Pregnancy and Delivery with Cardiac Disease in Dr. Soetomo Hospital 2018

Submission: November 8th, 2020 Review: December 3th, 2020 Publish: July 25th, 2021 Background: Cardiac disease is one of the non obstetric problems causing mortality both in pregnancy and labor due to the complications. Preventions for the complications have not been implemented, thus the number of patients which have cardiac disease with complications and perinatal outcome with low birth weight is still high. Objective : To identify maternal and neonatal outcome of pregnant women with cardiac disease in dr. Soetomo Surabaya hospital in 2018. Method: Descriptive retrospective study using medical records in dr. Soetomo Surabaya hospital 2018. Result: We found 1433 pregnancy cases with 51 (3,6 %) patients were having cardiac disease and included in this research. The most common maternal complication was pulmonary hypertension 16 cases. A dead case was found 1 case (1,9 %) with eissenmenger syndrome. We found the perinatal outcome of 30 babies (58.8%) born with a weight of 2500 gram and under. There are 7 patients with cardiac disease that have been corrected (13,7%). Among those 7 patients, 6 had a perinatal outcome with a birth weight of more than 2500 gram. Conclusion : Most pregnant patients with cardiac disease in dr. Soetomo Surabaya hospital 2018 are already having some complications with perinatal outcomes of low birth weight. Therefore, management of cardiac disease in pregnancy to prevent complications by means of preconception counseling, good antenatal care, and appropriate referrels are still needed to improve the quality of maternal and neonatal outcomes.


Introduction
Cardiac disease is a non-obstetric problem that lead to morbidity and mortality for both maternal and fetal due to the complications of cardiac function disorder (Ruys, et al., 2013). In RSUD Dr. Soetomo Surabaya period 2014-2016, the second biggest causes of maternal death is cardiac disease, and the most cases happen is Eissenmenger syndrome.
Some studies report that the maternal outcome of cardiac disease in pregnancy is fetal growth restriction. By having an overview for maternal and fetal outcome in pregnancy with cardiac disease, the preventions of complication in pregnancy with cardiac disease are expected, also understand how to identify the Antenatal Care for patients with cardiac disease in pregnancy to improve the quality of maternal and fetal outcome (Fernandez, et al., 2010) . The objective of this study is to give an overview on maternal and fetal outcome in patients with cardiac disease in pregnancy in RSUD Dr. Soetomo 2018.

Methods
This research was a descriptive retrospective research which was located in dr. Soetomo Hospital in 2018 by using medical records. The samples were all mothers with heart disease. The inclusion criteria in this study were pregnant women with heart disease. While the exclusion criteria were pregnant women with hypertension, preeclampsia and mothers with incomplete data.
The investigated characteristics of the mothers were age, parity, arrival status, origin area of referrals, antenatal care (ANC), indication of termination, and the way of delivery. Obtained maternal outcomes were cardiac complications, obstetric complications, and maternal mortality. While the Obtained fetal outcomes were birthweight, Apgar score, complications and fetal mortality.

