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Metcalfe's Criteria for Heart Disease in Pregnancy

(Finding Suggestive of Heart Disease in Pregnancy)


  1. Progressive dyspnea or orthopnea
  2. Nocturnal cough
  3. Hemoptysis
  4. Syncope
  5. Chest pain

Clinical Findings

  1. Cyanosis
  2. Clubbing of fingers
  3. Persistent neck vein distention
  4. Systolic murmur grade 3/6 or greater
  5. Diastolic murmur
  6. Cardiomegaly
  7. Persistent split-second sound
  8. Criteria for pulmonary hypertension
  9. Persistent arrhythmias

Atrial and ventricular premature contractions 15° Left Axis Deviation and mild ST changes in inferior leads are considered normal during pregnancy.

Predictors of cardiac complications during pregnancy include the following

  1. Prior heart failure, transient ischemic attack, arrhythmia, or stroke.
  2. Baseline NYHA class III or greater, or cyanosis.
  3. Left-sided heart obstruction defined as mitral valve area below 2 cm2, aortic valve area below 1.5 cm2, or peak left ventricular outflow tract gradient above 30 mmHg by echocardiography.
  4. Ejection fraction less than 40%.

Intrapartum Management of Cardiac Patient

General measures for the cardiac patient in labor:

  1. Labor and delivery in lateral decubitus position/propped up position
  2. Adequate pain relief (epidural analgesia). Pain can cause tachycardia, which in turn can precipitate failure
  3. Restrict IV fluids to 75 mL/h (except in aortic stenosis)
  4. Oxygen by breathing mask
  5. Antibiotics (infective endocarditis prophylaxis = ampicillin and gentamycin)
  6. Cut short II stage of labor (forceps or vacuum)
  7. Prevention of postpartum pulmonary edema by giving IV frusemide after placental delivery
  8. Methergine is absolutely contraindicated
  9. In heart disease patients, LSCS should be done for obstetric indications only
  10. Heart disease in which elective LSCS should be done is Marfan syndrome with aortic root dilatation >4 cm (absolute indication)
  11. Coarctation of aorta is a relative indication for LSCS.
    1. Maximum risk of heart disease patient going in failure is postpartum, followed by intrapartum followed by 32 weeks of gestation.
    2. Mitral stenosis is the MC valvular heart disease in pregnancy
    3. Normal mitral valve area = 4-6 cm2

Mitral Valve Area (cm2)










  1. In cases of critical severe mitral stenosis balloon mitral valvuloplasty or closed mitral commissurotomy may have to be carried out during pregnancy, provided the valves are pliable and not calcified.
  2. If the valves are not pliable or are calcified then mitral valve replacement (MVR) will be required.
  3. MVR should ideally be done before the patient conceives. If MVR is done during pregnancy there is increased risk of maternal mortality (15-30%) and perinatal mortality (6-10%).
  4. Mechanical valves require lifelong anticoagulation.
  5. Bioprosthetic valves do not require anticoagulation.

Anticoagulant of choice





First trimester (till 12 weeks)


13--36 weeks


>36 weeks till delivery


Postpartum (breast feeding)


  1. Heparin is less effective than warfarin in preventing thromboembolic events. Unfortunately, spontaneous abortions, stillbirths, and malformed fetuses are more common if warfarin is used.
  2. Heparin substitution from 6 to 12 weeks eliminates risk of warfarin embryopathy.
  3. The ACOG advises against use of low-molecular-weight heparins in pregnant women with prosthetic heart valves. Unfractionated heparin should be used.
  4. For women with a mechanical heart valve, most clinicians recommend full anticoagulation throughout pregnancy. This may be accomplished with adjusted-dose heparin to prolong the partial thromboplastin time 1.5-2.5 times baseline values.
  5. Anticoagulant therapy with warfarin or heparin may be restarted following vaginal delivery. Following cesarean delivery, however, full anticoagulation should be withheld for at least 24 h.
  6. Heparin does not cross the placenta while warfarin crosses the placenta. With breast feeding warfarin is considered to be safe.

