Pregnancy complicated by heart disease (including pre-existing heart disease prior to pregnancy and newly diagnosed heart disease during pregnancy) ranks as the second leading cause of maternal mortality in China. It is the most common indirect cause of maternal death, with an incidence rate of 0.5%–3.0%.
Cardiovascular Changes during Pregnancy and Delivery
Pregnancy
The maternal circulatory system undergoes a series of adaptive changes during pregnancy. Total blood volume and cardiac output gradually increase, peaking at 32–34 weeks of gestation and persisting until delivery. Heart rate also progressively increases, with an average rise of 10–15 beats per minute by late pregnancy. These changes in blood volume and hemodynamics elevate the risk of heart failure in pregnant individuals with pre-existing heart disease.
Delivery
Delivery represents the period of greatest cardiovascular strain. During each uterine contraction, 250–500 mL of blood is transferred into the systemic circulation, leading to increases in blood volume, cardiac output, blood pressure, pulse pressure, and central venous pressure. During the second stage of labor, congenital heart disease patients may experience cyanosis as pulmonary circulation pressure rises, causing a left-to-right shunt to reverse into a right-to-left shunt. Following delivery of the fetus and placenta, the sudden uterine contraction, cessation of placental circulation, and increased venous return can result in abrupt hemodynamic fluctuations. Additionally, the rapid reduction in intra-abdominal pressure directs a significant volume of blood to the visceral organs. These changes place pregnant individuals with heart disease at high risk of heart failure during this phase.
Postpartum Period
The cardiovascular changes occurring during pregnancy do not immediately return to pre-pregnancy status during the postpartum period. Fluids retained in the interstitial tissues during pregnancy begin returning to the systemic circulation, and uterine contractions further return blood to the systemic circulation. These changes are particularly pronounced within the first 3 postpartum days, a period of significant cardiovascular burden. Heart failure may develop, requiring heightened vigilance in postpartum individuals with heart disease.
In summary, the periods beyond 32 weeks of pregnancy, during delivery, and within 3 days postpartum represent the peak times of cardiovascular burden for pregnant individuals with heart disease. These phases are particularly high-risk for heart failure.
Types of Heart Disease Complicating Pregnancy and Their Impact on Pregnancy
Heart disease complicating pregnancy can be categorized into three groups: structural heart disease, functional heart disease, and pregnancy-specific heart disease. Among these, structural heart disease is the most common, with congenital heart disease accounting for 35%–50% of cases. Over time, with improvements in living standards and healthcare systems, the incidence of rheumatic valvular heart disease, which was once common, has been declining. Pregnancy-specific heart diseases, such as hypertensive heart disease during pregnancy and peripartum cardiomyopathy, constitute a smaller but notable proportion.
Structural Heart Disease
Common examples of structural heart diseases complicating pregnancy include congenital heart disease, valvular heart disease, and myocarditis.
Congenital Heart Disease
Congenital heart disease refers to structural abnormalities in the heart and great vessels present at birth. It is classified into three categories: left-to-right shunt, right-to-left shunt, and non-shunting types.
Left-to-Right Shunt Congenital Heart Disease
Atrial Septal Defect (ASD)
This is the most common congenital heart disease, accounting for approximately 20% of all cases. Its impact on pregnancy depends on the size of the defect. Defects smaller than 1 cm2 are usually asymptomatic and are often discovered during routine physical examinations. These cases generally tolerate pregnancy and delivery well. However, larger defects can lead to pulmonary hypertension, reversing the left-to-right shunt into a right-to-left shunt during pregnancy or delivery, leading to cyanosis and increased risk of heart failure. For defects larger than 2 cm2, surgical correction is recommended prior to pregnancy.
Ventricular Septal Defect (VSD)
Membranous defects are the most common type. VSD results in left-to-right shunting at the ventricular level. When the defect size is smaller than 1.25 cm2, shunting volume is low, and in the absence of prior heart failure or other complications, pulmonary hypertension and heart failure are less likely, allowing for a successful pregnancy and delivery. However, larger defects that have not been surgically repaired increase the risks of pulmonary hypertension, heart failure, and bacterial endocarditis, with a high mortality rate. In such cases, pregnancy is contraindicated, and termination is advised if an unplanned pregnancy occurs during the early stages.
