The coexistence of heart disease and pregnancy presents a significant challenge, as it is a well-recognized risk factor for both maternal and fetal complications during pregnancy and childbirth. Heart disease is reported as a leading indirect cause of maternal mortality globally (1). The condition complicates approximately 0.5% to 4% of pregnancies, posing considerable risks for adverse outcomes (2). Neonatal complications, including preterm delivery and low birth weight, are observed in nearly 20% of pregnancies complicated by maternal heart disease (3). While the incidence of rheumatic heart disease (RHD) has decreased in developed countries, it continues to contribute significantly to maternal morbidity and mortality in the developing world, where mitral stenosis remains the most prevalent valvular lesion (4).

In many cases, heart disease is diagnosed for the first time during pregnancy, as the physiological demands of pregnancy can unmask latent cardiac conditions (5,6). Pregnancy induces profound hemodynamic changes, including a 40% increase in plasma volume and cardiac output, along with reduced systemic vascular resistance, which can exacerbate preexisting cardiovascular conditions (7). Additionally, hypercoagulability during pregnancy may predispose women to thromboembolic complications (8-10).

Cardiac diseases are broadly categorized into congenital and acquired types. Congenital conditions, such as atrial and ventricular septal defects, and acquired diseases, such as RHD, cardiomyopathies, and ischemic heart disease, are the most commonly encountered during pregnancy (11,12). Women with cardiac disease often present with symptoms like dyspnea, fatigue, syncope, and palpitations. Clinical findings may include cyanosis, clubbing, murmurs, arrhythmias, or signs of heart failure. Diagnostic evaluations typically involve electrocardiography, echocardiography, and laboratory investigations (13).

The prognosis of heart disease in pregnancy is closely linked to functional status. Maternal mortality is significantly higher in women with severe functional impairment, reaching up to 6.8% in New York Heart Association (NYHA) class III and IV cases compared to 0.4% in class I and II cases (14). Mitral stenosis, especially in severe cases, carries a maternal mortality rate of up to 10%, with additional risk associated with complications such as atrial fibrillation (15). Certain cardiac conditions, like mitral valve prolapse, may have a benign course during pregnancy, while others, such as pulmonary vascular disease, are associated with poor outcomes (16).

Fetal outcomes are largely influenced by maternal health. Pregnancies complicated by severe cardiac disease or pulmonary hypertension carry an increased risk of miscarriage, intrauterine growth restriction, preterm birth, and neonatal death (16). In cases of uncorrected severe valvular disease or the need for anticoagulation, pregnancies are often associated with high morbidity and mortality for both mother and fetus. Advances in medical therapy and procedures like balloon valvuloplasty have significantly improved outcomes, making term gestation feasible in many cases (17).

Optimal outcomes are achieved through accurate diagnosis, preconception counseling and a multidisciplinary approach involving obstetricians, cardiologists, and anesthesiologists. Specialized care at tertiary centers is crucial for managing these high-risk pregnancies (18). Careful planning, including preoperative optimization of cardiac status and the scheduling of elective deliveries, further enhances maternal and fetal outcomes.

Study Design and Setting

This prospective observational study was conducted at a tertiary care hospital in Mumbai, India. The study aimed to analyze the incidence, pattern, severity, and impact of heart disease on pregnancy outcomes. Study Population Pregnant women diagnosed with congenital or acquired cardiac lesions or cardiac arrhythmias who received care at the tertiary care hospital were included. Both booked patients and those referred from other hospitals with maternal complications were eligible for inclusion. Ethical approval was obtained from the institutional ethics committee, and written informed consent was secured from all participants. Data Collection Fifty pregnant women with heart disease were enrolled. Data collection was performed using a predesigned proforma to gather essential clinical and demographic information. The following baseline parameters were recorded:

• Demographics: Maternal age, parity, and gestational age.
• Cardiac parameters: Nature of the underlying cardiac lesion, New York Heart Association (NYHA) functional class, history of cardiac intervention, and use of cardiac medications or anticoagulants.
• Laboratory tests: Blood grouping, complete blood count, urine analysis, serum biochemistry, and screening for VDRL, HIV, and HBsAg.
• Cardiac evaluation: Electrocardiography (ECG) and echocardiography were performed for all patients suspected of having cardiac disease.

Antenatal Care and Monitoring

Patients were examined by an obstetrician and cardiologist every two weeks until 28 weeks of gestation, followed by weekly visits until delivery. Hospital admission was recommended for patients with worsening cardiac status, overt symptoms, or NYHA class III/IV irrespective of gestational age, and for all patients at 37 weeks of gestation.

Management Protocol

Women with rheumatic heart disease (RHD) received the following:

• Antibiotic prophylaxis: Benzathine penicillin (1.2 million units intramuscularly) every three weeks after a test dose.
• Intrapartum prophylaxis: Standard infective endocarditis prophylaxis with ampicillin and gentamicin or ceftriaxone.

Other interventions included positioning patients in a propped-up position, intermittent oxygen administration, and the use of analgesics. The second stage of labor was shortened, when necessary, with outlet forceps or ventouse extraction. Oxytocin was administered to control postpartum hemorrhage. Pregnancy was allowed to continue to term in uncomplicated cases.

Data Analysis

Obstetric, cardiac, and perinatal complications and management details were documented for all patients. Data were entered in Microsoft Excel and analyzed using SPSS version 18.

• Quantitative data: Presented as mean and median values.
• Qualitative data: Represented as frequencies and percentages, with graphical representation where applicable.