Recurrence Risk of Congenital Heart Disease


Congenital Heart Disease in Fetus (%)

Cardiac Lesion

Previous Sibling Affected

Father Affected

Mother Affected

Marfan syndrome




Aortic stenosis




Pulmonary stenosis




Ventricular septal defect




Atrial septal defect




Patent ductus arteriosus




Coarctation of the aorta




Tetralogy of Fallot




Pulmonary Hypertension

  1. High pulmonary blood pressure is generally secondary to cardiac or pulmonary disease, and common causes are persistent and prolonged left-to-right shunting with development of Eisenmenger syndrome.
  2. Primary pulmonary hypertension is a rare, usually idiopathic, condition that occurs in the absence of an intracardiac or aortopulmonary shunt. Suspected risk factors include certain appetite suppressants human immunodeficiency virus and human herpes virus 8 infections, and sickle cell disease.
  3. Some previously unexplained cases are now thought to be due to antiphospholipid antibodies.
  4. The criteria for diagnosis established by National Institutes of Health Registry included a mean pulmonary artery pressure of more than 25 mmHg at rest, or 30 mmHg with exertion, in the absence of heart disease, chronic thromboembolic disease, underlying pulmonary disorder, or other secondary causes.
  5. The prognosis is poor, and the mean survival from diagnosis is about 2 years. Long-term therapy with intravenous epoprostenol (prostacyclin) or with subcutaneous treprostinil a prostacyclin analog, significantly lowers pulmonary vasculare.

UTI In Pregnancy

  1. The most common infecting organism is Escherichia coli (90%).
  2. Asymptomatic bacteriuria: This refers to persistent, actively multiplying bacteria within the urinary tract in women who have no symptoms.
  3. A clean-voided specimen containing more than 100,000 organisms per milliliter is diagnostic. It may be prudent to treat when lower concentrations are identified, because pyelonephritis develops in some women with colony counts of 20,000-50,000 organisms/mL.
  4. A single episode of asymptomatic bacteriuria can cause acute pyelonephritis in 25-40% cases.
  5. Acute pyelonephritis can cause:
    1. IUGR
    2. Preterm labor
    3. Anemia
    4. Increased risk of PIH
  6. Cranberry fruit juice is known to prevent recurrences of UTI. It prevents the adhesions of the pilins of E. coli to uroepithelium.
  7. Nitrofurantoin is the drug of choice for prophylaxis of recurrent UTI in pregnancy.

Liver Disorders

Intrahepatic Cholestasis of Pregnancy (IHCP) = Icterus Gravidarum = Obstetric Cholestasis = Cholestatic Jaundice of Pregnancy = Obstetric Hepatosis

  1. 10-100-fold increase in bile acids (cholic/deoxycholic acids).
  2. Pruritus is the most common presenting feature.
  3. Onset is generally after 30 weeks of pregnancy.
  4. Serum bilirubin rarely exceeds 5 mg/ dL.
  5. Serum transaminases are normal to moderately elevated (seldom exceeds 250 U /L).
  6. Biopsy-centrilobular bile staining with bile plugs in canaliculi.
  7. Complications: preterm labor, PPH, IUFD, and MSAF (meconium stained amniotic fluid).
  8. Recurrences in future pregnancies is very common.


  1. Antihistamines and emollients
  2. Cholestyramine
  3. Vitamin K
  4. Ursodeoxycholic acid is the drug of choice

Acute Fatty Liver of Pregnancy = Acute Metamorphosis = Acute Yellow Atrophy

  1. Abnormal fatty acid oxidation
  2. LCHAD deficiency (long-chain hydroxyl acyl coenzyme A dehydrogenase)
  3. Microvascular steatosis with periportal sparing
  4. Greasy soft yellow liver
  5. Hyperbilirubinemia is less than 10 mg/ dL
  6. Complications-hypoglycemia, hepatic encephalopathy, coagulopathy, renal failure, mortality (10-75%), and increased risk of PIH
  7. Decrease in fibrinogen and increase in ammonia and SGOT
  8. Treatment-fresh frozen plasma, cryoprecipitate, platelets, and blood. Treat hepatic encephalopathy, deliver the patient
  9. Transient diabetes insipidus occurs during the period of recovery (due to elevated vasopressinase concentration).

Viral Hepatitis

  1. Maximum risk of maternal mortality is with hepatitis E.
  2. Maximum risk of hepatic encephalopathy is with hepatitis E.
  3. Maximum risk of perinatal transmission is with hepatitis B.
  4. Active and passive immunization, both are required for the newborn if the mother is HBsAg positive.

