Pregnancy imposes profound hemodynamic changes which continues even in immediate postpartum period. (1)During pregnancy, there is increase in plasma volume by 50%, cardiac output by 50% and heart rate by 17%.These changes returns back to normal only after 3-4weeks following delivery. (2) These burden in pre exsisting cardiac disease patient precipitates complication and makes them high risk. (3) Hence management of cardiac disease during pregnancy is challenging to the obstetricians, cardiologists and anaesthesiologists. (4) Cardiac disease in pregnancy is the indirect leading cause of maternal death. (5) It is one of the main cause for maternal mortality and morbidity.(6) Heart disease in pregnancy comprises 1-4% of pregnancies in India and maternal deaths is about 10-25%.(7) Cardiac disease in pregnancy can be either congenital or acquired heart disease. Congenital heart disease is common in developed countries whereas in developing countries like India still the rheumatic heart disease (RHD) is found to be predominant(8).Due to improved modern therapeutic options available, the number of women with cardiac disease who become pregnant are found to be increased in recent years. Maternal functional status can be predicted by NYHA functional status(9). Most common clinical features that cardiac disease patient present mimic physiological changes in pregnancy which causes diagnostic difficulty for obstetricians. Poor NYHA functional status has a bearing on maternal and fetal outcome(10). Maternal heart disease has a number of adverse outcome on the fetus such as spontaneous and therapeutic abortions and increased risk of developing congenital heart disease. Fetal health depends on adequate oxygen supply to the fetus from the mother however it is compromised in pregnant women with cardiac disease resulting in fetal growth restriction(11). In these patients normal cardiovascular changes in pregnancy can cause cardiac decompensation which can lead to maternal death. Complications like pre-eclampsia, anemia, preterm labour, fetal growth restriction worsens the outcomes of pregnancy complicated by cardiac disease(7). Cardiac disease requires preconceptional counselling and the main aim is to optimise cardiovascular status. It also requires vigilant monitoring during the antenatal, intrapartum and postpartum period. It requires a multidisciplinary team involvement like a cardiologist, obstetrician, neonatologist, physician and an intensivist. Women may require an admission to ICU or high dependency unit and longer hospital stay. Hence in this study we have analysed the prevalence of cardiac disease, foetal and maternal outcomes of patients with cardiac disease in pregnancy. 

This was a retrospective observational study carried out at the department of Obstetrics and Gynecology in a tertiary care centre, Pondicherry during the period of 2011 to 2018. All women with cardiac disease complicating pregnancy who delivered in a tertiary care centre from 2011 to 2018 were included in the study. Their details were collected from the case record and registers using data collection proforma. Detailed history of the women about demographic characteristics, duration of pregnancy, type of heart disease and any prior cardiac surgery, mode of delivery, obstetric and cardiac complications, ICU admissions, hospital stay and baby details like birth weight, NICU, APGAR score were collected from their case record and registers. Data were entered into a Microsoft Excel Spread Sheet and analysed using SPSS software

Based on the data, 136 patients were found to have cardiac disease and they were included in the study. Prevalence of cardiac disease in pregnancy was found to be 0.66% at our centre.

Out of which majority were in the age group 20-30 years which is 75% as illustrated in Table1.

TABLE 1: Demographic features of the study participants

Among 136 patients, 82.4% were booked in our centre and 17.6% were booked elsewhere and referred.Most patients included in the study were multigravida which was 55.1%.

Primigravida were 44.9%. Out of these 136 patients, Majority were in early term(37- 39weeks) group which was 57.4% followed by full term (39-41weeks) group.Most of the patients in the study had Acquired heart disease – 72.7%. Congenital heart disease was 27.2%. Most common congenital heart disease seen in study population was ASD and VSD which was seen in13 patients each respectively. Most common acquired heart disease was

Mitral stenosis which was seen in 35 patients. Surgical correction was done in almost 37 patients prior to pregnancy as illustrated in Table 2.

TABLE 2: Details of Cardiac disease in pregnancy

Labour was induced in 26.5% whereas spontaneous in 73.5%. Out of total 136 patients, majority had Vaginal delivery(46.3%), C-section was about 19.9%, Instrumental delivery which includes Forceps and Ventouse was 9.6% and 19.9% respectively. Most common indication for instrumental delivery was to cut short second stage. Indications for cesaerean section includes previous LSCS in labour, fetal distress, malpresentation as illustrated in Table 3.

Maternal antenatal complications noted were Anemia, Gestational diabetes, Preterm labour, Rh negative pregnancy, IUGR, Oligohydramnios, Fibroid complicating pregnancy and hypothyroidism. Intrapartum complications were PPH, left angle extension and shoulder dystocia. Postpartum complications were seen in 7 patients which includes cardiac failure, seizure and pulmonary edema. Maternal mortality was seen in 2 cases of Mitral stenosis who had cardiac failure. ICU admission was required in 5 patients. Minimum number of hospital stay was 7days whereas maximum was 18days as illustrated in Table 4.

