The Early Recognition of Cardiac Insufficiency in the Presence of Pregnancy

Abstract

The importance of the early detection of cardiac insufficiency during pregnancy is emphasized by the statistics of a maternal mortality report published by the Philadelphia County Medical Society. 1 In this 3-year study there were 69 maternal deaths with heart disease as a factor; in 16 cases heart disease was the primary and in 53 the secondary cause of death. This figure represents 9% of the total deaths of the series. Of the 78 maternal deaths with nonobstetric conditions as their primary cause, heart disease is second only to pneumonia. From a study by Fraser 2 comes the statement that among all causes of maternal deaths not due primarily to pregnancy, heart disease stands second only to nontuberculous lung disease. Forty of the 69 patients in the Philadelphia County Medical Society report, whose deaths were caused by or complicated by heart disease, had shown complications during previous deliveries. It seems justifiable to conclude from such figures that a substantial improvement in the maternal mortality rate might be effected if this group of cardiac deaths could be eliminated or markedly reduced. The observations that are presented in this study were made in the cardiac clinics of the Presbyterian and Woman's Hospitals of Philadelphia. The collection of data on pregnant patients was begun at the Woman's Hospital in 1931 and extended through the middle of 1936. At the Presbyterian Hospital observations were made during the years 1934, 1935, and 1936. The total number of patients passing through the prenatal clinics of these two hospitals during the years under consideration was 3059; of this number, 258 were referred to the cardiac clinics for study because of the presence of abnormal cardiovascular signs and symptoms. These patients were all examined before delivery and whenever possible were seen after delivery. When patients failed to return for check-up after their confinements, their hospital records were studied to determine the cardiac diagnoses at the time of their discharge. Those who were considered to have organic heart disease have, with few exceptions, been seen and reexamined at least once since their deliveries; many of them attend heart clinic regularly. Three cases without postpartum data were discarded from the series. Of the 255 who are included, 42 were found to have organic heart disease; this is 1.37% of the total number of patients passing through the prenatal clinics of the two hospitals. This figure is comparable with the data given by Herrick, 3 who found that 1% of all pregnancies are complicated by cardiac disease, and that 6% of these die. White 4 found that 2% of pregnant women have symptoms and signs of heart disease, and that 1% have organic heart disease. Lamb 5 found organic heart disease in 2.7% of pregnant women in a 4-year study. Sodeman 6 states that, in general, the incidence of heart disease in pregnancy is about 1%. Of the 42 cases, 12 or 28.6% showed some degree of congestive failure during pregnancy or at the time of delivery; the number of deaths was three. A brief review of these cases follows. In making the diagnoses, the functional classification approved by the American Heart Association was used. 7