Patent Ductus Arteriosus (PDA)
This condition is a relatively common congenital heart disease that can often be surgically corrected during childhood. Consequently, PDA complicating pregnancy is less frequently observed. Similar to other shunt conditions, pregnancy outcomes depend on the size of the defect. In cases with a small ductal diameter and normal pulmonary artery pressure, pregnancy is usually well-tolerated until term. Larger defects that have not been surgically corrected can lead to significant left-to-right shunting, pulmonary hypertension, cyanosis, and heart failure. For patients with pulmonary hypertension or right-to-left shunting detected during early pregnancy, termination of pregnancy is recommended.
Right-to-Left Shunt Congenital Heart Disease
The most common conditions in this category are tetralogy of Fallot and Eisenmenger syndrome.
Tetralogy of Fallot
Tetralogy of Fallot is a complex congenital cardiovascular malformation that includes pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. It is the most common cyanotic congenital heart disease. Individuals who do not undergo surgical correction rarely survive to childbearing age. Those who do survive have poor tolerance to the increased blood volume and hemodynamic changes during pregnancy, with a spontaneous abortion rate as high as 24% and increased maternal mortality. For this reason, pregnancy is not recommended for these patients. If pregnancy occurs, early termination is advisable. Patients who have undergone surgical correction and have cardiac function classified as grade I–II may continue pregnancy under close monitoring.
Eisenmenger Syndrome
Eisenmenger syndrome, also known as pulmonary hypertension with right-to-left shunting, is a complication of certain congenital heart defects. Conditions like ventricular septal defect, atrial septal defect, or patent ductus arteriosus may persist, resulting in progressive pulmonary hypertension. Sustained elevation of pulmonary artery pressure increases right-sided heart pressure, eventually exceeding left-sided heart pressure. This reverses the left-to-right shunt into a right-to-left shunt, leading to cyanosis. Maternal mortality is significantly increased in such cases.
Non-Shunting Congenital Heart Disease
Pulmonary Stenosis
The prognosis of isolated pulmonary valve stenosis is generally favorable, and many individuals can survive to childbearing age. Patients with mild stenosis often tolerate pregnancy and delivery well. In cases of severe stenosis, the increased blood volume and cardiac output during pregnancy and delivery place additional strain on the right ventricle, increasing the risk of right-sided heart failure. Severe pulmonary stenosis may require surgical correction before a pregnancy is planned.
Coarctation of the Aorta
Pregnancy complicated by coarctation of the aorta is relatively rare. This condition is often accompanied by other cardiovascular anomalies and carries a poor prognosis. Cardiac complications occur in approximately 20% of cases, with a mortality rate of 3.5%–9%.
Marfan Syndrome (MFS)
Marfan syndrome is a hereditary connective tissue defect that leads to cystic degeneration of the aortic media. Its prevalence ranges from 0.065‰ to 0.2‰. During pregnancy, the risk of aortic dissection in patients with Marfan syndrome is 1%–3%, with a mortality rate of up to 50%. Patients with an aortic root diameter exceeding 45 mm or a history of aortic dissection are not advised to conceive. Those who are already pregnant should have blood pressure strictly controlled and undergo regular echocardiographic monitoring throughout the pregnancy and for six months postpartum. Multidisciplinary management across specialties is essential for these patients.
Rheumatic Heart Disease
Mitral Stenosis
Mitral stenosis is the most common type of rheumatic heart disease and accounts for two-thirds to three-fourths of cases. Patients with mild mitral stenosis (valve area of 1.5–2.0 cm2) and no significant hemodynamic changes can tolerate pregnancy. For moderate to severe mitral stenosis cases, the risks of pulmonary edema and heart failure increase during pregnancy, delivery, and the postpartum period. Maternal and fetal mortality are also elevated. Patients with severe mitral stenosis, particularly those with pulmonary hypertension, should undergo corrective surgery before pregnancy. If pregnancy occurs, early termination may be preferable.
