By Dr V P Nair
If there is an urgent need for foreign investment in any sector, it is health care. India’s population has increased three to four times since independence from the British and local health care system is bursting at the seams. Of course, both in India and other countries across the world progress has been made in medical science but its overall impact has been mixed.
First the good news. Statistics of the World Health organization show that 289,000 women died worldwide from complications of pregnancy in 2013 compared with 523,000, around 25 years ago. This is a healthy 50 per cent drop, which is the good news. However, the bad news is that 800 women a day or 33 per hour are still dying globally from complications in pregnancy and childbirth.
The tragic part of the story is that most of these fatalities are preventable. Skilled care before, during and after childbirth can save the lives of mother and new born babies. Almost 99 per cent of these maternal deaths occur in developing countries, indicating that this group needs to do more about healthcare. Further, one needs to note that maternal mortality is higher in women living in rural areas and poor communities.
Another point to be noted is that adolescents have higher risk of complications and death from pregnancy than older women. This gives us an idea about our target population when it comes to tackling maternal mortality. This is a matter that requires immediate attention. Global success stories are not made from economic reforms alone. Social reforms are needed urgently to prevent teenage marriages and pregnancies.
Maternal Mortality Rate
Maternal mortality rate, or MMR is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management. This excludes accidental or incidental causes. The MMR in 2013 was 190 in India compared to 170 in Pakistan, 32 in China, 28 in Sri Lanka, 28 in USA, 8 in UK, 8 in Japan 6 in Singapore and 5 in Greece. It is very high in countries such as South Sudan where it is 730. Among many causes of maternal mortality, heart disease is one of the most important. The government, medical community and the public must work hard to bring down maternal mortality.
Physiology of Pregnancy
Physiological changes during pregnancy are the adaptations that a woman undergoes to accommodate the foetus. They are entirely normal, and include cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important especially in the event of any complications. The spectrum of adaptations to cope with the demands of pregnancy will act as additional stress to the heart, especially in women with underlying heart conditions which may cause new or worsening symptoms.
Why do some pregnant women die?
Many women die due to complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy. Other complications may exist before pregnancy but are worsened during pregnancy. The major complications that account for nearly 75 per cent of all maternal deaths are as follows:
• Severe bleeding, mostly after childbirth known as post-partum haemorrhage
• Infections usually after childbirth
• Hypertension during pregnancy also called pre-eclampsia and eclampsia
• Complications from delivery
• Unsafe abortion
• Diseases such as malaria, and AIDS
Changes in body and heart during pregnancy
During pregnancy, cardiac output or output of blood from the heart increases about 30 per cent to 40 per cent and blood volume increases by 20 per cent to 25 per cent. This increases blood flow to most parts of the body especially kidneys, skin and the uterus. Blood pressure falls during early pregnancy and increases again in late pregnancy. Heart rate also increases gradually during the first 32 weeks of pregnancy.
Common heart conditions in pregnant women
Valvular Heart Disease or Diseases of the heart valves
Human heart has 4 valves, known as mitral valve, aortic valve, tricuspid valve and the pulmonary valve. These valves may narrow or stenose, which means unable to open fully, or leak, regurgitate and unable to close properly. Normal physiological changes in pregnancy can aggravate the valve`s dysfunction.
As a result, these females will be breathless during activities involving exertion such as walking. They may even develop leg swelling, or edema. Most valvular lesions are tolerable and not harmful during pregnancy but some may deteriorate. They may need constant monitoring during pregnancy and delivery and a few may even require surgical or non-surgical treatment.
Women of child bearing age, with severely diseased native valve, may require artificial or prosthetic valve, also called metallic valve or biological valve, also known as tissue valve. If metallic valve is used, they will require lifelong blood thinning medications such as Warfarin. This has side effects. Warfarin may cause foetus deformity and bleeding during pregnancy. Pregnancy may also increase risk of blood clot formation in the metallic valve. Unless treated properly, this can be very dangerous.
