotics, glycosides, diuretics, peripheral vasodilators, beta-blockers, antithrombotics are used for treatment. Operations are performed in exceptional cases according to indications.
ICD 10
Q20-Q28 Congenital anomalies [malformations] of the circulatory system
General information
Heart disease in pregnancy eart disease in pregnancy affect from 3 to 4.7% of adult women. According to observations in the field of obstetrics, acquired structural abnormalities are detected in 75-90% of pregnant women with anatomical heart defects, congenital — in 7-8.5%, conditions after operations (mitral or mitral-aortic commissurotomy, valve replacement) — in 1-1.5%. The structure of acquired defects is dominated by rheumatic (85-89%), among which combined mitral make up 40-70%, mitral stenosis — 20%, mitral insufficiency — 15%, aortic – 8-10%. The urgency of timely detection of heart abnormalities in pregnant women, the choice of a rational pregnancy management scheme and the method of delivery is due to the significant risk of decompensation of the disease during gestation, the high probability of both maternal and perinatal mortality.
Causes of heart disease in pregnancy
Anomalies of the structure of the valve apparatus, partitions, openings and outgoing main vessels usually occur long before the onset of gestation. However, changes in hemodynamics characteristic of the pregnancy period may manifest a cardiological disease or aggravate its clinical picture. The most common causes of heart defects found in pregnant women are:
- Inflammation of the endocardium and myocardium. In 80-85% of cases, abnormalities of the structure of the heart develop due to rheumatic lesions. Less often they are the result of infectious endocarditis of a different genesis, syphilis, specific inflammatory changes in diffuse connective tissue diseases (scleroderma, systemic lupus erythematosus, rheumatoid arthritis).
- Birth defects. Up to 7.3-8.0% of cardiac defects are dysembriogenetic or inherited by autosomal recessive, autosomal dominant types. More often than others, pregnant women have signs of an open aortic duct, atrial and interventricular septum defects, pulmonary artery stenosis, aortic coarctation, transposition of the main vessels.
In some patients, secondary functional valve insufficiency occurs against the background of cardiac diseases that are accompanied by ventricular overload or expansion of the fibrous ring of valve structures (hypertension, symptomatic hypertension, dilated cardiomyopathy, cardiosclerosis, myocardial infarction).
Pathogenesis
The mechanism of development of pathological manifestations in heart defects in pregnant women depends on the characteristics of a particular anomaly, however, in the gestational period there are a number of general stress and adaptive hemodynamic factors affecting the course of cardiovascular disease. From 10 to 32 weeks, the volume of blood circulating in the vascular bed increases by 30-35%, which in combination with an increase in hydrostatic capillary pressure leads to an increase in the amount of extracellular fluid by 5-6 liters. At the same time, the work of the left ventricle increases, which is accompanied by an increase in shock and minute volumes by 35-50%, an increase in systolic and pulse pressure, a decrease in diastolic pressure on the hands. At the end of the second and third trimesters, physiological tachycardia occurs up to 85-90 heart contractions per minute.
An increase in the load on the myocardium leads to an increase in the mass of the left ventricle by 8-10% with hypertrophy and dilation of the cardiac cavities, the appearance of physiological arrhythmia against the background of disorders of excitability and conduction of the myocardium. The formation of the uteroplacental system increases the capacity of the vascular system of a pregnant woman. The growing uterus squeezes the inferior vena cava, shifts up the diaphragm and heart, changes the shape of the chest and restricts the excursion of the lungs. This, as well as the transposition of the main vessels and a more transverse arrangement of the heart increases the load on the myocardium. Insufficiency of adaptive mechanisms in pregnant women with organic heart defects is manifested by the development and progression of circulatory disorders, the occurrence of heart failure. In addition, in some patients, the rheumatic process worsens, which increases morphological changes in the heart.
Classification
Depending on the origin, heart defects detected in pregnant women can be congenital and acquired. Taking into account localization, isolated mitral, aortic, tricuspid anomalies, damage to the valves of the pulmonary artery, defects of the intracardiac septa, combined and combined lesions are distinguished. By the nature of pathological changes, stenosis (narrowing), insufficiency (expansion), abnormal openings, vascular transpositions are distinguished.
The severity of heart failure is of great prognostic importance in the systematization of defects: at the I (latent) stage, its signs appear only during physical exertion, at IIA there are moderately pronounced symptoms at rest, increasing with movement, at IIB — at rest, significant hemodynamic disorders are determined, for III (dystrophic) organ metabolic disorders are characteristic. Based on this criterion, there are four degrees of risk of complications in pregnant women suffering from heart defects:
- I degree. There is no risk. There are no signs of heart failure, the pressure in the pulmonary artery is normal, the rheumatic process is inactive. The divisions of the heart and the thickness of the myocardium are not changed. The probability of a complicated course of gestation does not differ from the indicators in the general population. Pregnancy is not contraindicated.
