Cardiac disease in pregnancy: A study of the patients with heart disease at the Philadelphia lying-in division of the Pennsylvania Hospital from 1937 to 1947, inclusive

1.1. A total of 26,628 pregnant women were delivered at the Pennsylvania Hospital from 1937 to 1947, inclusive. Of this total, 409 patients were found to have heart disease.2.2. Of the 409 patients with heart disease, 31.3 per cent received digitalis therapy at various periods before, during, and after pregnancy.3.3. There were fourteen maternal deaths, with a mortality rate of 3.4 per cent among the 409 pregnant patients with heart disease. (a) Heart failure was directly or indirectly responsible for ten of fourteen deaths. Failure occurred in seven patients between the seventh and eighth months of pregnancy and in three patients in the first forty-eight hours of the puerperium. (b) Fatal acute infections were present in seven of the fourteen patients.4.4. There were fifty-four fetal deaths in this series, making a mortality rate of 13.2 per cent. Prematurity was the most common cause of fetal death.5.5. Approximately 50 per cent of the patients were delivered by the use of low forceps during the second stage of labor. Abdominal delivery was used rarely for patients with rheumatic heart disease, except in the event of gynecological indications.6.6. Approximately 80 per cent of the 409 patients studied were found to have rheumatic heart disease. Of these, eleven died.7.7. Hypertensive cardiovascular disease was the diagnosis for fifty-one patients. These patients comprised an older average age group than the rheumatic heart disease patients. Abdominal delivery was well tolerated by this group.8.8. Congenital heart disease was the diagnosis for eighteen patients. With one exception, a case of coarctation of the aorta, these patients did well.9.9. Two instances of fatal acute bacterial endocarditis complicating pregnancy and delivery are reported.10.10. The problem of diagnosis and management of patients with heart disease during pregnancy includes: (a) the interpretation of heart murmurs in pregnancy; (b) the prenatal care of the patient; (c) the management of acute pulmonary edema complicating pregnancy; and (d) an evaluation of the choice of anesthetic and type of delivery.11.11. Careful prenatal observation, with the prevention and early control of acute respiratory infections, offers most in reducing the incidence of heart failure and the maternal mortality of this important group of patients.