Cardiovascular Disease in Pregnancy

Published on 06/06/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Chapter 201 Cardiovascular Disease in Pregnancy

THE CHALLENGE

Cardiac disease is one of the major causes of nonobstetric maternal mortality. Whereas in the past patients with congenital heart disease did not survive to reproductive age, it is now common for these patients to become pregnant, be it planned or unplanned.

Scope of the Problem: Cardiac disease complicates approximately 1% of all pregnancies. Mitral valve prolapse may be found in 5% to 7% of pregnant women. The type and severity of risk vary with the type of lesion and the functional abilities of the patient (see box). Patients with valvular disease have an increased risk for thromboembolic disease, subacute bacterial endocarditis, cardiac failure, and pulmonary edema during and after pregnancy.
Objectives of Management: Identify patients at risk because of cardiovascular conditions, provide realistic counseling regarding the risk to mother and fetus, and work to reduce this risk. The basis of antepartum management consists of frequent evaluations of maternal cardiac status and fetal well-being, combined with avoidance of conditions or actions that increase cardiac workload. The latter includes the treatment or avoidance of anemia, prompt treatment of any infection or fever, limitation of strenuous activity, and adherence to appropriate weight gain.

TACTICS

Relevant Pathophysiology: By midpregnancy there is a 40% increase in cardiac output; this increase in demand may be fatal. Cardiac output shows an additional increase in the immediate postpartum period, as up to 500 mL of additional blood enter the maternal circulation because of uterine contractions and rapid loss of uterine volume. Cardiac complications, such as peripartum cardiomyopathy, may occur up to 6 months after delivery. Valvular heart disease is the most commonly encountered cardiac complication of pregnancy, with rheumatic valvular disease being the most frequent type. The severity of the associated valvular lesion determines the degree of risk associated with pregnancy. Roughly 90% of these patients have mitral stenosis, which may result in worsening obstruction as cardiac output increases during the pregnancy. When severe or associated with atrial fibrillation, the risk of cardiac failure during pregnancy is increased.
Strategies: The New York Heart Association classification of heart disease is a useful guide to the risk of pregnancy (see box). Patients with class I or II disease, such as those with septal defects, patent ductus arteriosus, or mild mitral or aortic valvular disease, generally do well during pregnancy, although their fetuses are at greater risk for prematurity and low birthweight. Patients with class III or IV disease caused by primary pulmonary hypertension, uncorrected tetralogy of Fallot, Eisenmenger syndrome, or other conditions rarely do well, with pregnancy inducing a significant risk of death, often in excess of 50%. Patients with this degree of cardiac decompensation should be advised to avoid pregnancy or consider termination based on careful consultation with specialists in both cardiology and high-risk obstetrics.

IMPLEMENTATION

Special Considerations: Most patients with mitral valve prolapse do well. The rare patient with left atrial and ventricular enlargement may develop dysfunction during the course of pregnancy. The severity of the disease and impact on the atrium and ventricle may be assessed by echocardiography. Peripartum cardiomyopathy is rare but uniformly severe. Occurring in the last month of pregnancy or during the first 6 months after delivery, it is similar to other cardiomyopathies in symptoms and findings. Most often, a specific cause is not identified and the cause remains unknown. This process presents an especially grave risk, necessitating early suspicion and aggressive consultative management. Patients at highest risk are those in their 30s, who are multiparous, who are African American, who have delivered twins, or who have had pre-eclampsia. Unusual cardiac conditions, such as idiopathic hypertrophic subaortic stenosis and the structural anomalies associated with Marfan syndrome, are associated with maternal moralities of 25% to 50% or higher. The presence of such conditions demands realistic preconception counseling, and early transfer for specialized care, should a pregnancy occur.

Cardiac (Maternal) Mortality Associated with Pregnancy

Group I (Mortality <1%)

Atrial septal defect

• Bioprosthetic valve
• Mitral stenosis (functional class I and II)
• Patent ductus arteriosus
• Pulmonic/tricuspid disease
• Tetralogy of Fallot, corrected
• Ventricular septal defect

Group II (Mortality 5% to 15%)

Aortic stenosis

• Coarctation of aorta, without valvular involvement

IIA

Marfan Syndrome with Normal Aorta

• Mitral stenosis (functional class III and IV)
• Previous myocardial infarction
• Uncorrected tetralogy of Fallot

IIB

Artificial Valve

• Mitral stenosis with atrial fibrillation

Group III (Mortality 25% to 50%)

Coarctation of aorta, with valvular involvement

• Marfan syndrome with aortic involvement
• Pulmonary hypertension

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NEW YORK HEART ASSOCIATION CLASSIFICATION OF HEART DISEASE

Classification Symptoms
Class I No cardiac decompensation
Class II
No symptoms of decompensation at rest
Minor limitations of physical activity

Class III
No symptoms of decompensation at rest
Marked limitations of physical activity
Class IV
Symptoms of decompensation at rest
Discomfort with any physical activity

REFERENCES

Level II

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Drenthen W, Pieper PG, Roos-Hesselink JW, et alZAHARA Investigators. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol. 2007;49:2303. Epub 2007 Jun 4

Immer FF, Bansi AG, Immer-Bansi AS, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003;76:309.

Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006;195:673.

Siu SC, Sermer M, Colman JM, et alCardiac Disease in Pregnancy (CARPREG) Investigators. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104:515.

Level III

American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 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 (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2006;114:e84.

American College of Obstetricians and Gynecologists. Chronic hypertension in pregnancy. ACOG Practice Bulletin 29. Obstet Gynecol. 2001;98:177.

American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia. ACOG Practice Bulletin 33. Obstet Gynecol. 2002;99:159.

American College of Obstetricians and Gynecologists. Prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin 47. Obstet Gynecol. 2003;102:875.

Chamberlain G, Steer P. ABC of labour care: labour in special circumstances. BMJ. 1999;318:1124.

Elkayam U, Bitar F. Valvular heart disease and pregnancy: Part I: Native valves. J Am Coll Cardiol. 2005;46:223.

Elkayam U, Bitar F. Valvular heart disease and pregnancy: Part II: Prosthetic valves. J Am Coll Cardiol. 2005;46:403.

Milewicz DM, Dietz HC, Miller DC. Treatment of aortic disease in patients with Marfan syndrome. Circulation. 2005;111:e150.

Murali S, Baldisseri MR. Peripartum cardiomyopathy. Crit Care Med. 2005;33:S340.

Reimold SC, Rutherford JD. Clinical practice. Valvular heart disease in pregnancy. N Engl J Med. 2003;349:52.

Siu SC, Colman JM. Heart disease and pregnancy. Heart. 2001;85:710.

Sliwa K, Fett J, Elkayam U. Peripartum cardiomyopathy. Lancet. 2006;368:687.

Spirito P, Autore C. Management of hypertrophic cardiomyopathy. BMJ. 2006;332:1251.

Stout KK, Otto CM. Pregnancy in women with valvular heart disease. Heart. 2007;93:552. Epub 2006 Aug 11

Thorne S, MacGregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heart disease. Heart. 2006;92:1520.

Thorne SA. Pregnancy in heart disease. Heart. 2004;90:450.

Uebing A, Steer PJ, Yentis SM, Gatzoulis MA. Pregnancy and congenital heart disease. BMJ. 2006;332:401.

Vongpatanasin W, Brickner ME, Hillis LD, Lange RA. The Eisenmenger syndrome in adults. Ann Intern Med. 1998;128:745.

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