- II degree. Moderately increased risk. Latent heart failure and the first degree of rheumatism activity, a moderate increase in pressure in the pulmonary artery system are noted. The parts of the heart are slightly or moderately thickened and dilated. Pregnancy is allowed, but the patient’s condition may worsen.
- III degree. High risk of obstetric and cardiac complications. Heart failure of the IIA art., rheumatism of the II-III degree of activity, pulmonary hypertension, rhythm disturbances are determined. The departments of the heart are hypertrophied and expanded. Most patients are recommended to interrupt gestation before 12 weeks.
- IV degree. Extremely high risk of maternal mortality due to cardiac and obstetric complications. Heart failure of the IIB-III st., significant pulmonary hypertension, severe systolic dysfunction of the left ventricle, cyanosis are diagnosed. Pregnancy is usually terminated regardless of the timing.
Symptoms of heart disease in pregnancy
Clinical signs depend on the type of heart disease in pregnancy, the duration of the disease and the functional viability of the myocardium. Patients with cardiac defects complain of increased fatigue, drowsiness, a feeling of weakness in the muscles, heaviness in the legs. Under stress, shortness of breath, interruptions, palpitations are observed. In patients with severe circulatory insufficiency, these symptoms are also noted at rest. The appearance of pallor or cyanotic skin, swelling in the feet, ankle joints, shins, the occurrence of attacks of cardiac asthma with a dry cough or coughing up a small amount of mucosal sputum, sometimes containing streaks of blood, is possible.
Complications
Defects with significant decompensation of the heart are the leading cause of maternal mortality, which can reach 150-200 cases per 100 thousand live births, occupy the second place in terms of perinatal mortality (12-29%). The main obstetric complications with anomalies of the structure of the heart are spontaneous abortions, premature birth, early toxicosis, gestosis, HELLP syndrome, discoordination and weakness of labor, coagulopathic bleeding in the postpartum period. Almost every fifth pregnant woman has an untimely discharge of amniotic fluid.
In every second case of pregnancy (except for patients at risk of grade I), there are signs of developmental delay and fetal hypoxia caused by chronic placental insufficiency. Women with congenital heart abnormalities are more likely to have children with the same cardiac pathology. With heart defects, the likelihood of developing clinically significant rhythm disturbances requiring special therapy, cardiovascular complications (thromboembolism, myocardial infarction, stroke), endocarditis increases.
Diagnostics
Since congenital and acquired heart disease in pregnancy can occur subclinically, in 27% of cases they are first diagnosed during pregnancy. In addition to traditional physical examinations (percussion and auscultation of the heart), modern instrumental methods are used to make a diagnosis, allowing to visualize anatomical defects and evaluate the functionality of the cardiovascular system. The most informative for the diagnosis of heart defects in pregnant women are:
- Echocardiography. The combined use of various ultrasound techniques (one-dimensional and two-dimensional echocardiography), Doppler scanning makes it possible to examine the condition of the valve apparatus, assess the thickness of the heart walls and the volume of cavities, perform phase analysis and assessment of contractility. With this method, defects of large vessels (thoracic aorta, etc.) are also determined.
- Electrocardiography. ECG is used to screen for violations of the frequency and regularity of the heart rhythm, changes in conduction, to identify possible acute and chronic myocardial injuries that complicate the clinical picture and worsen the prognosis of pregnancy with heart disease. According to the indications, the study is supplemented with daily ECG monitoring and phonocardiography.
Due to possible damaging effects on the fetus, pregnant women with anatomical heart defects are not recommended to conduct X-ray examinations and MRI. As an exception, in preparation for cardiac interventions, probing of the cavities of the heart is permissible. To assess the state of the electrolyte balance and the coagulation system, the determination of the concentration of potassium and sodium in the blood serum, a coagulogram is shown. Differential diagnosis is carried out with functional heart murmurs in anemia, vegetative-vascular dystonia, coronary artery disease with the development of aneurysm, hypertension in pregnant women, myocarditis, toxic cardiomyopathies, myocardiodystrophy, cardiomegaly. In addition to an obstetrician-gynecologist, a cardiologist is involved in accompanying a pregnant woman. If necessary, the patient is examined by a cardiac surgeon, rheumatologist, infectious disease specialist, neurologist, hematologist.
Treatment
In case of cardiac defects, there are three critical periods of gestation, during which planned hospitalization is recommended. At 10-12 weeks, an exacerbation of rheumatism is possible due to a physiological decrease in immunity and a decrease in the secretion of corticosteroids. It is at this time that a decision is made on the possibility of prolongation of pregnancy. At 26-32 weeks, the patient’s cardiovascular system experiences the greatest stress, which requires additional correction of therapy. 2-3 weeks before delivery, the development or aggravation of heart failure may occur under the influence of overload hemodynamic factors that should be taken into account when choosing a method of delivery.
