A series of two hundred and twenty -five patients
with heart disease is reviewed, showing its incidence
in pregnancy to be 0.8 per cent, and its mortality
3.1 per cent.
With better obstetrics and fewer deaths from
sepsis, heart disease is occupying a relatively more
prominent position as a cause of maternal deaths,
being the fourth most common cause in this series,
and accounting for 11.6 per cent of all maternal
deaths.
Rheumatic fever was responsible for 93 per cent
of cases, and the mitral valve was the site of the
lesion in all but a few.
Observation of patients with heart disease at
weekly intervals is recommended, owing to the danger
of their condition deteriorating and in order
immediately to observe any adverse change: and it is
recommended that all patients should be admitted for
one week about the twenty- eighth week, for rest and
assessment, and again seven to ten days before full
term. Antenatal care is one of the major factors
in lowering the mortality rate, and each visit of the
patient should include careful medical examination,
especially of her lung bases for the early crepitations, close questioning as to her daily routine and an assurance that she keeps within the limits of her
cardiac reserve. It is possible that the more
frequent examination and earlier advice and treatment
of the Group II patients may be the key to the
avoidance of the occasional failure in this group.
Respiratory infections, however trivial, have
to be treated seriously, as they have a tendency to
resist ordinary treatment and may precipitate.heart
failure; anaemia, too, should be avoided, and, if
marked, a careful look-out kept for signs which might
suggest subacute endocarditis, and the patient should
be advised to report should she develop any new
symptom.
The functional heart grouping of the American
Heart Association gives a good indication of the
cardiac reserve, and offers a common nomenclature for
reporting results.
Some additional factors in assessment in individual cases, as suggested by Lamb (1934), may help
to lessen the dangers of cardiac decompensation and,
towards this end, the co- operation between the
cardiologist and the obstetrician is essential.
A history of previous failure is a bad prognosti
sign, and, although there is an apparent recovery,
such patients should be regarded as group IV cases.
It may, in fact, be advisable, as regards the
obstetric treatment, to place the patient in the least favourable group to which she may have reached, no
matter what the improvement obtained with treatment,
or what more favourable group she may later occupy
during pregnancy.
Spontaneous labour, aided, if necessary, by forceps,
would seem to be the best mode of delivery, and
is possible in the vast majority of cases; Caesarean
section being reserved for the presence of other
obstetrical complications, or, in some cases, where
surgical termination of the pregnancy is indicated.
It has been noted in this series, that patients
with heart disease do not stand up well to prolonged
labour or to accouchement force, and, if these are
anticipated, a Caesarean section may be less of a risk
to the patient. Observation of the pulse and respiration
rates during the first stage of labour, as
recommended by Mendelson and Pardee (1942), and
immediate digitalisation, if necessary, may serve to
prevent decompensation developing.
The anaesthetic which is best advised is morphia
for the first stage and pudendal block for the second
stage of labour, supplemented by a light gas and
oxygen and episiotomy when forceps are used.
There is a definite place for therapeutic abortion
in the group III and IV patients; and in others,
rho have given a history of previous heart failure,
it is assessed individually.
The selection of bad-risk cardiac patients
should be one at cardiac clinics, where they should
be advised against becoming pregnant: and this precaution
together with careful choosing of patients
who are to proceed with pregnancy and avoid decompensation,
with its attendant risks, can serve
greatly to lower the mortality rate. Gilchrist and
Murray Lyon (1933) say that one or two pregnancies do
not shorten the expectation of life in the cardiac:
and Jones (1944) advises against a third pregnancy.
These observations have shown, however, that, altho
pregnancy may not induce heart failure, it may leave
the heart severely crippled. It has been shown in
this series that patients who have changed to a less
favourable functional heart group during pregnancy
are more liable to show these adverse effects in
later years. No difference, however, in the age of
death has been shown in nulliparous and parous women.
Of congenital lesions, unless there is persistent
cyanosis, which would justify advising against
pregnancy, or securing an early termination, the
patient is treated as for other heart lesions: the
exception being in those lesions where excess
straining must be avoided and when, therefore, a
Caesarean section should be performed.
A guarded prognosis has to be given until the
end of the puerperium, since the majority of
fatalities occur then, and additional rest in
hospital should be advised for patients at this time.
Before the patient leaves hospital, to assume the
extensive burdens of the care of her child, a full
opportunity should be taken to discuss with her the
domestic responsibilities which she has to meet:
and if indicated, as it is in most cases, arrangements
made whereby she may have the assistance of a
Home-help, such as is now available from most local
Authority Departments. Finally, a date is given to
the patient for attendance at a Cardiological clinic
for future advice and guidance.
