Pregnancy management. Hospitalization of a patient with cardiovascular disease

Every patient with cardiovascular disease should be hospitalized thrice during pregnancy, even if she feels well.

The 1^st hospitalization is at term prior to 12 weeks of gestation (thereafter the pregnancy was determined). Hospitalization should be in a hospital of cardiologic type.

The aim of this hospitalization is to examine woman’s condition and determine contraindications to pregnancy, if any.

The basic tasks of examination of pregnant during the first hospitalization are:
- establishment of obstetric diagnosis;
- determination of form and stage of development of heart disease;
- establishment of degree of cardiac insufficiency, state of myocardium, activity of rheumatic process;
- revealing the foci of chronic infection (pyelonephritis, tonsillitis, otitis, etc).

Because of high risk of maternal death rate, pregnancy and birth are contraindicated in case of the following heart diseases:
- Presence of cardiac insufficiency regardless of form of heart disease already at small terms of pregnancy.
- Active rheumatic carditis, recurrent rheumatic carditis, bacterial rheumatic carditis.
- Mitral stenosis of III-IV stages (according to A. Bakulev’s classification).
- Combination of mitral stenosis and aortic insufficiency.

- Tricuspid incompetence.
- All congenital defects with cyanotic syndrome (all Fallot’s defects, transposition of great vessels, common arterial trunk).
- Eisenmenger’s syndrome, Marfan’s syndrome.
- Combination of congenital and acquired defects.
- Restenosis after surgical treatment.
- Presence of mitral incompetence with disturbance of blood circulation, blood regurgitation.
- Some others.

In patients with recurrent myocarditis the conducting of pregnancy will depend on results of antirheumatic therapy. If the treatment is ineffective, the artificial termination of pregnancy is indicated. Aortic diseases during pregnancy remain compensated for a long time. In absence of cardiac insufficiency the pregnancy may be prolonged; at decompensated diseases the termination of pregnancy should be done in early terms of gestation.

In connection with growing number of women having the previous operations on the heart, it is necessary to decide the question of permissibility of pregnancy and labor for them. Thus, pregnancy after mitral commissurotomy may be allowed not earlier than 7 months and not later than 1.5 years after the operation. Pregnancy is allowed at excellent and good results after the operation in case of absence of operated heart trouble. At second-rate results of commissurotomy the pregnancy and birth are contraindicated.

Pregnancy and labor are contraindicated for patients after the operation of aortic and mitral valve replacement.

If necessary, the artificial termination of pregnancy should be performed with a single-stage operation (curettage of the uterine cavity, vacuum aspiration).

The 2^nd hospitalization should be at term of 26-32 weeks of gestation in the period of maximal hemodynamic loading on the heart.

Significant hemodynamic changes occur at this term, so the aim of hospitalization is to prevent decompensation of cardiovascular system. Observation of the patient, examination, prophylaxis and treatment of fetal and maternal complications, if any, should be provided.

Medical treatment at the in-patient department during the second hospitalization includes the following:

· Limitation of physical exertion (bed regimen) during 2-3 weeks.

· Sedative therapy (preparations of valerian, motherwort).

· Diet limited in salt up to 1-3 g/d and liquid up to 1,000 ml/d. In pregnant with cardiovascular diseases the mucous membrane of gastrointestinal tract is edematous, the absorption is labored; therefore it is recommended to take meals rich in vitamins, potassium, in small portions, 5-6 times a day.

- The main drugs for treatment are cardiac glycosides, which increase cardiac output and diuresis, decrease congestion of blood in lungs and liver, diminish edema. Cardiac glycosides change potassium and sodium transport through the myofibril membrane, and promote muscular contractions. Cardiac glycosides improve blood supply of organs and tissues, restore metabolic processes.

The index of efficiency of medical treatment with cardiac glycosides is decrease of pulse rate (if there was tachycardia), elimination of other symptoms of decompensation: breathlessness, edema. Cardiac glycosides for these patients should be administered by a cardiologist with an individual choice of preparation and dose. Strophanthine, then corglycon, digoxin, digitoxin produce the greatest effect. To achieve a good therapeutic effect 0.5 mg of strophanthine or 1.8 mg of corglycon a day should be introduced; or digitoxin in a dose of 2 tablets 4 times, or 2 tablets of digoxin (izolanid) 4 times a day orally should be administered.

The overdose of cardiac glycosides is accompanied by intoxication (nausea, vomiting, diarrhea, visual impairment: painting of visual field in a green or yellow color). Intoxication is quickly controlled by introduction of unithiol: 5 mg intramuscularly 3-4 times a day. With the same purpose β-blockers, such as inderal, obzidan in small doses are recommended. In case of absence of these drugs 2 ml of a 2% solution of sodium citrate may be introduced.

- Diuretic therapy is also administered. At I stage of blood circulation insufficiency diuretics are not administered. In such cases it is possible to prescribe aminophylline, which improves renal blood flow and indirectly results in moderate increase of diuresis. It should be remembered about the features of individual tolerance of preparation during pregnancy; in addition, there is information that aminophylline somehow “robs” myocardium. At IIA stage of blood circulation insufficiency, thiazide diuretics and non-thiazide sulfanilamides (brinaldix) in combination with potassium-saving diuretics (verospiron) are effective.

- At IIB stage of blood circulation insufficiency more powerful diuretics are administered: furosemide, uregit in combination with potassium-saving diuretics. At III stage of insufficiency of blood circulation the medical treatment is similar to the above-stated. The courses of medical treatment with diuretics can last 3-5 days, in milder cases they are irregular. It is recommended to begin the treatment with small doses, gradually increasing them, achieving 2-3 litres of diurnal urine excretion.

- Along with diuretics and cardiac glycosides preparations of camphor and caffeine are applied.

