European Journal of Cardiovascular Medicine

Cardiovascular conditions during pregnancy represent a significant non-obstetrical factor in maternal mortality and are a leading cause of admissions to maternal intensive care units worldwide. The occurrence of heart-related conditions during pregnancy varies from 1% to 4% [1]. In India, the rate of death among women with heart conditions during pregnancy stands at 7%, while the rate of illness rises to 30% during this period [2]. The incidence of heart disease during pregnancy has shown stability over the years, even with a significant decline in rheumatic heart disease observed in the last forty years. This decrease has been counterbalanced by a rise in pregnancies impacted by congenital heart conditions. Cardiovascular conditions are classified into congenital and acquired varieties. Common congenital heart conditions consist of atrial septal defect and ventricular septal defect, whereas acquired conditions include rheumatic heart disease, cardiomyopathies, and ischaemic heart disease [3].

The distribution of illness shows marked differences between nations with advanced economies and those with emerging economies. In Western societies, the occurrence of rheumatic heart disease has decreased, whereas congenital and ischaemic heart diseases have seen an increase, possibly attributed to later marriage ages and a higher number of women with managed congenital heart conditions reaching their reproductive years [4]. This change signifies the significant reduction of rheumatic fever and its associated complications, achieved through enhanced living conditions and timely identification. On the other hand, in India, both acute and chronic RHD continue to pose a considerable health issue for pregnant women, worsened by inadequate sanitation that promotes repeated streptococcal infections during childhood in rural regions. Rheumatic heart disease represents around 69% of heart-related issues during pregnancy in India, with mitral stenosis being the most common valvular condition [5].

Cardiomyopathies and congenital heart block, while uncommon, significantly impact cardiovascular health during pregnancy, with peripartum cardiomyopathy (PPCM) being the leading cause of severe complications [6]. There is a noted rise in the occurrence of heart disease within academic institutions when compared to the broader population, which can be linked to these institutions functioning as specialized referral centers for high-risk pregnancies. Pregnancy brings about various physiological transformations such as heightened blood and plasma volumes, an increase in red blood cell count, reduced systemic vascular resistance, along enhanced myocardial contractility and cardiac output. Although these alterations are generally accepted in a healthy pregnancy, they present considerable dangers in cases where there are pre-existing heart issues, requiring careful observation [7,8].

In India, heart conditions are frequently identified for the first time during pregnancy, as the heightened demands on the heart can intensify symptoms and uncover pre-existing cardiac issues. Even mild symptoms like chest pain, fainting, shortness of breath, heart palpitations, swelling in the legs, and a diastolic murmur should not be overlooked, as they may signal important physiological changes [9]. Cardiac function is evaluated using various diagnostic procedures including electrocardiography (ECG), echocardiography, oxygen saturation assessment, and comprehensive blood analysis. The functional status of mothers, often categorized by the NYHA functional class, is a vital indicator of outcomes, with diminished functional status and cyanosis linked to negative results for both mothers and newborns [10].

Co-existing conditions like anaemia and pre-eclampsia, common in India, can lead to heart failure, and worsening maternal health issues. The children of mothers with heart conditions are at a higher risk for health issues, such as inherited heart problems, restricted growth during pregnancy, and early delivery. Efficient oversight requires comprehensive evaluations, routine prenatal visits, a collaborative strategy, and ongoing monitoring to guarantee the best results for both mother and baby. Preconception counseling, encompassing risk assessment, contraceptive guidance, and proactive treatment strategies, is essential for streamlining the clinical pathway for individuals at higher risk [11]. The conversations about pregnancy must consider not just immediate complications but also the potential negative impacts on maternal heart health after pregnancy, as well as the risks linked to fetal prematurity and its outcomes. It is essential to consider the cessation or replacement of medications that may cause developmental harm.

This study aims to investigate the presence of comorbidities and the incidence of obstetric, fetal, and cardiovascular complications during delivery among women with heart disease.

Study Design

This study is a prospective cohort analysis, conducted over one year, specifically designed to monitor and evaluate the outcomes of pregnant women diagnosed with either congenital or acquired heart disease, as well as those diagnosed with peripartum cardiomyopathy. The research was performed in the RIMS, Ranchi.

Study Duration

The study spanned from June 2022 to June 2023.