The main therapeutic tasks are prevention of obstetric complications, relief of exacerbations and relapses in patients with rheumatism, prevention of rhythm and conduction disorders. Adequate medical treatment is preferable for the management of most pregnant women with heart defects, including patients with heart failure. Medications for pharmacotherapy are selected individually by a cardiologist. Usually pregnant women are prescribed:
- Antibacterial therapy. 10-14-day preventive courses of semi-synthetic penicillins are indicated for women with rheumatic defects from risk groups I and II. Antibiotics are used according to indications, taking into account the activity of the rheumatic process and, if necessary, supplemented with glucocorticoids.
- Thiazide and loop diuretics. They provide a decrease in the volume of circulating blood with insufficient contractile activity of the ventricles. In case of left ventricular insufficiency, the funds are combined with drugs that reduce blood flow to the chambers of the heart, and peripheral vasodilators.
- Cardiac glycosides. In the absence of pulmonary hypertension, such medications support cardiac output and adequate perfusion of various organs and systems, including the fetoplacental complex. With the help of glycosides, tachysystolic atrial fibrillation can also be stopped.
- Nitrates. Due to the deposition of blood in the veins of the large circulatory circle, the funds of this group reduce the preload on the heart, which reduces the signs of venous pulmonary hypertension and stagnation of blood in the small circle. The disadvantage of using nitrates is a possible decrease in cardiac output.
- Beta-blockers. Drugs that reduce the strength of myocardial contractions are recommended for pregnant women with sinus tachycardia, in which pressure increases in the cavity of the left atrium, there is stagnation of blood in the pulmonary circulation. They can be used for tachysystolic atrial fibrillation.
- Anticoagulants. Taking into account the duration of pregnancy and the results of a thromboelastogram, women with heart defects are prescribed low-molecular-weight heparins, antiplatelet agents in combination with peripheral vasodilators that improve capillary blood flow. During childbirth, the administration of heparin is stopped.
In the presence of indications, minimally invasive operations (endovascular balloon dilation of aortic stenosis, etc.) and closed mitral commissurotomy are performed. Open surgical interventions for prosthetic valves with the shutdown of natural blood circulation are carried out only if a woman’s life is threatened and percutaneous correction of the anomaly is impossible.
In the presence of a heart defect, programmed natural childbirth in the daytime with the introduction of a hormonal-energy complex for the prevention of abnormal labor activity and maximum increasing anesthesia using mask anesthesia and epidural analgesia are preferred. Amniotomy is used for gentle birth acceleration. In childbirth, the appointment of uterotonics, antispasmodics, antihypoxants is permissible. Attempts during the period of exile are turned off with high activity of rheumatism, combined and combined defects, stenosis, circulatory disorders.
If an active rheumatic process is detected, signs of circulatory disorders, the development of late gestosis, placental insufficiency with chronic hypoxia or delayed fetal development, delivery is performed ahead of schedule at 34-37 weeks. Absolute indications for cesarean section are therapeutically resistant progressive heart failure, III degree of rheumocarditis activity, aortic aneurysm, aortic coarctation with severe hypertension, complete violation of atrioventricular conduction, the use of an artificial pacemaker, subacute septic endocarditis, malformations with a load mainly on the left heart, concomitant obstetric pathology (large fetus, narrow pelvis, incorrect position of the child).
Prognosis and prevention
The outcome of pregnancy and childbirth with heart defects depends on the variant of the anatomical defect, the presence of circulatory disorders, the activity of rheumatism (with anomalies of rheumatic origin). Absolute contraindications to carrying a child are considered to be combined and combined types of defects, a single ventricle, aortic coarctation, severe aortic stenosis, a combination of anatomical anomalies with bacterial endocarditis, tachyarrhythmia, pulmonary hypertension of 2-3 degrees, Eisenmenger syndrome, Marfan syndrome with an increase in the diameter of the aortic root more than 4.5 cm, previous postpartum cardiomyopathy. The prognosis also worsens with pronounced degrees of narrowing (insufficiency) of the heart valves and as the age of the pregnant woman increases – after 30 years, the probability of developing circulatory insufficiency doubles.
In other cases, when planning pregnancy, it is necessary to take into account the recommendations of a cardiologist, at the pre-pregnancy stage to compensate for the defect as much as possible and to stop rheumatic fever, according to indications, perform an operation to correct the defect before conception. Pregnant women are shown early registration in a women’s clinic, diet therapy with sufficient intake of protein, trace elements and vitamins, limiting the amount of liquid and table salt. Dosed physical activity, normalization of work and rest, preventive use of herbal preparations with sedative effect are recommended.