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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 2  |  Page : 431-436

Spectrum of pregnancy with heart diseases in Menoufia governorate


1 Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetric and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Cardiology, Elmenshawy Hospital, Tanta, Egypt

Date of Submission30-Sep-2014
Date of Acceptance15-Feb-2015
Date of Web Publication18-Oct-2016

Correspondence Address:
Amr Refaat Hamed Elgarf
Department of Cardiology, Elmenshawy Hospital, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.192434

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  Abstract 

Objective:
The aim of this study was to assess the spectrum of pregnancy with heart diseases in Menoufia governorate.
Background:
Heart diseases during pregnancy are the leading indirect cause of maternal death worldwide.Although the incidence of cardiac abnormalities during pregnancy has remained more or less unchanged, the relative contribution of the different causes of heart disease preceding or diagnosed during pregnancy varies with study population and study period.
Patients and methods:
This is a cross-sectional study of pregnant women with heart disease who underwent delivery between January 2012 and January 2013 at University Hospital and Shebin El Kom Teaching Hospital (Menoufia, Egypt). Maternal and fetal outcome and complications were evaluated for each patient.
Results:
The overall prevalence of pregnant women with heart disease was 9.3%. Hypertensive disorders during pregnancy were the most common cardiac disease diagnosed in our study (83%); native and prosthetic valvular heart diseases were present in 10 and 1.1%, respectively, whereas cardiomyopathy and congenital heart disease were present in 5.7 and 0.2%, respectively. The most prevalent maternal complication was bleeding (4.8%). Most women had spontaneous vaginal deliveries (57.4%), although 42.6% of women underwent cesarean sections. The most prevalent neonatal complications were premature birth (1.5%), babies requiring incubator support or on mechanical ventilation (7.8%), and fetal mortality (1.7%).
Conclusion:
Women of child-bearing age who are at risk for, or already have, cardiovascular disease should receive early counseling and treatment not only from their family physician but also from an interdisciplinary team comprising gynecologists, cardiologists, and, if necessary, cardiac surgeons.

Keywords: complications, heart diseases, pregnant women


How to cite this article:
Soliman MA, Abd El-Gayed AM, Elgarf AR. Spectrum of pregnancy with heart diseases in Menoufia governorate. Menoufia Med J 2016;29:431-6

How to cite this URL:
Soliman MA, Abd El-Gayed AM, Elgarf AR. Spectrum of pregnancy with heart diseases in Menoufia governorate. Menoufia Med J [serial online] 2016 [cited 2019 Nov 18];29:431-6. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/431/192434


  Introduction Top


Heart diseases during pregnancy are the leading indirect cause of maternal death worldwide [1].

The incidence of clinically significant cardiac disease during pregnancy has not changed for decades. The most recent studies report incidences of 0.1–4% [2].

The largest group (70–80%) now comprises women with congenital heart disease (CHD) (adult congenital heart patients due to improved pediatric surgery outcomes and medical therapy), followed by women with rheumatic heart disease (which has decreased because of the decrease in the incidence of rheumatic fever) [3].

Although the incidence of cardiac abnormalities during pregnancy has remained more or less unchanged, the relative contribution of the different causes of heart disease preceding or diagnosed during pregnancy varies with study population and study period [4].

Although in developing countries rheumatic heart disease, for example, is still a major problem, it is now far less frequent in developed countries [5].

Hypertension is the most common medical disorder that occurs during pregnancy; preeclampsia constitutes two-thirds of cases of hypertension with pregnancy [6].

In Egypt 16% of maternal deaths are due to heart diseases during pregnancy. This percentage means that heart disease during pregnancy is the fourth most common cause of maternal mortality following hemorrhage, sepsis, and hypertensive diseases [7].

In developed countries, where the incidence of postpartum hemorrhage is low, heart diseases during pregnancy and labor are the leading cause of maternal mortality [8].

In this study we aimed to assess the spectrum of pregnancy with heart diseases in Menoufia governorate.


  Patients and Methods Top


Methods

The study included pregnant women who were admitted to Menoufia University Hospital and Shebin El Kom Teaching Hospital between 1 January 2012 and 1 January 2013 with one of the following conditions:

  1. Pregnant with valvular heart disease, either native or prosthetic.
  2. Pregnant with hypertensive heart disease.
  3. Pregnant with CHD.
  4. Pregnant with cardiomyopathies.
  5. Pregnant with ischemic heart disease.


Miscellaneous heart diseases were recorded (e.g. pulmonary hypertension).

All patients were subjected to the following:

  1. Cardiac assessment:

    1. Careful history taking.
    2. General and local examination.


  2. Gynecological examination.
  3. Fetal examination.
  4. Laboratory examination.
  5. Investigations (ECG and echocardiography).


