Gupta AS

Medical disorders in pregnancy is a reality for the practicing obstetrician. Most of the times medical disorders in a gravida are diagnosed in the antenatal period as more and more women are registering and following up in the antenatal period. However, in a significant number these disorders are still diagnosed in labor or in the postpartum period. In such emergency situation the obstetrician has to depend on self to confirm and or manage these conditions which may have adversely or positively affected pregnancy or labor. Obtaining a physician or a cardiologists consultation may not always be feasible in emergency hours.

Cardiac disorders in pregnancy is one such medical disorder frequently suspected or diagnosed by the obstetrician as many women visit a doctor for the first time during their pregnancy due to the social structure of the Indian society. Incidence of cardiovascular disorders in pregnancy ranges from 1 to 4 %. Mortality attributed to cardiac disorders is about 10 %. Even though in the western world congenital heart diseases form the bulk in India rheumatic valvular lesions still predominate. Another category of ischemic heart disease that was previously not seen in Indian pregnant population is now seen in the pregnant women, probably due to late marriages, late child birth, obesity, diabetes mellitus either preexisting or gestational and hypertension. All these patients require multidisciplinary management

The cardiologist and the obstetricians also face the task to identify those cardiac cases who should not conceive or should conceive after cardiac surgery or stabilization of their cardiac condition. Some of the cardiac conditions wherein pregnancy is contraindicated includes primary pulmonary hypertension, critical mitral stenosis or aortic stenosis, certain cases of cardiomyopathy wherein the ejection fraction is less than 30 %, uncorrected coarctation of the aorta especially if associated with aneurysm. Since many times the obstetrician sees the patient first only in pregnancy the cardiologist and the physicians have a main role to play in imparting contraceptive counseling or referring them to a contraceptive provider and convince the couple to either avoid pregnancy totally or to defer it at least till a definitive correction of her cardiac lesion has been done. Unfortunately this is not the norm and the social fabric of our society pressurizes this woman to conceive in poor general health.
When such a woman conceives; the obstetrician is faced with the daunting task of managing a very high risk pregnancy with significant chance of maternal and perinatal morbidity or mortality. Sometimes if these women present in the first trimester of pregnancy, termination of pregnancy can be done. Both these scenarios can be avoided if medical providers of all specialties and sub specialties realize their responsibility and counsel the couple with contraceptive advises during their reproductive life rather then leaving this task to the obstetrician, gynecologist or family physicians.  

This November issue of the journal has three cardiac cases with pregnancy. Pregnancy should have been avoided in one woman who had to undergo mitral valve replacement as an emergency procedure in pregnancy and the remaining two were diagnosed in their current pregnancy with life threatening cardiac condition. Fortunately all three women survived their condition and were counseled to avoid pregnancy in future or to consider it only after confirming with the cardiologist.