Cardiac Disease and Pregnancy

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Chapter 16 Cardiac Disease and Pregnancy

Cardiac disease complicates approximately 1% to 2% of all pregnancies and is a leading cause of maternal death.1,2 Historically, rheumatic valvular heart disease, particularly mitral stenosis, has been the predominant cause of heart disease in pregnancy, and in developing countries this is still the case. However, in the United States and other developed nations, corrected or palliated congenital heart disease is becoming more common. In this chapter the management of pregnant patients with cardiac disease is reviewed briefly.


Pregnancy and labor impose a huge metabolic burden on the mother; the result is profound alterations in maternal physiology, particularly of the cardiovascular system.24 These physiologic changes begin about week 6, become maximal early in the third trimester (about week 30), and thereafter remain relatively stable until labor.


A number of kinds of cardiac lesions are associated with increased risk for adverse outcome during pregnancy (Table 16-1).58 In general, regurgitant valvular lesions are better tolerated than stenotic lesions. With a stenotic lesion, in which cardiac output is relatively fixed, the vasodilatation and increased preload associated with pregnancy can result in hypotension and pulmonary edema. In contrast, vasodilatation and increased preload in the setting of a regurgitant lesion tend to encourage forward flow. However, any valve lesion causing New York Heart Association (NYHA) class III or IV symptoms prior to pregnancy is unlikely to be compatible with progress to term. Some conditions, notably Eisenmenger syndrome and severe cyanotic heart disease, are associated with such a high maternal and fetal mortality rate that pregnancy is inadvisable.

Table 16-1 Cardiac Lesions Associated With High Maternal and Fetal Risk During Pregnancy

Cyanotic heart disease
Severe aortic stenosis with or without symptoms
Mitral stenosis with NYHA functional class II to class IV symptoms
Mitral or aortic regurgitation with NYHA functional class III to class IV symptoms
Valvular heart disease resulting in severe pulmonary hypertension (pulmonary artery pressure > 75% systemic pressure)
Left ventricular dysfunction (ejection fraction < 40%)
Mechanical prosthetic valve requiring anticoagulation
Aortic regurgitation in Marfan syndrome

From Siu SC, Sermer M, Harrison DA, et al: Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 96:2789-2794, 1997; and from Bonow RO, Carabello B, de Leon AC, et al: ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [Committee on Management of Patients With Valvular Heart Disease]. J Am Coll Cardiol 32:1486-1588, 1998. NYHA, New York Heart Association.

Mitral Stenosis

Rheumatic mitral stenosis (see Chapter 10) is the valve lesion that most commonly complicates pregnancy. The increased circulating volume and heart rate that occur during pregnancy can cause pulmonary congestion or frank pulmonary edema. The development of rapid atrial fibrillation can precipitate acute cardiac decompensation.

Mitral and Aortic Regurgitation

Mitral regurgitation (see Chapter 10

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