Statistical analysis

The level of significance was 95%. Therefore, P value greater than 0.05 was considered nonsignificant, P value less than 0.05 was considered significant, and P value less than 0.001 was considered highly significant [9].


  Results Top


During the study period (2012–2013), 4947 pregnant women were admitted to the University Hospital and Shebin El Kom Teaching Hospital, and 460 women with various types of heart diseases underwent delivery during this period. Women with heart diseases accounted for 9.3% of all deliveries during this period in the two hospitals. Hypertensive disorders during pregnancy (HDPs) were the most common cardiac disease in our study, seen in 382/460 (83%) patients; native and prosthetic valvular heart diseases presented in 46/460 (10%) and 5/460 (1.1%) patients, respectively, whereas cardiomyopathy and CHDs presented in 26/460 (5.7%) and 1/460 (0.2%), respectively, as shown in [Table 1].
Table 1: Diagnosis of maternal heart diseases

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The average maternal age was 25 years (range 19–37 years). A total of 205 (44.6%) women were nulliparous and 255 (55.4%) women were multiparous. The majority of our patients were given antenatal care (93%, 428/460). Maternal complications such as bleeding and venous thromboembolism were seen, as shown in [Table 2]: bleeding presented in 22/460 (4.8%) patients and venous thromboembolism in 2/460 (0.4%).
Table 2: Maternal complications

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The majority of women achieved spontaneous vaginal delivery. A total of 196 (42.6%) women underwent a cesarean section. All of them were due to obstetric reasons, except one, which was because of preterm labor in a woman with a mitral prosthetic valve who was on oral anticoagulants.

Albumin in urine on laboratory analysis was present in 308 women diagnosed with preeclampsia, whereas 74 women were diagnosed with gestational hypertension; all 382 patients with hypertension presented with pregnancy-induced hypertension.

There were a total of 460 successful deliveries. The live birth rate in our study was 98.3%. Around 1.5% were premature babies (a baby born before 37 weeks of gestation), 7.8% of babies required incubator support or mechanical ventilation, and fetal mortality was 1.7%.

There were highly statistically significant differences between babies requiring incubator support or mechanical ventilation, APGAR score less than 8, stillbirth babies, premature babies, and fetal mortality (P < 0.0001), as shown in [Table 3],[Table 4],[Table 5],[Table 6].
Table 3: Incubation or mechanical ventilation and fetal mortality (P < 0.0001)

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Table 4: APGAR score and fetal mortality (P < 0.0001)

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Table 5: Stillbirth and fetal mortality (P < 0.0001)

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Table 6: Prematurity fetal mortality (P < 0.0001)

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There were highly statistically significant differences between diagnosis, complaint, type of labor, and maternal complications (P < 0.0001), as shown in [Table 7],[Table 8],[Table 9].
Table 7: Diagnosis and maternal complications (P < 0.0001)

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Table 8: Complaint and maternal complications (P < 0.0001)

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Table 9: Type of labor and maternal complications (P < 0.0001)

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  Discussion Top


Accurate assessment of the individual maternal and fetal risk in pregnant women with heart disease is important for optimal patient care.

In our study the prevalence of pregnancy with cardiovascular heart diseases was 9.3% (460/4947).

There has been a major decrease in the incidence of rheumatic fever during the last decades in western countries, leading to a decrease in the prevalence of chronic rheumatic heart valve disease. However, rheumatic fever remains endemic in a number of developing countries. In school surveys performed in India and Nepal, the prevalence of rheumatic heart disease was estimated as being between 1/1000 and 5.4/1000 between 1984 and 1995, whereas the corresponding figure was below 0.5/1000 in western countries [10],[11].

In our study the prevalence of native valvular heart disease was 9/1000, and in prosthetic valvular heart disease the prevalence was 1/1000.

In rural Pakistan, an important survey, including systematic clinical screening and confirmation using Doppler echocardiography, led to a consistent prevalence of 5.7/1000, with higher figures, between 8/1000 and 12/1000, in women of child-bearing age [2]. More than 80% of the patients who had rheumatic heart disease were not aware of the diagnosis, 78% had few or no symptoms [New York Heart Association (NYHA) class I or II], and only 8% received rheumatic prophylaxis [2]. The lack of adherence to prophylaxis has been observed in other countries and is a probable explanation for why the prevalence of rheumatic heart disease has not decreased in developing countries.

Although far less prevalent than degenerative etiologies, rheumatic heart disease still represents 27% of native valve diseases in Europe [3].

