CLINICAL FINDINGS AND MATERNAL OUTCOME OF PREGNANT PATIENTS WITH VALVULAR HEART DISEASE

351    http://www. pakheartjournal.com  ORIGINAL ARTICLE CLINICAL FINDINGS AND MATERNAL OUTCOME OF PREGNANT PATIENTS WITH VALVULAR HEART DISEASE Rajkumar Sachdewani, Shoaibunisa Soomro, Nand Lal Rathi, Kousar Abro, Abdul Qadir Bhutto, Faizan Shaukat Ghulam Muhammad Mahar Medical College, Sukkur, Pakistan, National Institute of Cardiovascular Diseases, TMK, Pakistan, Jinnah Post Graduate Medical Center, Karachi, Pakistan


INTRODUCTION
In developing countries, valvular disease is almost exclusively the consequence of childhood rheumatic fever, although valvular dysfunction may also develop in some patients who have a prolapse of the mitral valve leaflets (Barlow's syndrome), or ventricular dilation due to elevated afterload or cardiomyopathy. 1 Pregnancy is associated with significant hemodynamic changes that may aggravate valvular heart disease and increase the risk of thrombo-embolic events. Valvular heart disease accounts for approximately a quarter of the cardiac diseases complicating pregnancy and is an important cause of maternal mortality, posing many challenges in management. 2 Pregnancy in women with valvular heart disease is associated with remarkable unfavorable effect on maternal and fetal outcome, which are related to severity of disease. 3 The incidence of preterm birth, and small for gestational age newborn was 11.69% and 13.36% respectively. There was one (1.67%) maternal death. 3 Mechanical prosthetic valves pose unique challenges in management of the pregnant patient given the requirement for anticoagulation. Given the complexity of valvular heart disease in pregnancy, women with congenital and acquired heart disease should be managed with a multidisciplinary approach before and throughout pregnancy. [4][5][6] Data related to risk factors and diagnostic findings in pregnant women with valvular disorder in Pakistan is limited. In this study, we have evaluated the risk factors, clinical presentation, ECG, and Xray findings in pregnant women with valvular disorder.

METHODOLOGY
This cross-sectional study was conducted in cardiology unit of Ghulam Muhammad Mahar Medical College (GMMMC), Sukkur in close association with gynecology department from January 2019 to December 2019. Thirty (30) pregnant women were enrolled in study after informed consent. Inclusion criteria included participants who were diagnosed with valvular disorder based on clinical presentation. Exclusion criteria included patients presenting with symptoms of preeclampsia, eclampsia or HELPP syndrome. Ethical approval was taken from Ghulam Muhammad Mahar Medical College. After enrolment, participant age, gestational age, parity and gravida was noted in self-structure questionnaire. Participants were asked history about socioeconomic status, previous history of rheumatic fever, history of C-section and smoking etc. Participants with household income of less than 50,000 PKR monthly were classified as participants with poor socio-economic background Diagnostic test such as X-rays, ECGs and Echocardiography was done and their findings were noted. Statistical analysis was done using Statistical Package of Social Sciences (SPSS) v. 21.0 (IBM Corporation, Armonk, New York, United States). Continuous variables were presented as means and standard deviations (SDs) while categorical variables were presented as percentages and frequencies.

Results
The mean age of participants was 28 ± 6 years. The mean gestational age at the time of enrollment in study was 21 ± 8 weeks. 18 (60%) participants belonged to poor socio-economic status. 14 (46.6%) participants were primigravida. History of Atrial fibrillation was present in 05 (16.6%) pregnant women (15%). The most common clinical symptom was shortness of breath (93.6%), followed by palpitation (30%).

DISCUSSION
Significant hemodynamic changes occur during pregnancy, which can lead to decompensation in the setting of severe valvular disease. Cardiac output increases by 30-50% due to increased stroke volume and, to a lesser extent, increased heart rate later in pregnancy. http://www. pakheartjournal.com Cardiac output rises early in pregnancy and plateaus between the second and third trimesters. [7][8][9] Additionally, systemic vascular resistance decreases by the end of the second trimester and then slowly begins to increase until term. 10 Pregnancy is accompanied by physiologic anemia due to greater expansion in plasma volume than in red blood cell mass. 11 Together, these changes lead to increased flow, and thus increased gradients, across preexisting valvular lesions. 12 In this study, the mean gestational age at the time of presentation was 21 ± 8 weeks. This is late presentation compared to other studies, where most women present by 1st trimester. 1 This delay in presentation may be due to lack of antenatal visits in first trimester, particularly in women belonging to poor socio-economic background. Valvular heart disease is present in 80% of patients with heart disease during pregnancy in developing countries, with rheumatic fever as the most common etiology. 13 However, in this study rheumatic fever was present in only two (02) participants out of thirty participants. Stenotic lesions that limit the ability to increase cardiac output may not be well tolerated during pregnancy and delivery. Regurgitant lesions are generally better tolerated, especially if the underlying cardiac function is normal. 14 In our study, most common valvular lesion was mitral regurgitation. The effects of rheumatic mitral regurgitation are usually ameliorated in early pregnancy by the dominant physiological change, peripheral vasodilatation. The increased plasma volume is offset by the reduction in systemic vascular resistance and consequently, the extent of the regurgitation diminishes.1 Second most common valvular lesion in our study was mitral stenosis. Mitral stenosis is poorly tolerated in pregnancy, and it is the leading cardiac cause of maternal mortality in the developing world. 15 Poor fetal outcomes including fetal growth restriction, low birth weight and preterm birth increase with increasing severity of MS. 16,17 It is important to identify the patients at risk of valvular lesion. Early in pregnancy to reduce complications associated with valvular disease. The American College of Cardiology/American Heart Association adult congenital heart disease guidelines, valvular heart disease guidelines, and European Society of Cardiology guidelines all endorse preconception counseling and discussion of contraception as the duty of the cardiologist. [18][19][20] Individual counseling by experts, advice on contraception, and ultimately close follow-up between the patient and a multidisciplinary care team, which includes a cardiologist and obstetrician, can potentially impact the lives of both mother and baby To the best of our knowledge, this is first study on valvular lesion in pregnant women in Pakistan in this decade. However, there were various limitations as well.
First, since the sample size was taken from one institute, it was less diverse and small. Second, since it was a crosssectional study hence fetal outcome was not noted.

CONCLUSION
Valvular heart disease in pregnancy is an increasingly common cause of adverse complications for both mother and baby, with medical and surgical advances allowing for many patients with VHD to survive to childbearing age. We recommend both preconception counseling and anticoagulation strategy as outlined here, as well as early referral to cardiologist with expertise in the management of cardiac disease and pregnancy for these complex patients.

AUTHORS' CONTRIBUTION
RS: Concept and design, data acquisition, interpretation, drafting, final approval, and agree to be accountable for all aspects of the work. SS, NLR, KA, AQB, FS: Data acquisition, interpretation, drafting, final approval and agree to be accountable for all aspects of the work.