Worldwide, the frequency of pregnancy complicated by maternal heart disease does not appear to have changed over the years, with overall prevalence of less than 0.1 to4%.¹

Cardiac disease in a pregnancy is a high-risk pregnancy which possess a significant challenge to an obstetrician. Cardiac disease in pregnancy is broadly divided into congenital and acquired. The acquired group includes rheumatic heart disease (RHD), cardiomyopathies and ischemic heart disease. Of these, in developing countries rheumatic heart disease is the commonest type, whereas cardiomyopathies and congenital heart disease one more common in developed countries.² The congenital group include atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), Patent ductus arteriosus (PDA), transposition of the great arteries (TGA) and Ebstein’s anomaly. In India, RHD continues to be a major cause of cardiac illness in pregnancy.

Around 15-52% of cardiac abnormalities first diagnosed during routine antenatal check-ups or due to the signs and symptoms similar to physiological changes of pregnancy.³ Incidence of cardiac disease is reported in 1 to 4% of pregnancies in India.

The primary goal of care for the pregnant woman and her family when cardiac disease complicates the pregnancy is prevention of complications that may occur from the cardiac condition through performing a comprehensive assessment to identify individual needs for teaching, emotional support and physical care.⁴

This is accomplished by education of the woman and husband; assessment of all systems involved on a routine basis; referral to appropriate nutritional, social and medical experts; and facilitation of patient participation in decisions. Early diagnoses, proper follow up and counselling are keys for reducing morbidity and mortality and this strategy requires a collaboration between obstetrician and cardiologists.⁵

This was a hospital based prospective observational study that include 130 pregnant women booked or non-booked, who were admitted in the Department of OBG, Ballari Medical College and Research Centre, Bellary with diagnosed cardiac disease or had symptoms and signs suggestive of cardiac disease which were later confirmed by relevant investigations during the study period of January 2024 to December 2024.

Inclusion criteria

Only those pregnant ladies with heart disease (CHD and RHD with valvular lesions) who were got admitted and delivered during the study period were included.

Exclusion criteria

Patients with associated medical disorders like diabetes mellitus, thyroid disease, pulmonary disease, renal disease, myocardial infarction (MI) and stroke were excluded from this study.

Apart from obstetric indications, women were hospitalized if they had overt symptoms and signs suggestive of worsening cardiac status, if they were in NYHA class III and IV irrespective of the period of gestation.

A pre tasted semi structured proforma was used to collect the relevant information by interviewing, clinical examination of patients, relevant investigation and treatment for each case. Baseline data recorded including age, parity, gestational age, cardiac lesions, New York heart association (NYHA) functional class, use of cardiac medications, thorough clinical examination including chest and cardiovascular auscultation, ECG and echocardiographic assessment of left and right ventricular systolic function. Which will be confirmed on consultation of experts (physician, Cardiologist) by specific interventions. Fetal echocardiography was performed in patients with congenital heart disease (CHD) and in those who had received anticoagulants during pregnancy. The mode of delivery whether vaginal, use of instrumental or the caesarean will be decided as per needful management of patients. Heparin was discontinued at the onset of labor. All patients received antibiotics for prophylaxis against infective endocarditis during labor. They were kept in a propped-up position.

Intermittent oxygen and analgesics were provided whenever needed. Following delivery, injection furosemide 20 mg was administered intravenously. Oxytocin was used for control of postpartum hemorrhage Women who had been on anticoagulants were restarted on heparin within 4 h of vaginal delivery and 8 h of cesarean delivery. Oral anticoagulants were resumed and heparin discontinued when pro-thrombin time reached 1.5–2 times normal. Early ambulation was encouraged.

Patients remained in hospital for 5–7 days postpartum. Maternal outcomes were analyzed on the basis of antepartum, intrapartum, postpartum new-onset or exacerbation of cardiac complications, postpartum complications. Neonatal outcome was studied.