Statistical Methods

The study employed descriptive statistical methods to interpret clinical findings and outcomes, facilitating a comprehensive understanding of the relationship between maternal heart disease and pregnancy outcomes.

Incidence of Heart Disease in Pregnancy

During the study period, 4104 confinements occurred at the tertiary care hospital, with 50 women (1.2%) diagnosed with heart disease.

Age Distribution

The majority of women with cardiac disease were aged 20–25 years (44%), followed by 36% in the 26–30 age group. The mean age was 26.52 years.

Type of Heart Disease

Rheumatic heart disease (RHD) was the most common diagnosis, present in 41 cases (82%). Congenital heart disease (CHD) accounted for 12% (6 cases), while 6% (3 cases) had other cardiac conditions such as cardiomyopathy or coronary artery disease.

Table 1: Incidence and Age Distribution

Table 2: Type of Heart Disease

Table 3: Maternal Complications

Incidence of Heart Disease

Out of 4104 confinements, 50 women (1.2%) were diagnosed with heart disease, highlighting its low but significant prevalence in pregnancy.

Age Distribution

Women aged 20–30 years constituted the majority (80%), indicating that reproductive age is a high-risk period for cardiac complications during pregnancy.

Type of Heart Disease

RHD was the most prevalent (82%), with multiple valve lesions observed in 70% of cases. Congenital heart disease was less common (12%), predominantly atrial septal defect (8%).

Maternal Complications

Anemia was the most frequent complication (46%), followed by pulmonary edema (22%) and congestive cardiac failure (6%). Spontaneous abortions occurred in 12%, and the maternal mortality rate was 12%. (Table 1-3)

These findings underscore the need for multidisciplinary management of pregnant women with heart disease to mitigate risks and improve outcomes.

Cardiac disease remains a significant contributor to maternal and neonatal morbidity and mortality, particularly in resource-constrained settings. Advances in medical care and understanding of hemodynamic changes during pregnancy have improved outcomes for pregnant women with cardiac disease (1,2). However, the management of these patients requires a multidisciplinary approach involving obstetricians, cardiologists, and anesthesiologists to optimize maternal and fetal outcomes (3).

In the present study, rheumatic heart disease (RHD) was the most common etiology, accounting for 82% of cases. This finding aligns with other Indian studies where RHD predominates due to the high prevalence of streptococcal infections and inadequate primary prevention (4,5). Conversely, studies from developed countries report congenital heart disease (CHD) as the leading cause of cardiac complications in pregnancy, reflecting better control of rheumatic fever (6,7).

The incidence of cardiac disease complicating pregnancy in this study was 1.2%, consistent with rates reported by Nagamani et al. (1.2%) and McFaul et al. (1.3%) (8,9). However, higher incidences have been reported in specific settings, such as 4.3% in the study by Suman Puri et al., likely due to regional variations in healthcare access and population characteristics (10).

RHD predominantly affected the mitral valve, with mitral stenosis being the most common lesion. Studies by Bhatala et al. and Konnar et al. also highlighted the prevalence of mitral valve involvement in RHD patients (11,12). Among the 12% of patients with CHD in this study, atrial septal defect (ASD) was the most frequent anomaly, similar to findings by Stangi et al., who observed CHD in 81.7% of cases in developed settings (13).

The mean age of patients in this study was 26.52 years, comparable to the findings of Malhotra et al. (25.2 years) and Chinchawade et al. (26.67 years) (14,15). Multigravida women constituted 56% of the cohort, emphasizing the cumulative risk of cardiac complications with successive pregnancies.

The distribution of patients across NYHA functional classes in this study revealed that 66% were in classes I and II, while 34% were in classes III and IV. This distribution is consistent with Chinchawade et al., who reported a higher proportion of low-risk cases (16). The severity of cardiac disease, as reflected in higher NYHA classes, correlates with increased maternal and perinatal morbidity and mortality.

The maternal mortality rate in this study was 12%, higher than reported in studies by Nagamani et al. (5%) and Sheela et al. (2%) (8,17). The higher mortality rate may reflect the severity of cardiac lesions and limited access to specialized care in the study population. Pulmonary edema, congestive cardiac failure, and atrial fibrillation were common complications, aligning with findings from Diao et al. (18).

Vaginal delivery was the most common mode of delivery (58%), consistent with the findings of Doshi et al. and Diao et al., who reported 68.08% and 63.4% vaginal deliveries, respectively (18,19). Cesarean sections were performed for obstetric indications in 26% of cases, reflecting the preference for minimizing maternal and neonatal risks in cases of severe cardiac disease.

Adverse perinatal outcomes were observed in 20.45% of cases, including preterm births (36.36%) and low birth weight (54.54%). These findings are higher than those reported by Nagamani et al., who observed 13.33% preterm births and 15% low birth weight (8). Perinatal mortality was influenced by maternal functional class and the severity of cardiac disease.

This study highlights the importance of early antenatal registration, multidisciplinary care, and timely intervention in managing cardiac disease in pregnancy. However, the single-center design and relatively small sample size limit the generalizability of findings.

Cardiac disease in pregnancy continues to pose significant challenges in maternal and perinatal care. Rheumatic heart disease remains the predominant etiology in India, emphasizing the need for primary prevention and improved access to specialized care. A multidisciplinary approach is essential for optimizing outcomes, and vaginal delivery should be preferred whenever feasible. Improved maternal health services and awareness are critical for reducing the burden of cardiac disease during pregnancy.

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