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Cardiac Disease In Pregnancy
Source: Disturbances Of The Heart
It is so serious a thing for a woman with valvular lesion or other
cardiac defect to become pregnant that no young woman with heart
disease should be allowed to marry. Perhaps every normal heart
during pregnancy hypertrophies somewhat to do the extra work thrown
on it, but it may easily become weakened and show serious
disturbance as its work grows harder and the distention of the
abdomen and the upward pressure on the diaphragm increase. This
pressure perhaps generally displaces the apex of the heart to the
left and causes the heart to lie a little more horizontal. If the
patient is normal, there may be a gradually increasing blood
pressure all through the months of pregnancy, and if the kidneys are
at all disturbed this pressure is increased, and there is, of
course, much increased resistance to the circulation during labor.
The better the heart acts, the less likely are edemas of the legs
during pregnancy. It is thus readily seen that pregnancy is a
serious thing for a damaged heart. The reserve strength of the heart
muscle, as has been previously stated, is much less in valvular
compensation than that of the normal heart, and this reserve force
is easily overcome by the pregnancy, and loss of compensation occurs
with all of its usual symptoms.
The most serious lesion a woman may have, as far as pregnancy is
concerned, is mitral stenosis. An increased abdnominal pressure
interferes with her lung capacity, and her lungs are already
overcongested. The left ventricle may be small with mitral stenosis,
and therefore her general systemic circulation poor. For those two
reasons mitral stenosis should absolutely prohibit pregnancy. While
many women with well compensated valvular disease go through
pregnancy without serious trouble, still, as stated above, they
should be advised never to marry. If they do marry, or if the lesion
develops after marriage, warning should be given of the seriousness
If a woman becomes pregnant while there are symptoms or signs of
broken compensation, there can be no question, medically or morally,
of the advisability of evacuating the uterus. The same ruling is
true if during pregnancy the heart fails, compensation is broken,
and the usual symptoms of such heart weakness develop, provided a
period of rest in bed, with proper treatment, has shown that the
heart will not again compensate. Under such a condition delay should
not be too long, as the heart may become permanently disabled. If,
during pregnancy in a patient with a damaged heart, albuminuria
develops and the blood pressure is increased, showing kidney
insufficiency, there can be no question of delay, from every point
of view, and labor must be precipitated; the uterus must be emptied
to save the mother's life.
If a pregnant woman is known to have a degenerative condition of the
myocardium, or arteriosclerosis, the danger from the pregnancy is
serious, and the pregnancy should rarely be allowed to continue.
Even if no serious symptoms occur during the term of the pregnancy,
and the heart continues to compensate sufficiently for its defect,
labor should never be allowed to be prolonged. The tension thrown on
the heart during labor is always severe, and has not infrequently
caused acute heart failure by causing acute dilatation, and in these
damaged hearts tediousness and severe, intense exertion should not
be allowed. Proper anesthetics and proper instrumentation should be
Patients who have successfully passed through the danger of
pregnancy with cardiac lesions, possibly relieved by radical
treatments, should be warned against ever again becoming pregnant.
If this warning does not prevent future pregnancies, the family
physician and his consultant must decide just what it is proper to
do. It is to be understood that no uterus should ever be emptied
until one or more consultants have approved of such treatment.
Sometimes serious heart weakness develops during the later weeks of
pregnancy, requiring the patient to remain in bed and receive every
advantage which rest, proper care and well judged medicinal
treatment will give the circulation.
If the heart is weak and there have been signs of myocardial
weakness or loss of compensation, the sudden loss of abdominal
pressure after delivery may allow the blood vessels of the abdomen
to become so overfilled as to cause serious cerebral anemia and
cardiac paralysis. Therefore in such cases a tight bandage must
immediately be applied, and it has even been suggested that a
weight, as a bag of sand weighing several pounds, be placed
temporarily on the abdomen. The greatest possible care should be
given these women during and after labor.
Acute dilatation is not an infrequent cause of death during ordinary
labor, and is more apt to occur in these cardiac patients. If signs
of acute dilatation of the heart occur, with associated pulmonary
edema, venesection (especially if there has not been much uterine
hemorrhage), with the coincident intramuscular injection of one or
two syringefuls of aseptic ergot, will often be found to be life-
saving treatment. Septic infections after parturition are prone to
cause endocarditis and myocarditis, and a malignant endocarditis may
develop from uterine infection or uterine putridity.
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