Cardiac Disease In Pregnancy

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

of pregnancies.

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

inaugurated early.

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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