Mitral Insufficiency
During pregnancy, peripheral vascular resistance decreases, which reduces the degree of mitral regurgitation; therefore, those with isolated mitral insufficiency generally tolerate pregnancy well. However, approximately half of patients with rheumatic mitral insufficiency also present with mitral stenosis.
Aortic Stenosis and Insufficiency
Aortic stenosis increases the resistance to left ventricular ejection. Severe cases should undergo surgical correction prior to considering pregnancy. For those with aortic insufficiency, peripheral vascular resistance decreases during pregnancy, lessening the severity of aortic regurgitation, thus allowing most patients to tolerate pregnancy.
Myocarditis
Myocarditis refers to localized or diffuse inflammatory changes in the myocardium and may occur at any stage of pregnancy. The most common cause is viral infection (e.g., Coxsackievirus group B/A, echovirus, influenza virus, and herpes virus). Other causes include bacterial, fungal, protozoal infections, or adverse reactions to drugs or toxins. Clinical manifestations depend on the extent and location of myocardial involvement. Mild cases may be asymptomatic, while severe cases can result in cardiogenic shock or sudden death. Patients with well-controlled acute myocarditis may proceed with pregnancy under close monitoring. However, those with significant myocardial dysfunction face a markedly increased risk of heart failure during pregnancy.
Functional Heart Disease
Functional heart disease is characterized by abnormalities in cardiac rhythm and conduction without structural abnormalities. This category primarily includes various arrhythmias. Arrhythmias are classified based on heart rate into tachyarrhythmias and bradyarrhythmias. Tachyarrhythmias include supraventricular and ventricular arrhythmias, while bradyarrhythmias primarily include sinus bradycardia, sick sinus syndrome, and atrioventricular block. The ability to tolerate pregnancy and the appropriate timing and method of termination depend on the type and severity of arrhythmia as well as its impact on cardiac function.
Pregnancy-Specific Heart Disease
Hypertensive Heart Disease Associated with Pregnancy
Hypertensive heart disease during pregnancy refers to acute heart failure, primarily presenting as left heart failure, that occurs in pregnant women with hypertensive disorders of pregnancy but no prior history of heart disease. This condition is induced by factors such as coronary artery spasm, myocardial ischemia, increased peripheral arterial resistance, water and sodium retention, and elevated blood viscosity, which increase the cardiac burden and trigger acute heart failure. When diagnosed and treated in a timely manner, patients often manage to overcome pregnancy and delivery, with the condition gradually resolving postpartum as the underlying causes are eliminated. In most cases, this condition does not leave residual organic heart damage.
Peripartum Cardiomyopathy (PPCM)
Peripartum cardiomyopathy is a type of dilated cardiomyopathy that occurs in pregnant women without pre-existing cardiovascular disease, from late pregnancy to six months postpartum. It is characterized by myocardial systolic dysfunction and congestive heart failure. The exact etiology is unknown but may be associated with factors such as viral infections, immune responses, hypertension, obesity, nutritional deficiencies, and genetics. The condition manifests in 30% of cases during late pregnancy, while the majority (about 60%) occur during the postpartum or puerperium period, especially within the first three months postpartum. Approximately 10% of cases occur after three months postpartum.
Clinical symptoms primarily include dyspnea, palpitations, cough, hemoptysis, orthopnea, chest pain, hepatomegaly, and edema, which are typical signs of heart failure. Some patients may also experience ventricular arrhythmias and/or cardiac arrest. The incidence of peripheral arterial and venous thromboembolism is about 7% before and after the diagnosis of PPCM. Nearly all patients exhibit electrocardiographic abnormalities, such as left ventricular hypertrophy, ST segment and T wave abnormalities, and various arrhythmias. Chest X-ray findings include generalized cardiac enlargement and pulmonary congestion. Echocardiography shows a left ventricular ejection fraction (LVEF) below 45% with or without ventricular cavity dilation, primarily involving enlargement of the left ventricle and left atrium, along with diffuse hypokinesis of the ventricular wall.