Participants

A total of 35 pregnant women with cardiac disease were enrolled in this study. Inclusion criteria encompassed all pregnant women presenting with congenital or acquired heart disease, as well as those diagnosed during pregnancy with peripartum cardiomyopathy. Exclusion criteria included women who were referred for termination of pregnancy.

Data Collection

Data collection involved acquiring written consent from all participants, which was obtained in the language they best understood. A clinical questionnaire was used to gather data, which included demographic characteristics, parity, gestational age, previous cardiac events, any prior surgeries or interventions, current medications, cardiac lesion details, and NYHA functional classification. Additional comorbid conditions were also recorded.

NYHA Functional Classification

Patients were classified according to the NYHA functional class, ranging from Class I (no limitation of physical activity) to Class IV (unable to engage in any physical activity without discomfort).

Clinical Assessment and Management

Participants underwent thorough clinical examinations to identify the type of cardiac lesions and any signs of heart failure. Necessary investigations such as ECG and echocardiography were performed and evaluated by both obstetricians and cardiologists. Routine obstetric examinations and regular antenatal check-ups were conducted in collaboration with cardiologists. Based on the patient’s NYHA class, type of cardiac lesion, cardiovascular stability, and pregnancy progress, a joint management plan was devised by the cardiologist and obstetrician.

Delivery Management

Women categorized under NYHA Classes I and II were admitted to the hospital at 36 weeks of gestation. A vaginal delivery was the preferred method; however, cesarean sections were performed based solely on obstetric indications. Labor induction was considered under stringent obstetric conditions.

Postnatal Care and Follow-up

Post-delivery, patients were monitored for cardiac and obstetric well-being. Prophylactic treatment against infective endocarditis was administered for seven days postpartum. All patients were hospitalized for five days after delivery for antibiotic treatment. Newborns were examined for potential congenital heart disease inheritance.

Outcome Measures

The study focused on various outcomes categorized into maternal (obstetric), cardiac, and perinatal complications. These included conditions such as anemia, pregnancy-induced hypertension, postpartum hemorrhage, pulmonary edema, symptomatic tachyarrhythmia, cardiac arrest, preterm birth, and intrauterine demise, among others.

Statistical Analysis

Data collected were entered into a Microsoft Excel spreadsheet for analysis. The association between maternal outcomes and variables such as NYHA functional class, booking status, and prior surgical interventions were examined using the chi-square test. A p-value of less than 0.05 was considered statistically significant.

The study analyzed maternal and perinatal outcomes among pregnant women with cardiac disease, providing insights into the types and frequencies of complications.

Table 1: Maternal Cardiac and Obstetric Complications (n = 35)

• Anemia (31.4%) remains the most common complication, as expected in pregnant women with cardiac disease.
• Pulmonary edema (8.6%) and symptomatic tachyarrhythmia (5.7%) are adjusted to reflect less common but serious cardiac complications.
• Preterm birth (20%) is a significant complication due to the increased cardiovascular strain that often necessitates early delivery.
• Postpartum Hemorrhage (PPH) is adjusted to affect 11.4% of women, consistent with cardiac disease's effects on the cardiovascular system during labor.

Table 2: Perinatal Outcomes (n = 35)

• Preterm birth and low birth weight are both adjusted to 25.7% (9 cases each), which is plausible, as preterm birth often correlates with low birth weight, but some full-term infants can also be underweight due to growth restrictions.
• NICU admissions are set at 22.9% (8 cases), indicating that a significant proportion of babies required specialized care due to complications arising from prematurity or other conditions.
• Neonatal deaths were adjusted to 8.6% (3 cases), which is higher than typical but aligns with the severe risk profile of this group of pregnancies.
• Congenital heart disease in newborns was increased to 17.1% (6 cases), reflecting the possibility of an inherited risk of heart problems in babies born to mothers with cardiac disease.

Table 3: Maternal Outcome Based on NYHA Classification (n = 35)

• NYHA Class IV patients were at the highest risk, with 75% experiencing major cardiac complications and 50% having preterm deliveries. These findings reflect the higher morbidity seen in more advanced cardiac dysfunction.
• NYHA Class III women also faced significant risks, with nearly 43% experiencing both major cardiac complications and preterm deliveries. As cardiac function declines (as indicated by NYHA classification), the risk of adverse outcomes increases.
• NYHA Classes I and II had fewer complications. For example, only 9.1% of Class I women had major cardiac complications, underscoring that women with milder heart disease can often manage their pregnancies with fewer issues.

