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Maternal and fetal outcome in cardiac disease in pregnancy: a retrospective study at tertiary care center

Cardiac disease in pregnancy is a high-risk pregnancy which is still a major problem worldwide, particularly in developing countries. It is still a major cause of maternal mortality. Today the management of cardiac disease in pregnancy is a team effort controlled by cardiologists and obstetricians. Obstetricians are often the first to identify cardiac lesions as part of pre-pregnancy and routine antenatal check-up and the ones who often face cardiac emergencies during pregnancy. At present cardiac disease complicates 0.2-4% of all pregnancies in western countries. In developing countries, the incidence is 2% and contribute to about one-fifth of maternal deaths. cardiac disease in pregnancy most commonly due to congenital heart disease, rheumatic heart disease, less commonly due to ischaemic heart disease or cardiomyopathy.


INTRODUCTION
Cardiac disease in pregnancy is a high-risk pregnancy which is still a major problem worldwide, particularly in developing countries. It is still a major cause of maternal mortality. Today the management of cardiac disease in pregnancy is a team effort controlled by cardiologists and obstetricians. Obstetricians are often the first to identify cardiac lesions as part of pre-pregnancy and routine antenatal check-up and the ones who often face cardiac emergencies during pregnancy. At present cardiac disease complicates 0.2-4% of all pregnancies in western countries. 1 In developing countries, the incidence is 2% and contribute to about one-fifth of maternal deaths. 2 cardiac disease in pregnancy most commonly due to congenital heart disease, rheumatic heart disease, less commonly due to ischaemic heart disease or cardiomyopathy.
Congenital heart disease is the most frequent cardiovascular disease present during pregnancy in developed country, while rheumatic heart disease is predominant in developing country like India. 3 Peripartum cardiomyopathy is the frequent cause of severe complications. Pregnancy makes a significant impact on cardiovascular system due to the haemodynamic changes. Around 15-50% of cardiac abnormalities first diagnosed during routine antenatal check-ups or due to the signs and symptoms caused by physiological changes of pregnancy. 4 The most common clinical features of cardiac lesions like breathlessness, pedal oedema, murmurs which mimic normal physiological changes in pregnancy pose a diagnostic difficulty to obstetricians. The obstetric complications like preeclampsia, anaemia, preterm labour, fetal growth restriction further worsen the outcome and complicate the management of pregnancy.
Pregnancy related complication along with the cardiac disease is ignored in the rural set up and patient rarely seek proper advice and treatment.

METHODS
This was a retrospective study carried out at the department of Obstetrics and Gynaecology in Maharaja krushnachandra Gajapati Medical College, Berhampur, Odisha during the period of August 2016 to August 2018.
A total 22 pregnant women with cardiac disease admitted during the study period were included in the study. All the patients detailed demographic information, diagnosis, course in hospital, management, maternal and fetal outcome obtained from the records and files.

Inclusion criteria
• Pregnant women with a history of cardiac disease of or newly diagnosed cardiac disease after they presented to hospital with cardiac symptoms, evaluated clinically and then sent for necessary investigation. Those who were finally diagnosed with structural or functional cardiac disease were included in the study.

Exclusion criteria
• All condition mimicking heart disease were excluded.

RESULTS
A total of 22 pregnant women with cardiac disease were included in the study. The incidence of cardiac disease in our hospital is 0.15%. Of the 22 patient's majority of the patients in the age group 21-25 years (45%).   Most of the patient in the study had rheumatic heart disease (68.1%), followed by congenital heart disease (22.7%), followed by peripartum cardiomyopathy (6.25%). surgical correction was done In 23% of patient prior to pregnancy. In those patients it was congenital heart disease in form of ASD and VSD. No patient have residual disease after correction. The most common congenital heart disease seen in study population was ASD (60%), followed by VSD (40%). The most common lesion in patients with RHD was mitral stenosis, followed by mitral stenosis with mitral regurgitation, followed by Aortic stenosis . Aortic lesion seen in 3 patients in form of aortic stenosis and in one patient in form of mitral stenosis with mitral regurgitation with aortic stenosis. The functional class of disease as per NYHA classification in present study depicted in (Table 6). Most of the patients are in NYHA class II. The outcome and complications are more in NYHA III and IV.
Most of the patients had vaginal delivery 95.4% and caesarean section was done in one patient, the indication being malpresentation.   The small for gestational age was seen in 54.5% babies, birth asphyxia in 27.2% babies, low APGAR at 1 min IN 27.2%, prematurity in 22.7% babies. NICU admission was 63.6%. perinatal mortality was in 2 cases (9%). One of which was fresh still born at 32 week and one neonatal death due to birth asphyxia.

DISCUSSION
Cardiac disease in pregnancy contribute a major risk factor for maternal and perinatal morbidity and mortality. The incidence of congenital heart disease in pregnancy has come down due advance surgical repair technique, but in countries like India both the incidence of congenital and rheumatic heart disease is still high due to poor socioeconomic status, ignorance about symptoms and negligence about own health. The incidence of cardiac disease in pregnancy in present study was 0.15%. It may not reflect the actual prevalence as most centres nearby our hospital is tertiary and referral centre.
Present study shows the predominant lesion was rheumatic heart disease (68.1%) followed by congenital heart disease (22.7%) and cardiomyopathy (6.25%).The results were comparable with Indiara et al (80%) and Sheela et al (67%). 5,6 The most common valvular lesion found to be in present study is mitral stenosis (46.6%),which is comparable with Manohar et al (38.6%). 7 Rheumatic heart disease complicates about 0.3% to 3.5% of women in child bearing age with global figure of 1%. 8 It accounts for about 30% of cardiac disease in pregnancy in developed countries and 90 % of cardiac lesion in developing countries. 9,10 Out of 22 patient 50% were in NYHA class 2 and 22.7% were in class 1, the complications were not severe in these patients. Among 4 (18.1%) cases who were in class 3 NYHA the complications were in form of pulmonary oedema and CHF. One patient who was in class 4, died due to severe mitral stensis with pulmonary oedema. This result was comparable with Indira et al. 5 Also the disease progress and the classification become higher class as compare to their status prior to pregnancy.
Maternal complications seen in 54.5% of cases. Obstetric complication in form of anaemia in 66.6% cases others in form of preterm labour, preeclampsia, abruptio. Cardiac complications in form of pulmonary oedema and congestive cardiac failure (16.6%). One patient died due to pulmonary oedema. Perinatal complication were also remarkable in form of prematurity, SGA, NICU admission, birth asphyxia. Authors had two perinatal mortality one due to severe birth asphyxia and other as a fresh still born. Results were comparable with Prameela et al. 11

CONCLUSION
Pregnancy with cardiac disease contribute major morbidity. The incidence of Rheumatic heart disease is still high in India inspite of deliberate use of antibiotics against streptococcal infection. Early detection of cardiac disease in pregnancy, frequent antenatal check-up, emphasizing the risk period for cardiac failure during pregnancy and combine effort of obstetrician, cardiologist, anaesthesiologist and neonatologist may ensure better prognosis for both mother and baby.