Some patients may die due to heart failure, pulmonary embolism, or arrhythmias. Prognosis depends on the severity of left ventricular dysfunction, with 50%–80% of PPCM patients achieving normalized left ventricular systolic function following treatment. Given the risk of recurrence in subsequent pregnancies, patients with previous PPCM, heart failure, and persistent cardiac enlargement are advised against future pregnancies.
Impact of Pregnancy-Associated Heart Disease on the Fetus
Pregnant individuals with contraindicated heart conditions, or deterioration of cardiac function during pregnancy, have significantly increased risks of miscarriage, preterm birth, stillbirth, fetal growth restriction, fetal distress, and neonatal asphyxia. Perinatal mortality is 2–3 times higher than in normal pregnancies. Most congenital heart diseases have multifactorial genetic origins. Offspring of either parent with congenital heart disease face a higher risk of congenital heart abnormalities or other malformations, such as ventricular septal defect, hypertrophic cardiomyopathy, and Marfan syndrome, which have relatively high heritability.
Diagnosis
Due to the physiological changes of normal pregnancy, non-cardiac pregnant individuals may display symptoms and signs that resemble heart disease, including palpitations, shortness of breath, ankle edema, fatigue, and tachycardia. Cardiac examinations may reveal mild enlargement or heart murmurs. Pregnant individuals with pre-existing heart disease may also experience changes in their clinical presentation, complicating the diagnostic process. Several key factors are considered in the diagnostic approach.
Medical History
For individuals with a confirmed diagnosis of heart disease prior to pregnancy, the cardiac condition should remain the working diagnosis during pregnancy, with additional attention to functional classification and any complications. For those without a prior history of heart disease, a thorough inquiry into symptoms such as palpitations and shortness of breath should be conducted. A family history of cardiac conditions or sudden death also warrants consideration.
Symptoms and Physical Signs
Symptoms
Common manifestations include palpitations, chest tightness, dyspnea, chest pain, exertional dyspnea, paroxysmal nocturnal dyspnea, and hemoptysis.
Physical Signs
Notable findings include cyanosis, clubbing of the fingers, and persistent jugular vein distension. Auscultation may reveal diastolic murmurs graded at 2/6 or higher or coarse systolic murmurs graded at 3/6 or higher, as well as signs such as pericardial friction rub, a diastolic gallop rhythm, or pulsus alternans.
Auxiliary Examinations
Electrocardiography (ECG) often indicates various arrhythmias, such as ST segment and T wave abnormalities, atrial fibrillation, atrial flutter, or atrioventricular block. Chest X-ray findings may show significant cardiac enlargement, especially of specific chambers. Echocardiographic studies frequently demonstrate myocardial hypertrophy, abnormal valve motion, or structural abnormalities within the heart. Levels of biochemical markers, such as troponin and brain natriuretic peptide (BNP), can assist in diagnosing heart failure.
Classification of Cardiac Function
The New York Heart Association (NYHA) classifies cardiac function into four grades based on the degree of limitation in daily physical activity:
- Grade I: No limitation of ordinary physical activity.
- Grade II: Mild limitation of ordinary physical activity; patients experience no discomfort at rest but report fatigue, palpitations, or mild shortness of breath after routine activities.
- Grade III: Significant limitation of ordinary physical activity; patients remain symptom-free at rest but develop fatigue, palpitations, and breathing difficulties with minimal activity.
- Grade IV: Severe limitation of physical activity; patients experience palpitations and shortness of breath both at rest and during any form of physical exertion.