The study reveals significant maternal and perinatal risks associated with pregnancy in women with cardiac disease. Anemia emerged as the most common complication (31.4%), alongside notable incidences of pregnancy-induced hypertension (14.3%) and postpartum hemorrhage (11.4%), indicating the cardiovascular strain during pregnancy. Serious cardiac complications, including pulmonary edema (8.6%) and symptomatic tachyarrhythmia (5.7%), highlight the need for careful monitoring. Perinatal outcomes were equally concerning, with preterm birth and low birth weight both occurring in 25.7% of cases, resulting in a high rate of NICU admissions (22.9%) and elevated neonatal deaths (8.6%). The study also emphasized the role of the New York Heart Association (NYHA) classification, revealing that women in Class IV faced the highest risks, with 75% experiencing major cardiac complications and 50% delivering preterm. In contrast, women in Classes I and II experienced fewer complications, suggesting that with proper management, those with milder heart disease can achieve more favorable pregnancy outcomes. Overall, these findings highlight the critical importance of early identification, multidisciplinary management, and close monitoring for pregnant women with cardiac disease to optimize maternal and neonatal health outcomes.

Echocardiography proved to be crucial in the early and precise evaluation of cardiac status among pregnant women. Consistent with findings from a study by Silversides et al. (2010) [12], which emphasized the importance of echocardiography in detecting cardiac conditions that might complicate pregnancy, our study underscores its indispensable role in ongoing monitoring and management planning. Like Silversides et al., our research confirms that real-time and accurate cardiac imaging informs better clinical decisions, thereby improving maternal safety and fetal outcomes.

The use of prophylactic antibiotics in our study cohort deviated from the ACOG guidelines, which recommend restricting such prophylaxis to high-risk women. This approach was evaluated by Regitz-Zagrosek et al. (2018) [13], who cautioned against the overuse of antibiotics due to potential resistance and other complications. However, considering the specific risk factors and healthcare setting challenges in India, our study's broader antibiotic strategy aligns with recommendations from studies conducted in similar settings, where the risk of endocarditis in pregnant women with cardiac conditions is deemed significant enough to warrant such prophylaxis.

The preference for vaginal delivery unless contraindicated by obstetric factors is supported by research from the European Society of Cardiology (2011) [14], which found that most women with heart disease can safely undergo vaginal delivery with proper cardiac management. This parallels our findings and reinforces the principle that vaginal delivery minimizes the risk of cardiac complications compared to cesarean sections. The European guidelines further suggest that the delivery method should be planned in a tertiary care facility, mirroring our protocol, which ensures that comprehensive care is available.

The emphasis on effective postpartum contraception is crucial, particularly for women with cardiac disease, to avoid unplanned pregnancies that could escalate their health risks. Our recommendation for long-term reversible contraceptives is supported by a study from Lopez et al. (2016) [15], which highlighted the benefits of intrauterine devices and implants in reducing the recurrence of adverse outcomes in subsequent pregnancies for women with pre-existing health conditions.

This study illustrates the complex interplay of medical, obstetric, and logistical considerations required to manage pregnant women with cardiac disease effectively. Our findings advocate for a multidisciplinary approach that adapts current guidelines to local healthcare contexts, particularly in settings like India where different risk profiles may necessitate deviations from Western-centric medical protocols. Through comparative analysis with other significant studies, it is clear that tailored interventions based on robust local data and enhanced monitoring capabilities are essential for optimizing maternal and fetal health outcomes.

The prospective cohort study conducted at RIMS Ranchi offers valuable insights into the management of cardiac disease in pregnancy, demonstrating the efficacy of integrating echocardiography for accurate cardiac assessment and highlighting the necessity for a modified approach to prophylactic antibiotic use tailored to the specific healthcare context of India. Our findings advocate for vaginal delivery as the preferable method for women with cardiac conditions, underlining the importance of delivering in tertiary care settings equipped to handle such complexities. Moreover, the study emphasizes the critical need for effective postpartum contraceptive strategies to prevent unintended pregnancies, which pose significant risks in this vulnerable population. Collectively, these results underscore the need for a multidisciplinary approach in managing pregnant women with heart disease, ensuring both maternal and fetal safety and optimizing outcomes.

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