Maternal and fetal outcome in cardiac disease complicating pregnancy at a tertiary centre in a rural area

4. Results A total of 60 pregnant women with cardiac disease were included in the study. Incidence of cardiac disease at our Centre was 0.4%. Of the 60 patients, majority of patients were in the age group of 21-25 years (48.3%) and 21.7% belonged to 26-30 years (as shown in table-1). Abstract: To evaluate the maternal and fetal outcomes of pregnancies, complicated by cardiac disease in a developing country. Material and Method: A retrospective analysis was carried out in 60 pregnant women with cardiac disease from June 2013 to June 2004 at a tertiary centre in Kolar. Results: In the present study, the incidence of cardiac disease was 0.4%, out of which 33.3% were Congenital Heart Diseases and 66.7% were Rheumatic Heart Diseases. Mitral stenosis was seen in 51.3% of cases, mitral regurgitation alone was seen in 7.8% and with mitral stenosis in 35.9%. Anemia was seen in 50% of cases, pre-eclampsia in 23.7% and preterm labor in 18.4%.Spontaneous vaginal delivery was seen in 50%, induced in 5%, instrumental deliveries in 16.6% and cesarean in 28.4%. Surgical correction for cardiac disease was done in 24 patients (40%) of which 6 were during pregnancy. Cardiac complications were noted in 8 patients, of which 6 had CCF, 1 had pulmonary edema and one had atrial fibrillation. The incidence of small for gestational age was 28.3%. Maternal mortality was 3.3% and perinatal mortality was 6.6%. Conclusions: Heart disease in pregnancy is a high risk condition and has a major impact on pregnancy. Rheumatic heart disease was the predominant cardiac problem in pregnancy. Associated obstetric complications along with lack of knowledge and ignorance regarding the pathology lead to unpleasant obstetric outcome. Maternal and perinatal morbidity and mortality can be reduced with proper antenatal, intrapartum and postnatal care in conjunction with cardiologist and neonatologist.

37wk-40wk 23(76.7%) 4. >40wks 2(11.6%) Most of the patient in the study had Rheumatic Heart Disease (66.7%), and rest had congenital heart disease (33.3%) as shown in table-4. 66.7% Most of the patients had single lesion (70%) and 18 patients (30%) had more than one lesion. The surgical correction was done in 40% of patients, of which 18 patients underwent surgery prior to pregnancy and 6 during pregnancy due to worsening of the disease, none of the patient had residual disease after surgery (Table-5a &Table-5b). Percutaneous transvenous mitral commisurotomy (PTMC) was performed in 6 pregnant women with mitral stenosis during second trimester (Table-5c)  The most common congenital heart disease seen in the study population was ASD (70%), VSD was seen in 3 patients and 1 patient had PDA. The most common lesion in patients with RHD was mitral stenosis (51.3%) followed by mitral stenosis and mitral regurgitation (35.9%).Aortic lesions were seen in 2 patients, one with aortic stenosis and one with mitral stenosis with aortic regurgitation (Table-6). .3% Most of patients had vaginal delivery (71.6%) and cesarean section was done in 17 patients (28.4%) as in table 8. The labour was of spontaneous onset in 50% of patients and induced in 3 cases (5%). The indication for induction was postdated pregnancy and severe pre-eclampsia. In ten patients outlet IJBR (2014) 05 (03) www.ssjournals.com forceps were used to cut short the second stage of labour. The various indications for LSCS were fetal distress, cephalopelvic disproportion and malpresentations. Induction of labour was not done in instrumental and cesarean section group.  10 16.6% C-section 17 28.4% The maternal complications were seen in 38(63.3%) pregnant women. The common non-cardiac complication noticed were anemia (50%), preeclampsia (23.7%) and preterm labour (18.4%). The other non-cardiac complications seen were eclampsia (2.6%), abruptio placentae (2.6%), PPH (5.2%), hypothyroidisim (2.6%) and LRTI (7.9%). Cardiac complications were seen in 9 cases out of which 7 required ICU care. The most common cardiac complication was CCF (6 patients). Pulmonary edema was seen in one patient with severe pre-eclampsia and one case of atrial fibrillation was noted. Among the 6 patients with CCF, 4 patients had anemia, one had pre-eclampsia and one had eclampsia. Of the 7 patients requiring ICU care, 5 patients recovered and there were two maternal deaths (3.34%). Of the two deaths seen, one was a case of severe Mitral stenosis with severe anemia in CCF, the other death was in a case of severe MS with severe pulmonary arterial hypertension with pneumonia with IUD. Maternal mortality 2 3.33% The small for gestation was seen in 28.3% of babies, prematurity were seen in 10% of babies and the other neonatal complications are shown in Table-10. A total of 20 babies required NICU care and the various indications are shown in table.10. There were 4 perinatal deaths, of which 2 were intrauterine deaths (at 28wks and at 34wks), one fresh stillborn (at 33wks) and one neonatal death (severe birth asphyxia, died after 3days of birth). The IUDs were seen at 28 and 34wks in mothers with RHD (mitral stenosis) with severe pre-eclampsia and eclampsia respectively, both had intrauterine fetal growth restriction and the scan at 20wks showed no congenital abnormalities.