Common Complications
Heart Failure
Heart failure is a serious complication frequently associated with pregnancy in individuals with heart disease. It is one of the leading causes of maternal mortality. Due to significant changes in blood volume and hemodynamics during pregnancy and delivery, heart failure most commonly occurs after 32 weeks of gestation, during delivery, or in the early postpartum period. Clinically, left-sided heart failure predominates and often manifests as acute pulmonary edema, typically arising suddenly. Severe cases may progress to hypotension, weakened pulse, altered consciousness, coma, shock, or asphyxia, which can result in death. Early clinical signs of heart failure merit attention and include:
- Chest tightness, palpitations, and shortness of breath following mild activity;
- Resting heart rate exceeding 110 beats per minute and respiratory rate above 20 breaths per minute;
- Episodes of sitting upright at night due to chest tightness, or seeking fresh air near windows;
- Persistent moist rales at the lung bases that do not resolve after coughing.
Infective Endocarditis
Infective endocarditis is characterized by inflammation of cardiac valves or the endocardium caused by direct infection from bacteria, fungi, or other microorganisms such as viruses, rickettsia, chlamydia, and spirochetes. It often presents with symptoms such as fever, cardiac murmurs, and signs of embolism. If not promptly managed, it can lead to heart failure.
Pulmonary Hypertension
Pulmonary hypertension is a common complication of heart disease. It is diagnosed when echocardiographic findings estimate pulmonary arterial systolic pressure at 40 mmHg or higher. Pregnancy may trigger the onset of pulmonary hypertension or exacerbate pre-existing pulmonary hypertension, with potential symptoms including fatigue, dyspnea, chest tightness, cyanosis, chest pain, and syncope. In cases of right heart dysfunction, symptoms such as nausea, vomiting, lower limb edema, or generalized edema may occur. Severe cases may progress to pulmonary hypertension crises.
Venous Thromboembolism and Pulmonary Embolism
During pregnancy, the blood is in a hypercoagulable state. Patients with heart disease, particularly those with elevated venous pressures and stasis, face an increased risk of deep vein thrombosis. If a thrombus dislodges, pulmonary embolism may occur, which can result in maternal mortality.
Malignant Arrhythmias
Malignant arrhythmias often develop in individuals with pre-existing heart disease, leading to hemodynamic instability, hypotension, or even shock. Insufficient blood supply to vital organs such as the heart, brain, and kidneys may occur. Severe cases can lead to maternal sudden death or cardiogenic shock.
Management
Heart failure remains one of the leading causes of maternal mortality in individuals with heart conditions. Pre-pregnancy counseling and evaluation, combined with standardized prenatal care and interventions, can reduce the risk of heart failure and aid in early detection.
Pre-Pregnancy Counseling and Evaluation
The course of heart disease can be altered by pregnancy. Comprehensive consultation and evaluation by both cardiologists and obstetricians are necessary prior to conception. Assessments should consider the type and severity of heart disease, the need for surgical correction, and NYHA classification of cardiac function to determine the heart’s ability to withstand pregnancy. Those for whom pregnancy is not advisable should receive contraceptive counseling. For patients who are deemed suitable for pregnancy, individualized preconception management plans should be developed. Patients undergoing pharmacological treatment may require adjustments based on disease condition and pregnancy needs.
Suitability for Pregnancy
Patients with mild cardiac disease, NYHA grades I–II cardiac function, no prior history of heart failure, and no other complications are considered to have a low risk for pregnancy and may proceed with pregnancy. However, they should be informed about the potential for exacerbation of heart disease or the development of severe complications during pregnancy and delivery, which may pose life-threatening risks. Starting from the preconception stage, standardized management practices and dynamic risk assessments throughout pregnancy are recommended.
Pregnancy Not Recommended
Patients with complex or severe cardiac disease, NYHA grades III–IV cardiac function, or those at exceptionally high risk of maternal mortality or serious maternal-fetal complications are advised against pregnancy. Individuals with a prolonged history of heart disease and an increased likelihood of heart failure are similarly discouraged from conceiving. Patients with heart disease requiring surgical correction should undergo surgery prior to attempting pregnancy, followed by joint assessments by cardiologists and obstetricians regarding the risks of pregnancy. Decisions to conceive should be made only after patients have been fully informed about their condition and pregnancy risks.
