Study of maternal and neonatal outcome in pregnancy with heart disease
Keywords:pregnancy with heart disease, Rheumatic heart disease, maternal and neonatal mortality and morbidity, maternal and neonatal outcome
Background: Pregnancy and child birth are part of the human development, which is affected by physical, biological, psychological and social factors. In pregnant women, maternal physiological state adapts to such an extent that it overcomes problems occurring in pregnancy, but still maternal and neonatal mortality and morbidity are seen in present conditions. As new advances in science, technology, research and improved socioeconomic status has given new methods and guidelines to control rate of maternal and neonatal mortality. In developing countries 75% maternal mortality are those resulting from direct obstetric causes and remaining are due to indirect causes like anemia , cardiac disease ,viral hepatitis , etc. In indirect causes, heart disease remains important cause of maternal mortality. Management of heart disease during pregnancy is challenging. Thorough knowledge of the expected natural history of the disease during pregnancy and of the possible treatment options is required for clinical decision making which will prevent maternal and neonatal complications. Material and Methods: This study was conducted in Department of Medicine with the help of Department obstetrics and Gynacology, at JIIU” Indian institute of medical sciences & research” Tq.Badnapur, Dist.Jalna.,Maharashtra state, India. From November 2012 to December 2015; consist of 71 women with heart disease in pregnancy admitted during the same period in this hospital. The study included both registered and unregistered cases. All pregnant women who attended antenatal clinic and found to have heart disease were referred to physician from Department obstetrics and Gynacology. After confirmation of diagnosis and grading of heart disease as per NYHA classification all patients were routinely followed with required investigation like electrocardiography, echocardiography, and chest radiography. Patients were followed in antenatal clinic regularly. In antenatal check-up counseling regarding risk of cardiac disease in pregnancy explained to patients and relatives. All patients detail information taken as per study Performa and after all data analyzed in the form of observations and results. Observation & results: Prevalence of heart disease in pregnancy was 0.87%. Most of the patients were registered 64 (90.15%) in our hospital or outside hospitals and 9 (9.85%) were totally unregistered. At the time of admission 13% cases were diagnosed as case of heart disease in pregnancy first time. Rheumatic heart disease 54 (76.05%) constituted the commonest type of heart disease. congenital heart disease constituted 11(15.49%) and arrhythmia found in patients 6 (8.45%).Pure mitral stenosis was found as commonest cardiac lesion in 28 cases out of 54 cases (51.85%) followed by mitral insufficiency in 13 (24.07%) patients. Out of 11 congenital heart disease patients atrial septal defect was most common lesion 7(63.63%) followed by ventricular septal defect 2 (18.18%), atrioventricular septal defect 1 (9.09%) and Patent ductus artreriosus in 1 (9.09%) case. According to NYHA classification we had class I 44 (61.77%) cases, class II 10 (14.08%) cases, class III 9 (12%) cases and class IV 8 (11.26%) cases. The most frequent symptom of heart disease in pregnancy was breathlessness 27 (38.02%). followed by cough and palpitations. Anemia and upper respiratory tract infection (URTI) remain most common risk factors. We delivered 18 (25.35%) patients by forceps application. LSCS was done for obstetric indication and none for cardiac reason. Most common indication for LSCS was fetal distress, followed by cephalopelvic disproportion and previous LSCS. Maternal morbidity seen in 30.98% patients. Maternal morbidity in NYHA class III and IV (82%) was six times more than in NYHA class I and II (13%). 5 (7%) patients developed CCF, 3 patients had Atrial fibrillation and 10 patients (14.08%) developed pulmonary edema. Neonatal outcome by Apgar score was four time better in NYHA class I/II as compare to NYHA class III/IV. Neonatal morbidity observed in 55.88% neonates. 27.94% neonates were preterm and 51.47% babies were admitted in NICU after delivery. Neonatal morbidity in NYHA class I and II was 56.60% and 64.28% in NYHA class III and IV. Two mothers with congenital heart disease had offspring with congenital heart disease. Maternal mortality observed in 4 patients out of 71 patients (5.63%) and neonatal mortality observed in 5 neonates (7.35%) out of 68 neonates. Out of 4 patients 3 maternal mortality were occurred in antenatal period and in 1 after 4hrs of delivery. All 4 maternal mortality occurred in NYHA class III and class IV. All four patients had CCF with atrial fibrillation. This maternal mortality were due to low socioeconomic status, illiteracy, lack of advanced facility in grass root level, low living standards and ignorance towards female regarding health issue. Conclusion: In conclusion, heart disease in pregnancy is associated with significant maternal and perinatal morbidity in NYHA class III & IV patients. Rheumatic heart disease was the predominant type. Patients in NYHA class I & II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesions prior to pregnancy was associated with better pregnancy outcome. Pregnancy in women with heart disease is associated with significantly higher maternal morbidity and adverse fetal outcomes and requires a team approach for optimal management.
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