Journal of Medical Sciences and Health

Introduction

The process of human pregnancy & child birth is affected by maternal physiological changes which occur during pregnancy. The normal hemodynamic changes occurring during Antenatal period and labour cause a significant burden on the maternal cardiovascular system and these changes are exacerbated if patient has any previous cardiac disease/surgery eventually leading to decompensation and death of mother and fetus.

Heart disease (HD) is a leading cause of maternal deaths in the United States and other developed countries1 and 0.2-0.4% of all pregnancies in western countries are complicated by cardiovascular disease2 of these congenital heart disease(CHD) is the most frequent cardiovascular disease during pregnancy (75- 82%), with a predominance of shunts (20-65%). 3 However In developing countries like India, incidence of cardiac disease that complicates pregnancy is between 1% to 4% 4 & Rheumatic heart disease (RHD) still remains the most common type of heart disease complicating pregnancy in developing world due to Poor socioeconomic condition associated with overcrowding, high prevalence of endemic streptococcal infection, decrease affordability and lack of access to quality medical facilities. 5 The World Health Organization (WHO) has recently released a statistics, which states that in developed economies the maternal mortality is around 0.012% as compared to 0.2% in emerging economies. This shows there is large disparity in Essential Health care services between developed and developing countries. 6

Roos–Hesselink JW (2013) et al stated that among women with HD, those with cardiomyopathy and pulmonary hypertension had the highest rates of prematurity and small-for-gestational age birth weight & Mothers with congenital heart disease had the highest rate of congenital heart disease in their infants. 7

The objective of the study was to estimate the prevalence of heart disease in pregnancy & determine maternal and foetal outcomes in pregnant women with heart disease at a tertiary care hospital serving in a Tribal area of Maharashtra with well-equipped cardiac care and obstetric setup.

Material & Methodology

This is a retrospective observational study carried out in Department of Obstetrics and Gynaecology at S.M.B.T. Institute of medical sciences, Dhamangaon. This was done during a period of 24 months starting from January 2018 to December 2019. Institutional ethical committee approval was obtained for this study. Telephonic Informed consent from all the patients involved in this study was obtained and Data was collected in structured format from Hospital records.

Inclusion Criteria: All pregnant women with heart disease delivering at S.M.B.T. Institute of medical sciences during study period. Heart disease was confirmed by cardiologist after scrutinizing Present and previous Medical, Surgical, echocardiography & ECG records.

Exclusion Criteria: Pregnant women with Heart disease delivered at study centre but refusing to give consent to be enrolled in the study.

Sample size: 35 pregnant women with heart disease.

Results

Total number of deliveries during the study period was 3182 and among these 35 had cardiac disease, prevalence of cardiac disease being 1.10% . The average age of the women enrolled in the study was 25 years and majority of the patients were booked. Among 35 patients, 21 were multigravida and rest were primigravida (Table 1).

Most common type of cardiac lesion was RHD i.e. 71.42% and among them severe MS with MR with Pulmonary hypertension (PHT) was the most common type (8 cases i.e. 22.85% of RHD patients) of these 8 cases, 4 underwent Balloon mitral valvotomy during their ANC period. CHD was seen in 7 cases i.e. 20 % of cases, with half of them operated for the same in the past. Remaining 3 cases were of mitral valve prolapse with mitral regurgitation, Paroxysmal supraventricular tachycardia (PSVT) and primary pulmonary hypertension. (Table 2)

Majority of the patients belonged to NYHA Grade II (15 cases) at the time of admission followed by grade I (10 cases), grade III (6 cases) and grade IV (4 cases) respectively (Figure 1).

In terms of obstetrical outcome, out of 35 patients, 2(5.7%) underwent early medical termination of pregnancy (The indications for early termination of pregnancy were primary pulmonary hypertension and severe mitral stenosis with mitral regurgitation), 15(42.85%) had LSCS (lower segment caesarean section) and rest were delivered vaginally (37.14%) instrumental application was done for 4(11.4%) deliveries (Table 3).