Pregnancy Period
Determination of Whether to Continue Pregnancy
For individuals with heart disease for whom pregnancy is contraindicated, termination of pregnancy is recommended during the early gestational period. If surgical termination is performed, perioperative analgesia and prophylactic antibiotics are used to prevent infections. For those undergoing their first prenatal examination during the second trimester, the timing and method of pregnancy termination depend on the healthcare conditions, severity of the disease, type of heart condition, and associated cardiac complications.
Enhanced Prenatal Care
Frequency of Prenatal Examinations
Prenatal check-ups begin in early pregnancy, accompanied by counseling on pregnancy risks and potential severe complications. Prenatal care is provided according to the risk classification across different levels of healthcare facilities. Each prenatal visit involves ongoing pregnancy risk assessments. With escalating pregnancy risk levels, the frequency of check-ups increases correspondingly. After 32 weeks of gestation, the risk of heart failure rises, warranting an increase in the frequency of prenatal visits based on individual circumstances.
Components of Prenatal Examinations
During the first prenatal visit, a comprehensive medical history should be obtained, and detailed cardiovascular and respiratory assessments are conducted. Subsequently, routine obstetric evaluations are supplemented by assessments of subjective symptoms and tests to evaluate cardiac function. Obstetricians and cardiologists collaboratively assess the severity of heart disease and cardiac function throughout prenatal care. Changes in the disease are identified promptly, and timely referrals are made when necessary. Signs of early heart failure indicate the need for immediate hospitalization. Even if pregnancy proceeds uneventfully, hospitalization between weeks 36 and 38 is necessary to prepare for delivery.
Fetal Monitoring
The risk of congenital heart disease in offspring of congenital heart disease patients is 5%–8%. Prenatal screening for fetal cardiac structures is necessary, with genetic counseling and prognosis evaluations performed if abnormalities are detected. Fetal complications are closely related to the type of maternal heart disease, the severity of hypoxia, maternal cardiac function, pregnancy-related medication use, and the presence of severe complications. These factors may lead to miscarriage, preterm birth, fetal growth restriction, low birth weight, fetal intracranial hemorrhage, neonatal asphyxia, or neonatal death. Enhanced fetal monitoring begins after 28 weeks of gestation.
Prevention and Management of Heart Failure
Adequate Rest
Excessive physical exertion and emotional agitation are avoided.
Balanced Diet and Controlled Weight Gain
A reasonable diet is essential, with appropriate limitations on salt intake and a focus on micronutrient supplementation to prevent and treat iron-deficiency anemia.
Prevention and Treatment of Heart Failure Triggers
Preventative measures include reducing the risk of upper respiratory tract infections and correcting anemia. Frequent premature ventricular contractions or rapid ventricular arrhythmias can be managed with medication. Blood pressure, urinary protein, and other indicators are monitored dynamically to prevent hypertensive disorders of pregnancy and other accompanying or secondary complications.
Dynamic Monitoring of Cardiac Function
Regular echocardiographic examinations evaluate ejection fraction, cardiac output, cardiac index, and wall motion status to assess cardiac function changes as pregnancy progresses.
Treatment of Heart Failure
Acute heart failure is managed through multidisciplinary collaboration. The timing and method for pregnancy termination depend on the severity of the condition, the disease progression, gestational age, and maternal and fetal status. Management of acute left-sided heart failure follows the same principles as outside of pregnancy; however, the pharmacokinetics in pregnancy differ. Pregnancy-related hemodilution, increased blood volume, and enhanced glomerular filtration result in relatively lower plasma concentrations of the same dosage of medication. Additionally, pregnant individuals exhibit reduced tolerance to cardiac glycosides, necessitating caution regarding toxic reactions. For cases of heart failure occurring in late pregnancy, obstetric management is typically deferred until after heart failure is under control. In cases of severe heart failure that do not respond to standard treatment, continued progression may result in worsening outcomes for both mother and fetus. Emergency cesarean delivery may be performed alongside heart failure management to alleviate the cardiac burden and preserve the lives of both mother and child.
