Chronic Rheumatic Heart Disease in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  CARDIO-OBSTETRICS CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Management of Pregnancy & Labour in Valvular Rheumatic Heart Disease (RHD)

RHD in pregnancy is primarily a hemodynamic problem — increases in plasma volume, heart rate, and cardiac output can unmask or worsen valve obstruction/regurgitation and precipitate heart failure and arrhythmias. Outcomes correlate strongly with lesion severity, baseline NYHA class, and prior decompensation — the core message is early risk stratification, multidisciplinary planning, and tightly managed intrapartum/postpartum physiology.

🚦 AT A GLANCE — RISK STRATIFICATION

Risk Drivers

NYHA ≥ II early in pregnancy and/or deterioration during pregnancy

Prior acute decompensated heart failure admission before pregnancy

Multivalve disease (common in RHD)

Severe stenotic lesions (esp. mitral stenosis), pulmonary hypertension, atrial fibrillation

GREEN — Lower risk: NYHA I, mild lesions, no pulmonary HTN/AF

AMBER — Moderate risk: NYHA II, moderate lesions and/or prior intervention

RED — High/very high risk: NYHA III–IV, severe MS/AS, pulmonary HTN, recurrent HF/AF, mechanical valve

🎯 ANTENATAL MANAGEMENT GOALS

Physiology Targets

Avoid tachycardia — protects diastolic filling, critical in mitral stenosis

Maintain euvolemia — "slightly dry" often safer than overloaded in MS

Prevent / rapidly treat pulmonary edema and arrhythmias

Reduce thromboembolism risk (AF, large LA, mechanical valve)

Surveillance Across Trimesters

BaselineEcho + ECG; repeat if symptoms change or mod–severe disease

Each VisitFunctional assessment: NYHA, orthopnea, exertional symptoms

If HF/StenosisFetal growth surveillance (placental hypoperfusion risk)

Meds: diuretics for congestion (cautious dosing); rate control for AF/MS; individualized anticoagulation (cardio-ob + hematology)

Secondary prevention: continue rheumatic fever prophylaxis (e.g., long-acting penicillin programs)

🚨 ESCALATE / ADMIT —
RED FLAGS

New/worsening dyspnea at rest, orthopnea/PND, pulmonary edema Resting tachycardia, new AF/flutter, syncope SpO₂ drop, rising BNP, ↑ pulmonary pressures on echo Hemoptysis (severe MS/pulmonary HTN) Recurrent admissions / cannot maintain euvolemia as outpatient

🗓️ DELIVERY PLANNING

Vaginal delivery preferred for most stable valvular disease; cesarean reserved for obstetric indications or selected cardiac indications (decompensated severe stenosis, severe pulmonary HTN, inability to tolerate labor)

Vaginal delivery with epidural is commonly recommended for stable disease

Plan early with a Pregnancy Heart Team — cardiology + MFM/obstetrics + anesthesia + neonatology

Timing: aim for controlled, planned delivery — avoid emergency physiology when possible.

🩺 INTRAPARTUM CHEAT SHEET

Hemodynamic Goals in Labour

1

Maintain preload — avoid sudden venodilation

2

Avoid tachycardia + pain-driven catecholamine surges

3

Avoid fluid overload — strict I&O, judicious IV fluids

4

Maintain oxygenation; treat pulmonary edema early

Analgesia: early neuraxial (epidural), titrated slowly to avoid abrupt SVR/preload shifts; blunts sympathetic surge, reduces Valsalva urge. 2nd stage: avoid prolonged Valsalva; consider assisted vaginal delivery to shorten it (esp. MS).

GREEN: Standard monitoring + careful fluids

AMBER/RED: Arterial line, continuous ECG, strict output, low threshold for ICU/HDU postpartum

Uterotonics: prefer controlled oxytocin (avoid large bolus); avoid ergot derivatives in significant pulmonary HTN/valvular disease (local protocols apply).

Mitral Stenosis

Avoid tachycardia; maintain sinus rhythm if possible

Diurese congestion carefully; avoid overload

If refractory / PH despite therapy: consider PBMV/BMV at experienced centers; combined cesarean + BMV reported feasible in late presenters

Mitral / Aortic Regurgitation

Often better tolerated than stenosis, but decompensation can occur

Manage HF symptoms & arrhythmias promptly

Avoid excessive afterload increases

Aortic Stenosis

Fixed obstruction — avoid hypotension and tachycardia

Delivery / anesthetic plan should be senior-led

Mechanical Valve

"Anticoagulation is the lesion" — high maternal thrombosis & fetal risk

Requires tightly coordinated peripartum anticoagulation plan and timed neuraxial considerations

Critical Window

Postpartum

24–72

HOURS
HIGHEST RISK

Autotransfusion from uterine involution and mobilization of extracellular fluid can precipitate pulmonary edema and arrhythmias.

Close monitoring; strict fluids/diuresis as needed

Resume / adjust anticoagulation per plan

Discuss contraception and long-term valve plan — including consideration of intervention before next pregnancy

Reminder: the highest-risk window is often after delivery, not during it — do not de-escalate monitoring too early.

Swaraj Hospital & Research Institute · Department of Obstetrics and Gynecology, Bolangir, Odisha

Clinician-facing summary for structured planning; tailor to lesion severity, NYHA class, rhythm, pulmonary pressures, and local cardio-obstetric pathways.