- Metabolic therapy is administered for improvement of cardiac muscle function. Medical treatment is long, not less than a month: panangin 1-3 pills 3 times a day, potassium orotate (vitamin B₁₃) by 0.25 g 3-4 times a day, folic acid 0.001g three times a day, inosine 0.4 g 3 times a day.

- Oxygen therapy (oxygen froth, inhalation of moist oxygen, hyperbaric oxygenation).

- Antirheumatic medical treatment: a) antibiotics — etiotropic medical treatment (penicillin and his analogues depress vitality of hemolytic streptococcus), b) antiinflammatory therapy (glucocorticoids, salicylates, pyrazolone, indole derivative).

The 3^rd hospitalization should be at term of 36-37 weeks of gestation for examining the patient before labor and choosing the obstetric management.

Management during Delivery. The choice of obstetric management for pregnant with heart diseases is determined not only by form of disease, but also by presence and degree of insufficiency of blood circulation, i.e. functional condition of the heart. The delivery through the maternal passages is the most preferable type of birth, of course in the absence of obstetric indications for cesarean section. The incidence of maternal morbidity and death at such patients is lower at vaginal birth than at cesarean section.

The patient should be placed in a lateral position. The maternal pulse and respiratory rate should be monitored. The increase of pulse over 100 beats per minute or respiratory rate over 24/min is a sign of possible cardiac decompensation. The obstetric management is directed at shortening of the second (expulsive) stage of labor: up to 2 hours in primiparae, and up to 1 hour in multiparae. For this purpose a dynamic evaluation of contractile activity of the uterus is made at birth, prophylaxis and medical treatment of anomalies of labor pains is performed.

An adequate analgesia, better a continuous epidural anesthesia, is appropriate for most patients to relieve pain. Avoidance of hypotension is of importance. A continuous hemodynamic monitoring is indicated for the patient and her fetus. The treatment before full opening of the cervix includes promedol, oxygen, digitalization. The basic danger in respect of developing decompensation of cardiac activity in birth is presented by expulsive (the second) stage of labor because of highest physical load which the woman’s organism undergoes in this period. Therefore the main question to decide for obstetrician-gynecologist and cardiologist at choice of obstetric approach is the question about the necessity of elimination of expulsive pains. The choice of obstetric approach in the second stage of labor should be oriented to degree of risk of unfavorable outcome of pregnancy in patients with cardiac diseases (according to Vanina L.V.).

The I degree of risk: pregnancy at heart disease without expressed signs of insufficiency and without exacerbation of rheumatic process. Women of this risk group do not require elimination of expulsive pains.

During birth the following urgent indications for forceps delivery can occur:
- worsening of state in the second period of birth;
- hypoxia of the fetus;
- bleedings.

The II degree of risk is pregnancy at heart disease with the initial signs of cardiac insufficiency (breathlessness, tachycardia), presence of signs of active phase of rheumatism (AI stage by Nesterov). Delivery is conducted through maternal passages with maximum anaesthetizing, in the presence of cardiologist; elimination of expulsive pains is absolutely indicated in the second stage of labor.

The III degree of risk: pregnancy at a decompensated heart disease with signs of predominance of the right ventricular failure, at presence of active phase of rheumatism (AII), recently occurred fibrillation, pulmonary hypertension of II stage.

The IV degree of risk is pregnancy at a decompensated heart disease with signs of the

left ventricular failure, or total insufficiency, presence of active phase of rheumatism (AIII), long-existing fibrillation, pulmonary hypertension of III stage.

Pregnancy and birth for women of III and IV degree of risk are contraindicated.

Cesarean section in patients with decompensated heart diseases presents an increased risk for mother, so there are no generally accepted, expressly grounded indications for this operation.

In patients with severe decompensation the cesarean section is the “operation of despair”, which is performed in the absence of requisite condition for delivery through maternal passages. Indications for cesarean section in pregnant women with heart diseases are the following:

- blood circulation insufficiency of IIB, III degree, maintained to the term of birth irrespective of disease causing decompensation;
- septic endocarditis;
- acute cardiac insufficiency, observed during pregnancy or developed in birth;
- severe pulmonary hypertension combined with IIB-III degree of insufficiency of blood circulation.

Management in Puerperium. The patient is to be closely observed for the first 24 hours. Autotransfusion that occurs after delivery of placenta can cause a marginally compensated woman to go into heart failure. Absolute bed rest, intramuscular injections of promedol just after delivery; oxygen continuously or intermittently should be administered. For prophylaxis of bleeding 0.25 mg (1 ml) of methylergometrine is introduced intravenously in combination with 20 ml of a 40% glucose solution at the end of the second stage of labor. Methylergometrine is additionally introduced after delivery of afterbirth. Methylergometrine leads to effective contraction of uterus and decreases pressure in pulmonary circulation.

An early puerperal period (the first 2 hours after birth) is conducted depending on form of disease. To patients with mitral stenosis (pulmonary hypervolemia) it is not recommended to place weight on the abdomen in order to avoid repletion of lungs with blood from the abdominal cavity. To patients with aortic insufficiency, mitral incompetence (increased cardiac output), placing of weight on the abdomen is indicated, because it provides sufficient inflow of blood to the heart, helping to avoid hypervolemia.

In subsequent days patients with heart diseases need careful medical supervision. Regardless of type of delivery, there are 2 two critical periods in such patients after labor:
- from the first hours to 3-5 days;
- 7-8th day after labor (danger of exacerbation of rheumatic process).

In this connection patients with heart diseases are administered bed regimen from the 1^st to 7-8^th day after delivery; prophylaxis of exacerbation of rheumatic process should be carried out. Patients may be discharged from maternity hospital 2 weeks after birth.