Result
Search data on medical records was succeeded in getting 1433 women who Gave birth in 2018. Some 67 of them were pregnant women with heart disease. We sorted them According to inclusion criteria. The total number of pregnant women who met the criteria were 51 women. At the time of delivery, gestational age of <20 weeks were 1 case (1.9%), 20 weeks were less than 37 weeks were 24 cases (47.1%) and > 37 weeks were 26 cases (51.0 %). The most common congenital heart disease was ASD, 13 Patients (25.5%), Followed by 4 Patients of VSD (7.8%), 2 Patients of PDA (3.9%), 1 patient had TOF (1.9%), and 1 patient with ASD and VSD (1.9%)) and 1 patient with PDA and VSD (1.9%). For acquired heart disease, RHD was dominated by 13 Patients (25.5%) and coronary heart disease was not obtained during 2018. The number of pregnant women with RHD during 2018 were 13 women. Involvement of more than one valve (multiple valve), there were 11 cases (84.6%) while single valve were only 2 cases.
Based on the mode of delivery in pregnant patients with heart disease, predominantly labor perabdominam 30 cases (59%) and vaginal many as 20 cases (39%) and least curettage 1 case (2%). Indications of SC for heart disease in pregnancy were dominated by fetal distress in 10 cases, Followed by the class III obesity were 8 cases, severe oligohydramnios were 7 cases, fetal malpresentation were 5 cases, BSC were 4 cases, Eisenmenger syndrome were 4 cases, Pulmonary edema were 2 cases, placenta previa was 1 case, IUGR were 6 cases, and abortion was 1 case. From birth perabdominam, who performed the action B-Lynch as much as 6 cases (22%), while that does not do the B-Lynch 24 cases (78%). Of vaginal delivery, which do painless labor as many as 13 cases (76%), do not painless labor as much as 4 cases (24%).
From persainan vaginal, spontaneous back of the head 7 cases (13.7%), while those with forceps extraction of 13 (25.5%). Based on the ANC of pregnant Patients with complications of cardiac diseases, there were 4 cases (7.8%) in Patients who had never had the ANC were not Obtained DCFC> class II, it was Obtained DCC> class II as many as 1 case (1.9 %), with the number of pregnant Patients with heart disease were that the ANC had never had as many as five cases (9.8%). In Patients with ANC as many as 1-4 times during pregnancy, there were no complications of DCFC> class II in 24 cases (47.0%), while Reviews those who Obtained DCFC complications> class II were 6 cases (11.8%). The total number of pregnant Patients with cardiac disease, with 1-4 times Reviews their ANC during pregnancy as many as 30 cases ( Based on ANC correlation of pregnant patients with PHT complications, there were 3 patients (5.9%) who had never had ANC and did not have complications of PHT, while severe PHT were 2 cases (3.9%). The number of patients who had never had ANC were 5 cases (9.8%). Patients who had 1-4 times of ANC, and did not have complications of PHT were 19 cases (37.6%), mild PHT were 2 cases (3.9%), moderate PHT were 4 cases (7.8%), severe PHT were 5 cases (9.8%). The total number of patients with ANC were 30 cases (58.8%). Patients with ANC> 4 times and did not have PHT were 12 cases (23.5%), mild PHT was 1 case (1.9%), moderate PHT were 2 cases (3.9%), severe PHT was 1 case (1.9%). Total patients with ANC> 4 times were 16 cases (31.3%).
There is one case of death of pregnant patients with heart disease in 2018 with secundum ASD sekundum R to L shunt + Severe PHT + Eissenmenger Syndrom + moderate TR + mild PR. The patient is reffered from RSUD Nganjuk and never come to RSUD dr. Soetomo Surabaya before.
There are 7 pregnant Patients with heart disease, post-correction in 2018, that have a better maternal and perinatal outcome compared with uncorrected cardiac disease in pregnancy (Yap, et al., 2010).

Discussion
Based on the number of parity, cardiac disease found in multigravida more than primigravida. It shows that family planning hasn't working optimally in Indonesia. Most patients diagnosed with cardiac disease in the next pregnancy, because the in the first pregnancy, no signs and symptoms are shown and there is no complications. In the next pregnancy signs and symptoms are shown because maternal adaptation is not optimal (Gumilar and Pradyani, 2020).  (Nguyen Mahn, et al., 2019). ANC frequency on pastients with PHT and DCFC is not significantly associated. It shows that the quality of ANC needs to consider as associated with the prevalence of cardiac and obstetric complications. During pregnancy, the regularity of ANC in Policlinic is needed to monitor the maternal and fetal condition.
The pregnant patients with cardiac disease post correction shown low in number, among 51 patients, there are only 7 patients are being corrected. The fetal outcome of 6 among 7 patients that being corrected is good, with fetal birth weight is more than 2500 g. It shows that cardiac correction is significant to decrease the complications in maternal and fetal (Bills, et al., 2018). Otherwise in primigravida patients with cardiac disease that are not allowed to be pregnant before correction shows that preconceptional counseling is not optimal. Precoceptional counselling is very important in patients with among reproductive age with cardiac disease (Iserine, 2001). Counseling are given as needed for the patient to know the risk on the pregnancy. Informations needs to be given completely for the patients to understand the prognosis of the pregnancy and the baby (Gumilar and Pradyani, 2020). Perinatal outcome found 30 babies (58,8 %) are born with low birth weight ≤ 2500 g, it also found in the study conducted in Vietnam period 2014-2016 by Thang Nguyen Manh, the perinatal outcome IUGR found 26 among 284 cases (9,2%) (Nguyen Manh, et al., 2019).
A death case is found in patients with cardiac disease in 2018 due to complications which is Eissenmenger syndrome (Regitz-Zagrosek, et al., 2018). The patient is referred from outside Surabaya and have never come to Policlinic in RSUD dr. Soetomo Surabaya. The patients came in a poor conditions and having an advanced underlying disease is the causes of the death (Wolfe, et al., 2019). Late refferal shows that the ANC and management of patients with cardiac disease is not optimal yet (Gumilar and Pradyani, 2020).

Conclusion
Most of the pregnant patients with cardiac disease in RSUD dr. Soetomo Surabaya in 2018 are having cardiac complications with perinatal outcome low birth weight. Thus, the integrated management needs to be conducted since the preconceptional care until post partum to prevent the complications by preconceptional counseling, screening, antenatal care, and refferal on time to improve the maternal and fetal outcome.