Obstetrics and Gynaecology · MU Sofia

23. Cardiovascular disease and pregnancy

Covers how pregnancy loads the heart, noting the rise in cardiac output and plasma volume, and the critical times of mid-pregnancy, labour and the period straight after delivery. It then sets out risk classification using the modified WHO and NYHA systems, with conditions where pregnancy is not advised. A table compares mitral stenosis, mechanical valves, congenital disease, peripartum cardiomyopathy and arrhythmias, followed by management points on delivery, drugs to use or avoid, and monitoring.

Inside: 5 sections · 1 table · 15 flashcards · 2 min

Topic 23 of 61 in the MU Sofia syllabus for Obstetrics and Gynaecology (Dental Medicine, Year 4). The free AceMed note covers it in 5 sections, about 257 words (2 min of reading), with 15 flashcards.

In this note

  1. Introduction
  2. Critical times
  3. Risk assessment
  4. Common conditions
  5. Management

Introduction

Heart disease complicates about 1–4% of pregnancies and is now the leading indirect cause of maternal death in high-income countries. The danger comes from the normal pregnancy load: cardiac output ↑ 30–50%, heart rate ↑, plasma volume ↑, plus surges in labour and straight after delivery.

Critical times

  • End of the 2nd trimester (peak blood volume).
  • Labour (each contraction adds about 300–500 ml to the circulation; pain and pushing).
  • Immediately after delivery (autotransfusion from the contracted uterus): heart failure and pulmonary oedema are most common here.

Risk assessment

The modified WHO classification (I–IV) and NYHA class guide counselling. Pregnancy is not advised (mWHO IV) in:

  • Pulmonary arterial hypertension (including Eisenmenger syndrome).
  • Severe left ventricular dysfunction (ejection fraction < 30%, NYHA III–IV).
  • Severe mitral stenosis, severe symptomatic aortic stenosis.
  • Marfan syndrome with an aorta > 45 mm; previous peripartum cardiomyopathy with residual dysfunction.

Management

  • Joint care by obstetrician, cardiologist and anaesthetist; plan delivery in advance.
  • Echocardiography; treat anaemia, infection and hypertension, which overload the heart.
  • Drugs: β-blockers, diuretics, heparin are usable; ACE inhibitors, ARBs and amiodarone are avoided.
  • Vaginal delivery is preferred in most cases, with epidural analgesia, left lateral position, careful fluid balance and an assisted (shortened) second stage with forceps or vacuum. Caesarean section is mainly for obstetric reasons or aortic disease.
  • Avoid ergometrine (vasoconstriction); give oxytocin slowly. Close monitoring for 24–72 hours after birth.
  • Endocarditis prophylaxis only for the highest-risk patients (prosthetic valves, previous endocarditis).

The most dangerous moment for a woman with heart disease is just after delivery, when blood from the contracted uterus floods back into the circulation.

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