In recent times, earlier diagnosis of pregnant women with heart disease has increased due to improvement in health care services. Cardiac disease complicating pregnancy is one of the leading causes of maternal death. It’s a great challenge to health care provider. This study was aimed to evaluate the prevalence of cardiac disease in pregnancy and fetomaternal outcome. Prevalence of cardiac disease in our study was found to be 0.66% which was similar to various studies including study by Wasim et al(12) which is almost 1%.

Distribution of age in our pregnancy was maximum in 21-30years which was comparable with Salam Set al (6)and Kapadia et al (10)which was between 21-25years. Cardiac disease was common in multigravida in our study which is comparable to Sneha et al(13) and Abbasi et al(4) where it is common in primigravidas. Gestational age at which the patients delivered was commonly found to be at early term which was 57.4% which was term 83.3%Sneha et al(13) and term pregnancy 44% in Abbasi et al(4).

In study conducted by Thakkar et al(8),Salam et al.,(6) and various other studies, Rheumatic heart disease was found to be predominant heart disease with 60% and 56.6% respectively, which was comparable with our study we found it to be 76.5%. Most common lesion in rheumatic heart disease was found to be Mitral stenosis in our study which was comparable with Pujitha KS et al., (7). Surgical correction of heart disease was found in 27.2% whereas it was 40.6% in study by Pujitha et al(7).

Labour was induced in about 26.5% in our study which was contrary to Salam S et al(6) where induction was done in 5.6% patients. Mode of delivery was predominatly by vaginal delivery which was 46.3% which was comparable to Kapadia LD(10) et al and Thakkar JK et al.,(8)where it was 48.9% and 40% respectively. Cesaerean section was done is 19,9% of which common indication was previous LSCS in labour whereas vaginal delivery was 63% and cesearean was 37% in study by Diao et al.,(14). Antenatal complications in our study was anemia, preterm labour,gestational diabetes, hypothyroidism whereas anemia, preeclampsia, Abruptio placenta was seen in Pujitha KS et al(7). Cardiac complication found were cardiac failure in 4 patients, pulmonary edema in 2patients, ICU admission in 5 patients and maternal mortality in 2patients whereas cardiac failure in 14 patients, pulmonary edema in 6 patient and maternal mortality in 3 patient in study by Sen et al,(15).

Neonatal outcomes studied were birth weight, where 25.7% were small for gestational age babies in our study which was contrary to Wasim T et al (12)and Sneha et al (13)study were it was 45.6 % and 50% respectively. APGAR score <7 was seen in 4.4% babies which was almost similar to 5.9% in a study conducted by Abbasi S et al,(4). NICU admissions were found in 5.6% in our study but it was about 28.6% in study by Salam S et al(6). There was no perinatal mortality in our study probably due to good NICU.

Cardiac disease is a high risk pregnancy and has major effect on morbidity and mortality in pregnancy. Early detection and treatment either by medical or surgical management is essential. Hence preconceptional counselling, antenatal monitoring, involvement of multidisciplinary team and delivery in a tertiary care setup with ICU and Cardiac care facilities will definitely improve the fetal and maternal outcomes in cardiac disease complicating pregnancy.

1. Shabbir DS, Shabbir DrZ, Qibtia Fetomaternal Outcome of Pregnancy in Women with Mild-Moderate Mitral Stenosis. J Med Biophys. 2018;42:69–74.

2. Franklin WJ, Benton MK, Parekh Cardiac Disease in Pregnancy. Tex Heart Inst J. 2011;38(2):3.
3. Sayeeda S, Wahid F, Begum F, Zaman A Two Years Study on Pregnant Women with Cardiac Disease in a Tertiary Care Centre. Bangladesh J Obstet Gynaecol. 1970 Jan 1;23(1):8–14.
4. Abbasi S, Siddiqua SF, Rijvi S, Akhtar S, Haque B, Jesmin Study of Maternal and Fetal Outcome in Pregnancy with Heart Disease. Anwer Khan Mod Med Coll J. 2017 Aug 23;8(2):112–6.
5. Ray P, Murphy GJ, Shutt LE. Recognition and management of maternal cardiac disease in pregnancy. Br J Anaesth. 2004 Sep;93(3):428–39. 
6. Salam S, Mushtaq S, Mohi-ud-Din K, Gul I, Ali A. Maternal and fetal outcome in pregnancy with heart disease in tertiary care hospital in India. Int J Reprod Contracept Obstet Gynecol. 2017 Aug 28;6(9):3947.
7. Pujitha KS, SS, S. NJ. A study of maternal and fetal outcome in cardiac disease in pregnancy at tertiary care center. Int J Reprod Contracept Obstet Gynecol. 2017 Oct 28;6(11):5095. 
8. Thakkar JK, Yadav PA, Vyas A Study of Pregnant Women with Cardiac disease J Dent Med Sci. 2016 Mar;15(3):27–9.
9. Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJM, et al.  Outcome of Pregnancy in Women With Congenital Heart Disease. J Am Coll Cardiol. 2007  Jun;49(24):2303–11. 
10. Kapadia LD, Thummar Fetomaternal Outcome in Cardiac disease with pregnancy. Glob J Res Anal. 2019 Nov;8(11):48–50.