Nearly 10 to 15 per cent of women die in child birth and one to three per cent pregnancies are complicated due to cardiovascular disease. Heart disease is considered to be one of the most common causes of maternal mortality. Valvular heart disease (VHD) remains an important cause of morbidity and mortality in post-partum women.
Therefore, pregnant women with VHD require specialised care and with appropriate diagnosis and treatment, they too can successfully bear healthy children.
Valvular heart disease can be an already-existing complication of pregnancy or may be diagnosed during pregnancy. Appropriate diagnosis, therapy and a thorough assessment of the physiology and patho-physiology of pregnancy are necessary components of managing VHD in pregnant women.
The rise of pregnancy in patients with congenital or acquired VHD present challenges to its management. The good news is there have been many advancements in its diagnosis, treatment and therapy to counter this complication. Often, women do not have an idea about the symptoms prior to their pregnancy. In most cases, it is diagnosed only when the haemo-dynamic changes in pregnancy. This becomes an indicator of the clinical symptoms.
Some considerations to be made while treating pregnant women with VHD are pre-conception evaluation, ante-partal and peri-partal care, labour and delivery, early puerperium and antibiotic prophylaxis.
The management of women with VHD should preferably begin before conception itself. A cardiac examination and evaluation are necessary tests to be taken to determine and assess whether or not the patient can stand the increased haemo-dynamic burden of pregnancy and the risk of complications during gestation. Pre-conception evaluation is highly advisable, as it includes the careful examination of history and physical examination, a 12-lead electrocardiogram, an echo-cardiogram, and a doppler study. It is also essential to obtain accurate information about the patient’s cardiac status.
The timing and mode of delivery are to be discussed between the obstetrician, cardiologist and obstetric anaesthesiologist. Normal delivery with the right amount of anaesthesia and shortening of the second stage is safe and can be performed in a majority of patients with VHD.
Major blood loss is associated with delivery; hence, the early puerperium is associated with increased venous return to the heart caused by blood shift from the emptied uterus into the systemic circulation, decreased caval compression, and mobilisation of fluid from the limbs and lower body. Hence, there is the need for haemo-dynamic monitoring for 12 to 24 hours after the delivery. Antibiotic prophylaxis is recommended for patients with VHD, as they undergo manipulations or surgical procedures likely to result in bacteraemia.
Management of valvular heart disease during pregnancy can be quite demanding. A thorough knowledge of the expected history of the disease during pregnancy and of the likely treatment options is suggested for clinical decision-making. A personalised patient care that includes a physician, obstetrician, and anaesthetist is required for bringing about effective outcome of the pregnancy for the mother and the baby.