Most common cause for LSCS was repeat emergency LSCS in case of previous LSCS with premature rupture of membranes (53%)

Complications of pregnant women with the heart disease were as follows: Table 4

Table 4 patients were referred to our hospital in 3^rd trimester with severe mitral stenosis & underwent Balloon mitral valvotomy (BMV) for the same among them 1 patient was taken for Elective LSCS 48 hrs after the BMV & developed Acute pulmonary oedema in postpartum period which was treated successfully the rest, 3 cases were uneventful (2 delivered vaginally & 1 LSCS). This justifies the role of BMV in the cases of severe mitral stenosis (MS) (with due risk) in reducing the maternal mortality. One patient with MS undergoing LSCS went into Atonic Postpartum Hemorrage (PPH) after 2 hrs post-operative and was managed by concentrated oxytocin infusion for 4 hrs and 800mg of misoprostol per rectally. One patient of MS with MR and Gestational hypertension developed Abruption which was immediately diagnosed on ultrasonography (USG), and Emergency LSCS was done baby shifted to NICU and blood transfusion under cover of diuretics was given in ICU. Atrial fibrillation developed in one patient of MS with MVP, post-delivery which was treated in ICCU by cardiologist. In terms of perinatal complications, IUGR was most common i.e. in 40.00% of cases followed by respiratory depression, prematurity and meconium aspiration. Neonatal death was seen in 1 baby at 5th day of life due to the sepsis. (Table 5)

Average gestational age at delivery in our study was 34 wks, and average birth weight of babies born to mothers having heart disease was 1.9 kg in our study

Discussion

The present study provides a contemporary assessment of maternal and neonatal complications in patients with cardiac disease and the prevalence is found to be 1.10%. The prevalence varies in developed and developing countries due to different geographical locations, seasons and incidence of Rheumatic fever, varying between 0.2–3.6% in India, 1–3% in USA, 0.5–1.8% in London and 0.8% in South Africa. 7

RHD is still the most common type of heart disease in the developing countries due to the inadequate antibiotic treatment for Streptococcal infection in childhood and adolescence. The incidence of RHD in present study is 70% as compared to 82% to 88% in other Indian studies. 7, 8, 9, 10, 11

In the study by Hiralal konar 12 31% patients were diagnosed to have heart disease for the first time during labour, however ours being a referral centre 100% patients were diagnosed during Antenatal visits Figure 2 .

In a study done by Sharma, Jai Bhagwan et al 13 BMV was done prior to pregnancy in 14 women and during pregnancy in 10 women, they concluded that NYHA deterioration was seen in 10 women in whom the BMV was done during pregnancy we also found that there was deterioration in 1 patient out of 4 in whom BMV was done during pregnancy. The mean birth weight in their study was 2.3 kg which is more than our study as we cater to a tribal population having poor nutritional status.

In a study by Khanna et al 14 they concluded that preterm labour, abortions were increased in patients when BMV was done during pregnancy. In our study BMV was done in all patients after 36 wks and hence no preterm labour was seen.

In terms of obstetrical outcome, LSCS rate was found to be 42% which is comparable with Roos-Hesselink et al study Figure 3.

Highest maternal morbidity was found to be anaemia in the present study i.e 42.86% followed by CCF and arrhythmia which was comparable with the Pandey et al., study. There was no maternal mortality however neonatal mortality was seen in 1 case (7.14%) which was comparable with Pandey et al., study(7.7%) Table 6.

Conclusion

Cardiac disease in pregnancy is a high risk condition which has a major impact on pregnancy and its outcome. This study results conclude that Rheumatic heart disease is still a predominant cardiac problem affecting the pregnancy and its outcome. Maternal and perinatal outcome in women with heart disease depends mainly on the functional cardiac status during pregnancy, the risk being greater in NYHA III and IV. Our study shows that surgical intervention or medical management in pregnancy improves the functional class. Pre pregnancy diagnosis, counselling, routine antenatal supervision, delivery at an equipped centre, early detection and management of cardiac failure throughout the course of pregnancy, labour and puerperium is of prime importance to determine the favourable maternal and fetal outcome in patients with heart disease.