Statistical analysis

Data were presented as Mean±SD. Statistical significance was accepted at the 95% confidence level (p=0.05). The Chi square test was applied.

The present study consisted of 130 pregnant patients during the study period of January 2024 to December 2024. (Table 1) presents demographic data of the patients. In our study, the mean age of the patients was 24.33±2.93 years (ranging from 19-36 years). Most commonly affected age group was 21-25 years (64.62%) followed by age group 26-30 years (23.08%). 68 patients (52.30%) were primigravida, while the 32 patients (24.62%) were gravida 2, remaining 30 cases (23.07%) were gravida 3 and more. Mean gestational age at delivery was 37.46±2.14 weeks. Majority patients (70.77%) are present between 37-40 weeks of gestational age. Majority (58.46%) cases were from rural area. Out of 130 patients, 56 patients (41.54%) were booked while 76 patients (58.46%) were unbooked. Most unbooked patients are from rural area. Most of patients had vaginal delivery (64.62%) with spontaneous onset in 70 patients (53.85%) and induced in 14 cases (10.78%).

Table 1: Socio demographic details of study participants (n=130).

Table 2: Clinical observations in study participants (n=130).

Table 3: Distribution of valvular lesions among rheumatic heart disease cases (n=44).

Table 4: Fetal and maternal complications

Table 5: Maternal complications in operated and non-operated patients

Table 6: Comparison of fetomaternal complications with or without cardiac medications (n=98).

In this study total of 130 pregnant women with heart disease admitted and studied and the outcome was analyzed. Total number of pregnant patients with heart diseases delivered during the study period at our institute was 130 out of 30,000 deliveries. Incidence of heart disease in the study was 0.22%. Reason may be underreporting of the deliveries at periphery by Dais or other health personnel’s and they remain undiagnosed. Similar findings were seen in the study conducted by Prasanna et al where the incidence of heart disease was 0.5%. Incidence of heart disease in pregnancy varies from 0.5-3%.⁷

In our study, the mean age of the patients was 24.33 years (ranging from 19-36 years). The age group 21-25 year is most commonly affected 64.62% (84 cases) followed by age group 26-30 years 23.08% (30 cases). In a study conducted by Sayeeda et al it was reported that the mean age of the patients was 27.00 years (ranging from 18-35 years) and most (82%) belonged to age group 21-30 years.⁸

Out of 130 cases enrolled for the study, 52.30% patients (68 cases) were primigravida while the 24.62% patients (32) were gravida 2, remaining 23.07% cases (30) were gravida 3 and more. Trevino et al reported in their study that 62.5% patients were nulliparous. Sayeeda et al also showed in their study that most of the patients (46%) were primigravida.⁹

In our study population of 130 patients, mean gestational age at delivery was 37.46±2.14 weeks. In a study conducted by Aisha et al, it was reported that mean gestational age at delivery was 36.8±5.64 weeks. Maximum number of patients had term delivery i.e., 65.45%.

In our study out of 130 cases, majority (76 cases, 58.46%) cases from rural area and 41.53% (54 cases) from urban area. Similar findings were seen in the study conducted by Pandey et al where out of 117 patients, 41.02% (48) from urban and 58.9% (69) from rural area.

In our study, majority patients 58.46% (76 patients) were unbooked while 41.54% (54 patients) were booked. Similar findings were seen in the study conducted by Prasanna et al where 64% patients were unbooked and 36% patients were booked. Most of unbooked patients are from rural areas.¹⁰

In conclusion, the results of the present study suggest that management of the pregnant women with cardiac abnormalities should be multidisciplinary to enhance care for these patients. There is need for pre-pregnancy counseling, early diagnosis, correction of cardiac lesions where indicated, close surveillance during pregnancy and a team approach comprising of obstetricians, cardiologists, neonatologists and nursing personnel for a successful pregnancy outcome. It is mandatory to provide better health care facilities to rural and periphery areas for diagnosis and management and early referral in such pregnant to prevent morbidity and mortality.

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