Time to Pregnancy Termination
Individuals with low-risk heart disease and NYHA grade I cardiac function may carry pregnancies to term. This includes conditions such as atrial septal defect, ventricular septal defect, or patent ductus arteriosus without associated pulmonary hypertension, and isolated, sporadic supraventricular or ventricular premature contractions without structural cardiac abnormalities. However, early termination of pregnancy may be required if severe cardiac complications arise or cardiac function declines.
Those with higher-risk heart disease but NYHA grade I cardiac function may continue pregnancy up to 32–36 weeks before termination. Close monitoring during pregnancy is required, with early termination considered if necessary.
Individuals with severe heart disease that poses a contraindication to pregnancy require immediate termination once the diagnosis is confirmed.
Delivery Period
During late pregnancy, an appropriate delivery method is selected in advance.
Vaginal Delivery
Vaginal delivery is generally well-tolerated by individuals with low-risk cardiac disease and NYHA grade I cardiac function. For those with a small fetus, normal fetal position, and favorable cervical conditions, vaginal delivery under close monitoring may be considered. Monitoring during labor involves electrocardiography and continuous observation of self-reported symptoms, as well as cardiovascular and pulmonary status, with measures taken to avoid prolonged labor. The use of labor analgesia is encouraged to reduce the impact of pain on hemodynamics.
First Stage of Labor
Efforts focus on providing comfort and encouragement to the patient in order to alleviate anxiety. Blood pressure, pulse, respiratory rate, and heart rate are closely monitored. If signs of heart failure arise, a semi-recumbent position and high-flow oxygen therapy via mask are utilized. Administration of deslanoside (0.2–0.4 mg diluted in 5% glucose injection) is given slowly via intravenous injection, with dosing repeated every 4–6 hours if necessary. Antibiotics are initiated at the onset of labor to prevent infections.
Second Stage of Labor
Strenuous breath-holding is avoided during this stage. Active assistance in delivery is emphasized to minimize the duration of the second stage.
Third Stage of Labor
Following delivery of the fetus, moderate abdominal compression is employed to prevent abrupt decreases in intra-abdominal pressure that may induce heart failure. Postpartum hemorrhage exacerbates myocardial ischemia and heart failure, warranting preventive measures. Uterotonic agents like oxytocin are administered, while methylergometrine is contraindicated. In cases of severe postpartum hemorrhage, blood transfusions or fluid replacement are implemented, ensuring that infusion rates are controlled to avoid excessive fluid administration.
Cesarean Delivery
Cesarean delivery is indicated for individuals with obstetric indications or those with NYHA grade III–IV cardiac function. Scheduled cesarean delivery is also recommended for individuals with high-risk cardiac disease and NYHA grade II cardiac function. Broader indications for cesarean delivery are advocated for patients with heart disease to reduce the risk of hemodynamic disturbances caused by prolonged uterine contractions. Proper anesthetic techniques are considered for patients undergoing cesarean delivery. Prophylactic antibiotics are administered 1–2 days prior to surgery for those with structural cardiac abnormalities. During surgery, abdominal compression following fetal delivery and the use of oxytocin are strategies to prevent postpartum hemorrhage. For individuals for whom future pregnancy is not advisable, tubal ligation is considered during the procedure.
Postpartum Period
The first three days postpartum, particularly within the first 24 hours, represent a critical period with a heightened risk of heart failure. Sufficient rest and close monitoring are essential during this time.
Fluid intake and intravenous infusion rates are controlled daily, and antibiotics are continued for 5–10 days to prevent infections. Effective postoperative pain management is provided to reduce stress responses caused by pain. Postpartum hemorrhage, infections, and venous thromboembolism are serious complications that can easily trigger heart failure and require focused preventive measures.
Individuals with low-risk heart disease and NYHA grade I cardiac function may breastfeed. However, artificial feeding is recommended for those with severe cardiac disease. Warfarin is known to pass into breast milk, and individuals on long-term warfarin therapy are advised to use artificial feeding. For vaginal delivery patients for whom future pregnancy is contraindicated, contraceptive counseling and education are provided.