Thyroid Disorders

  1. Moderate thyroid enlargement occurs in pregnancy due to glandular hyperplasia, and thyroid volume determined ultrasonographically increases, although its echostructure and echogenicity remain unchanged.
  2. Thyrotropin, or thyroid-stimulating hormone (TSH), currently plays a central role in screening and diagnosis of many thyroid disorders. In early pregnancy, thyrotropin activity decreases because of thyroid stimulation from the weak crossover activity of chorionic gonadotropin. The hormone does not cross the placenta. In the first 12 weeks, when chorionic gonadotropin levels are maximal, free thyroxine levels increase, and this suppresses thyrotropin levels.
  3. Thyroid-stimulating autoantibodies, also called thyroid-stimulating immunoglobulins, attach to the thyrotropin receptor and activate it, causing thyroid hyperfunction and growth. These antibodies are identified in the majority of patients with classic Graves' disease.
  4. Thyroid peroxidase antibodies, previously called thyroid microsomal autoantibodies, have been identified in 10-20% of pregnant women. Up to half develop autoimmune thyroiditis that may be transient, but thyroid failure occurs in a significant number of women. These antibodies are also associated with miscarriage and Down syndrome.
  5. Graves' disease is the MC cause of hyperthyroidism in pregnancy.
  6. Hashimoto's thyroiditis is the MC cause of hypothyroidism in pregnancy.

Complications associated with both hypo- and hyperthyroidism in pregnancy:

  1. Recurrent first trimester abortions
  2. IUGR
  3. Increased risk of preeclampsia
  4. Abruption
  5. Stillbirths, hydrop fetalis
  6. Preterm labor

Extra Edge

  1. Hypothyroidism is also associated with cretinism.
  2. Propylthiouracil is the DOC for hyperthyroidism in pregnancy.
  3. Methimazole and carbimazole used in early pregnancy have been associated with esophageal and choanal atresia, aplasia cutis, and fetal agranulocytosis.
  4. Labor and LSCS can precipitate thyroid storm.
  5. Cord blood should be collected at the time of delivery for estimation of TSH, T3, T4 to detect neonatal thyroid disorders.

NOTE: Fetal thyroid gland is able to synthesize hormones by 10-12 weeks of gestation.


Clinical Phases of Postpartum Thyroiditis


Postpartum Thyroiditis





1-4 months postpartum

4-8 months postpartum





Destruction-induced hormone release

Thyroid insufficiency


Small, painless goiter, fatigue, palpitations

Goiter, fatigue, inability to concentrate


(3-Blockers for symptoms

Thyroxine for 6-12 months


Two-thirds become euthyroid One-third develop

One-third permanent hypothyroidism




Epilepsy In Pregnancy

  1. Epilepsy is the most common neurological disorder encountered in pregnancy.
  2. The most common cause for epilepsy in pregnant women is idiopathic.
    D/D's of convulsions in pregnancy Eclampsia
    Cerebral vein thrombosis
    Cerebral infarction
  3. Hypoglycemia /hypona tremia /hypocalcem ia
  4. Risk of congenital anomalies is about 4% in epileptic patients and there is 4-5% risk of epilepsy in the child if parents are affected.
  5. All anticonvulsant drugs are associated with congenital anomalies (6%--one drug; 15%-two or more drugs).
  6. Phenobarbitone is considered the safest in pregnancy.
  7. All women on anticonvulsants should take folic acid: 4 mg/ day for 12 weeks preconception and throughout pregnancy.
  8. Prenatal screening: MSAFP + level II USG (watch for neural tube defects).
  9. Therapeutic drug monitoring.
  10. Vitamin K 10 mg/ day orally from 36 weeks onward to prevent hemorrhagic disease of newborn.
  11. Higher dose of estrogen required in OCPs if patient is on phenytoin, phenobarbitone and carbamazepine.

Thromboembolic Disorders


Deep Vein Thrombosis

  1. In 1856, Virchow postulated the conditions that predispose to the development of venous thrombosis: (1) stasis, (2) local trauma to the vessel wall, and (3) hypercoagulability. The risk for each increases during normal pregnancy.
  2. The incidence of deep vein thrombosis is 1/1000 pregnancies. Fifty percent occur in the antepartum period and 50% in the postpartum period.
  3. Several independent risk factors are associated with the development of thromboembolism during pregnancy:
    1. Severe preeclampsia
    2. Cesarean delivery
    3. Diabetes
    4. Multifetal gestation
    5. Age 35 years or more
    6. Obesity
    7. Smoking
    8. Dehydration
    9. Prolonged bed rest
    10. Prior thromboembolism

Treatment of Deep Vein Thrombosis

  1. IV unfractionated heparin for 5-7 days followed by subcutaneous heparin for the rest of pregnancy to maintain APTT 1.5-2.5 times control
  2. Warfarin for 6-18 weeks in the postpartum period.

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