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Heart disease in pregnancy 

Heart disease in pregnancy

Chapter:
Heart disease in pregnancy
Author(s):

Catherine E.G. Head

DOI:
10.1093/med/9780199204854.003.1406_update_001

Update:

Cardiovascular investigation—expanded notes on the ECG and exercise testing.

Maternal risk—use of modified WHO risk classification.

Specific conditions—(1) peripartum cardiomypathy—role of proteolytic cleavage products of prolactin in pathogenesis; (2) dilated aortic root—revised recommendations for imaging and prophylactic surgery.

Updated on 30 May 2013. The previous version of this content can be found here.
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date: 24 April 2017

Pregnancy is a vasodilator state in which plasma volume and cardiac output increase such that many symptoms and signs of cardiac disease can occur physiologically. Disproportionate symptoms or abnormal signs such as a diastolic murmur require investigation as usual; necessary radiological investigations should not be withheld as the risks to the fetus are generally low.

Prepregnancy risk assessment—this is ideally based on data related to the specific cardiac abnormality, with prepregnancy functional status an important predictor of outcome. Issues of particular note are (1) pregnancy is high risk in pulmonary hypertension or severe left ventricular dysfunction—effective contraception and termination should be offered; (2) women at risk of aortic dissection are at increased risk during pregnancy—prepregnancy elective replacement of the aortic root should be considered if its diameter at its widest point is greater than 4.5 –5.0cm, depending on the underlying aetiology; β‎-blockers and regular echo monitoring should continue through pregnancy.

Delivery of the baby—vaginal delivery is recommended, other than in the presence of a dilated aortic root, aneurysm or dissection, or if the fetal INR is elevated. Low dose infusions of epidural anaesthesia and oxytoxic drugs are safe.

Heart conditions arising in pregnancy

Peripartum cardiomyopathy—this should be considered in any woman presenting peripartum with dyspnoea or tachycardia.

Myocardial infarction—when occurring in pregnancy this may be due to coronary dissection: immediate angiography with percutaneous coronary intervention is the management of choice, but thrombolysis is not contraindicated.

Pregnancy in women with known cardiac disorders

Valve diseases and cardiomyopathies—(1) Symptomatic mitral stenosis—may be managed medically with diuretics, β‎-blockade and maintenance of sinus rhythm; failing this, balloon valvuloplasty is usually successful. (2) Aortic stenosis—women with satisfactory prepregnancy haemodynamics are at low risk of problems in pregnancy. (3) Hypertrophic cardiomyopathy—patients generally tolerate pregnancy well.

Congenital cardiac lesions—low-risk conditions include atrial septal defect, restrictive ventricular septal defect and corrected tetralogy of Fallot in the absence of severe pulmonary regurgitation or aortic root dilatation. All cases other than those at low risk should be managed by a multidisciplinary team in a specialist centre.

Anticoagulation—the optimal anticoagulation management of a pregnant patient with a mechanical prosthetic valve is not known. Continued warfarin therapy carries the risk of warfarin embryopathy for the fetus, but switching to heparin increases the maternal risk of thromboembolism, although newer regimens using LMW heparin with monitoring of anti-Xa levels almost certainly perform better than historical regimens using unfractionated heparin.

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