The prevalence of PPCM is not known because recognition and accurate diagnosis depend on the availability and application of echocardiography. This would require its routine use in every parturient woman within sizeable defined populations to gain insight into its true prevalence. M-mode echocardiography was only just becoming available in the cardiology departments of major hospitals in the 1960s and so had not contributed to the diagnosis of the retrospective series of patients described in key papers from New Orleans in 1965 or from Chicago in 1971. Even now cases go undiagnosed, and this is true of major centers as well as less developed ones. The condition has been described from all around the world in both small personal series and in reviews of accumulated cases from many sources, and over different observation periods, thus providing little idea of its true prevalence [14],[15],[16],[17],[18],[19].

It is no wonder that estimates are in truth just wild guesses. They vary widely from 1/1485 to 1/15 000 live births even in the USA [14],[15],[16],[17],[18].

The disease appears to be more common in African-American women. Much higher figures come from South Africa (1/1000 live births) [0] and from Haiti (1/350–400 live births) [9].

In our study the prevalence of peripartum cardiomyopathy was 5/1000.

Both the relative incidence and the absolute numbers of pregnant women with CHD have increased. This is because rheumatic heart disease in young adults is rare in developed countries and a larger number of children with complex CHD are surviving into reproductive age after surgery in infancy or childhood [1].

CHD is not infrequently discovered first during pregnancy, particularly now that structural heart disease can be differentiated by echocardiography whenever there is clinical doubt.

Many congenital cardiac defects allow survival into adult life. Most of the simple acyanotic defects cause no trouble during pregnancy, but women from medically unmonitored communities with previously unsuspected major cardiac defects may be diagnosed first during pregnancy. Most infants and children in developed countries are examined regularly and simple cardiac defects are usually corrected at a young age.

The birth prevalence of CHD is thought to be relatively similar worldwide, with variations between regions and countries due to genetic, environmental, and epigenetic differences [2].

The estimate of 8/1000 live births is generally accepted as the most reliable; however, a recent systematic review emphasized potential significant differences, with the lowest prevalence rate observed in Africa, particularly in lowest-income populations [2].

In our study one pregnant woman with an atrial septal defect was the only case with CHD.

HDPs are associated with severe maternal obstetric complications and are a leading contributor to maternal mortality [3]. Furthermore, HDPs lead to preterm delivery, fetal intrauterine growth restriction, low birth weight, and prenatal death.

Although the exact incidence is unknown, it has been estimated that 5–10% of US pregnancies are complicated by HDPs [4]. Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project and National Hospital Discharge Survey have shown marked increases in the incidence of gestational hypertension and preeclampsia in the past two decades, and more women entering pregnancy with chronic (pre-existing) hypertension [24],[25].

Women with chronic (pre-existing) hypertension have been shown to have a markedly increased risk of severe adverse outcomes, such as maternal cerebrovascular accidents and placental abruption, compared with normotensive women [6].

Although there are many different causes of hypertension during pregnancy, the most clinically important condition is preeclampsia, affecting between 1 and 3% of pregnancies [7]. Preeclampsia is associated with increased maternal and fetal morbidity and mortality [8]. As there is no effective intervention for preeclampsia, except delivery, preeclampsia is responsible for about a half of induced preterm deliveries, with the associated consequences of premature birth.

In our study, pregnant women with hypertensive heart diseases represented 83% of all cases during pregnancy and the prevalence of HDPs in our study was 7.7%.

In our study, we had one stillbirth baby, and 36 (7.8%) neonates required ICU support (either incubator or mechanical ventilator) because of prematurity or respiratory distress, of whom 29 survived to discharge and seven died.

The stillbirth baby belonged to the pregnant woman with hypertension; of the other seven babies who died, six were delivered by mothers who had hypertensive disorders and only one from a mother with valvular heart disease.

We expected to find several cases of rheumatic heart diseases in pregnant women in Menoufia governorate, but in the current study the prevalence of native and prosthetic heart diseases was 9 and 1%, respectively, which was similar to another study that found the incidence of rheumatic heart diseases over the 5-year study period at two hospitals in San Luis and Mexico to be 7% [9].

We were surprised by the high incidence of hypertensive heart disease in pregnant women, especially the incidence of preeclampsia, which was 304 cases and quite similar to the incidence in the western world.

Anesthetic management of these patients includes prepregnancy evaluation and surveillance for cardiac disease and the determination of optimal delivery to minimize maternal and fetal burden. This can be accomplished only by close communication between the obstetrician, cardiologist, cardiac surgeon, anesthesiologist, intensivist, and neonatologist. It is vital to devise a plan that covers all possible obstetric complications. Postoperative monitoring and ICU resources are needed to ensure the safe resolution of operative hemodynamic changes.


  Conclusion Top


Women of child-bearing age who are at risk for, or already have, cardiovascular disease should receive early counseling and treatment not only from their family physician but also from an interdisciplinary team composed of gynecologists, cardiologists, and, if necessary, cardiac surgeons.

Conflicts of interest

There are no conflicts of interest.[29]

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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