Book of Medical Disorders in Pregnancy - Tintash

When heart disease is severe the patient
may get a fulminating pulmonary edema
which is frequently intractable. This is
most frequently seen in cases of mitral
stenosis. Cause of death is congestive
heart failure in 80% of these cases.
Acute heart failure may also de-velop
during pregnancy in the previously
"normal heart".
Detailed scrutiny of clinical features,
history and special investigations can
help a great deal in diagnosing the exact
cause.
Women who have cardiac dis-eases
often present with a diastolic mur-mur
and an enlarged heart. It has already
been stated that even in normal patient
there may be 10 per cent increase in the
size of the heart due to diaphragmatic
elevation and rotation of heart on its
long axis.
Systolic murmur of grade III intensity
may be heard. Sometimes the murmur in
the beginning of auscultation appears to
be of grade II and is described as slight
murmur, but it is actually grade V and
can be audible with the rim of the
stethoscope when placed on the chest.
The student should realize that a "coarse
or musical murmur" is of greater
significance than a "blowing" one.
The probability that a systolic murmur
indicates organic heart disease increases
as the murmur's intensity increases.
When severe arrhythmias are present,
they can lead to atrial flutter or complete
heart block. Occasionally one may find
pericardial friction rub as one would see
in cases of pericarditis. Dia-stolic gallop
rhythm, pulsus alternans or anginal pain
can be noted in case of myocardial pain.
Persistent bacteraemia may be associated
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with heart murmur. Notching of the
lower margin of the ribs is seen on X-ray
in cases of coarctation of the aorta.
Importance of past history - Absence
of cardiac murmurs is regarded as prime
evidence against the more common
cardiac disorders. If a history of
rheumatic fever is present and no evidence
of heart lesion is discovered one
or more years later then one may accept
that no significant cardiac damage has
occurred.
When there is no evidence of heart
disease, but predisposing factor such as
rheumatic fever is present, the patient
should be treated as a high risk patient.
The significance of cardiac disease is
based mainly on the occur-ence of
pulmonary edema, as 88% of antepartum
cardiac deaths and 37% of postpartum
deaths occur as a result of
pulmonary edema.
A detailed account of previous
pregnancies is very useful because
severe cardiac failure associated with
mitral stenosis is likely to reoccur in
successive pregnancies. However absence
of congestive heart failure in one
pregnancy does not guarantee that it will
not occur in a subsequent pregnancy.
Physical examination and auscultation
of the Heart:
The physical examination should be
carried out vigilantly. If pedal edema is
discovered, it should be thoroughly
evaluated and differentiated from edema
of normal pregnancy.
Innocent cardiac murmurs - Systolic
flow murmurs may be hard to