Discussion
Cardiac disease continues to be a risk factor for maternal and neonatal morbidity and mortality. The incidence of cardiac disease at our centre was 0.4%. In a study by Sheela et al, the incidence of cardiac disease in pregnancy was 1%. 9 In our study, the predominant lesion was Rheumatic Heart Disease (66.7%) and most of the women had involvement of mitral valve.The results were comparable with studies done by Sheela et al (67%), Mahesh et al (64%) and Nilajkumar et al (80%). 7,9,10 The ratio of RHD: CHDin our study was 2:1. The rheumatic heart disease is high in our centre due to lack of prevention, early detection with proper medical and surgical treatment, and proper follow-up of rheumatic fever in childhood, which could prevent complications during pregnancy. 9 Mitral stenosis was the predominant lesion in our study (51.3%). Similar results were noted in the studies by Mahesh et al (44.6%) and by Nilajkumar et al (55%). 7,10 Out of 60 pregnant women in the study group, only 24 (40%) had undergone surgical intervention for cardiac disease. The results were comparable with studies by Mahesh et al, Aggarwal et al and Bhatla et al. 7,8,11 During pregnancy, 6 patients underwent surgical intervention due to deterioration of the cardiac status. We attribute the lack of awareness of heart disease and poor economic status in our patients as the cause of such deterioration.
Congenital heart disease accounted for 33.33% (20 cases), among which the Atrial Septal Defect was common (16 cases). Similar results were seen in studies by Sheela et al and Nilajkumar et al. 7,9 IJBR (2014) 05 (03) www.ssjournals.com Majority of the patients (80%) were in NYHA class I and class II. The results are comparable with studies by Mahesh et al and Sheela et al. The patients with NYHA class III and class IV were less in number and had the worst outcome. Similar observations were seen in studies done by various authors. [9][10][11][12] In our study, most of the women went into spontaneous labour (50%) and majority was delivered vaginally (71.6%). The cesarean section (28.4%) was performed for various obstetric indications. The second stage was cut short by instrumentation in 16.6% of patients.
Maternal Complications were seen in 38 patients(63.3%) with cardiac disease, out of which the most common non-cardiac maternal complication was anemia seen in 19 patients (50%), followed by pre-eclampsia in 9 patients (23.7%) and pre-term labour in 7 patients (18.4%). Studies by Mahesh et al and Nilajkumar et al have shown similar results. Majority of complications were of non-cardiac origin that worsened the underlying cardiac lesion during pregnancy affecting the outcome. Thus the early diagnosis and treatment of complications such as anemia and pre-eclampsia can improve the outcome. Studies done by various authors have shown similar results. 7,10,[13][14][15] The cardiac complications were noted in eight patients, out of which six developed CCF, one developed pulmonary edema and the other had atrial fibrillation. All eight patients were treated in Intensive Care Unit, out of which six patients recovered and two died. Of two deaths seen, one was a case of severe Mitral stenosis with severe anemia in CCF; the other death was a case of severe MS with severe pulmonary hypertensi on, pneumonia and IUD. Both deaths occurred in cases of severe mitral stenosis; both cases were unbooked and came in labour which could have prevented by early detection and timely surgical intervention. The above findings suggest lack of awareness among the community about the heart disease and complications during pregnancy. Similar findings were in studies done by Mahesh et al. 10 The small for gestation (28.3%) and prematurity (10%) were the common neonatal complications. Total 20 (33.33%) babies were admitted to NICU. The perinatal mortality was 6.6% in our study. The results were comparable to the studies done by Mahesh et al, Hanania et al and Suri et al. 10,16,17

Conclusion
Heart disease in pregnancy is a high risk condition which has a major impact on pregnancy and its outcome. Rheumatic heart disease is the predominant cardiac problem affecting the pregnancy and its outcome. The early detection and treatment, proper follow up and correction prior to pregnancy shall improve the outcome and decrease the maternal morbidity and mortality in heart disease.
Maternal and perinatal morbidity and mortality can be reduced with early and frequent antenatal care in co-ordination with the cardiologist. The early detection and management of non-cardiac complications shall have a major impact on improvement of outcome Educating the community about the cardiac disease and its complications, need for early detection of cardiac lesion, close follow up during antenatal period, intrapartum and postpartum care plays a vital role in a rural set up.