Coronary Heart Disease, or CAD
Though less frequent, CAD is more prevalent in older women with diabetes, hypertension, high cholesterol and history of smoking. The risk of heart attack in women is around one in 10,000 and it occurs around third trimester in women older than 35 years old. Risk is increased by higher blood volume, cardiac output, hormonal changes and greater blood clot formation. These women require more frequent medical evaluation if they have chest pain during pregnancy. Medications to treat coronary artery blockage in pregnant patients may affect the developing foetus. Acute heart attack during pregnancy can still be treated with balloon angioplasty and stenting, but with the greater risk of radiation exposure to the foetus.
Cardiomyopathy
This is a condition affecting the heart muscles. During pregnancy, the heart can become weak and enlarged and the medical condition is known as Peripartum Cardiomyopathy. It usually occurs during the last month of pregnancy and may continue up to five months after the delivery of the child. Patients will have breathlessness due to heart failure and may require diuretics and other modalities of treatment. If the heart function does not recover after six to twelve months of treatment, further pregnancy is not advisable as it will carry higher risk.
Women born with hypertrophic cardiomyopathy or thick heart muscles, which is a case of inherited cardiomyopathy, may suffer from breathlessness during pregnancy. Echo cardiogram will be used to give a definite diagnosis, which is harmless to the foetus. Outcome of pregnancy in this group of patients depend on the thickness and function of the heart muscles. If there is obstruction in the flow of blood due to thick heart muscles, special treatment will be needed. Being a hereditary condition, the foetus has 50 per cent chance of inheriting it, and hence there is a need for echocardiography.
Congenital Heart Disease, or CHD
CHD is a collection of heart conditions present at birth. This can range from simple CHD such as a hole in the heart, atrial septal defect, ventricular septal defect, patent ductus arteriosis to complex and severe CHD such as a combination of heart defects called the Tetralogy of Fallot, to the blue or cyanosed baby, to even the highly complex single heart ventricle. The risk of pregnancy in women with CHD depends on underlying anatomy, high pressure in the lungs or heart rhythm disturbance, severity of the conditions, heart function and presence of cyanosis. Treatments include medical therapy or surgical repair before pregnancy or during pregnancy.
High Blood Pressure
Many pregnant women with high blood pressure have healthy babies without serious problems. However high blood pressure can be dangerous for both the mother and the fetus. Women with pre-existing, or chronic, high blood pressure are more likely to have complications during pregnancy than those with normal blood pressure. Some develop high blood pressure during pregnancy, or gestational hypertension. High blood pressure can harm mother’s kidneys and other organs, and result in early delivery and below normal weight of the baby. In more serious cases, the mother develops preeclampsia or “toxemia of pregnancy”, which can threaten the lives of both the mother and the fetus.
Medications during pregnancy
Many medications are not appropriate during pregnancy as they can cross the placenta and affect the baby’s growth and development. Some medications can cause palpitation and heart rhythm disturbance or high blood pressure during pregnancy. Breast feeding mothers also should avoid these medications, as they may be secreted into the milk. The doctor should evaluate the benefits of these medications to the mother and the baby vis-à-vis the risks involved.
CONCLUSION
Women with heart diseases may carry higher risk during pregnancy, depending on the type of heart defects and their severity. Pregnancy per se results in changes in the body such as hormonal, expansion of blood volume, redistribution of blood flow, increase in heart rate and other demands to the heart. These women need to get their heart properly assessed before they decide to have a child. Throughout the pregnancy they must ensure an uneventful development of the fetus and the subsequent delivery. Last but not the least foreign investors must positively consider investing in district level healthcare for the sake of not only the aam aadmi or common man but also “aam mahila and bachhe” {the common women and children}
Dr V P Nair is Consultant Interventional Cardiologist at the Nair Cardiac Medical Specialist Centre, Mount Elizabeth Hospital Singapore. He is also advisor to Foreign Investors on India.
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