Pregnancy is a remarkable journey that requires careful attention, particularly for women with pre-existing heart disease. Heart disease poses unique challenges during pregnancy, as the physiological changes of pregnancy can pose challenge to the cardiovascular system. In this article we explore the relationship between pregnancy and heart disease, discussing the risks, management strategies, and potential complications, highlighting the importance of a multidisciplinary team approach to ensure optimal mother and child outcomes.
Heart diseases complicate 1% to 4% of pregnancies in women without preexisting heart problems. A working knowledge of the normal physiology of pregnancy is often helpful in the management of these patients with heart disease. Patients with preexisting heart disease should be counseled in advance about the risk of pregnancy. Familiarity with the treatment of commonly encountered heart diseases during pregnancy is becoming increasingly important for internists and cardiologists as they join the team of obstetricians and anesthesiologists in the care of these special group of patients.
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Pregnancy increases the demands placed on the heart. Major hemodynamic alterations (blood volume/heart rate/blood pressure/cardiac output) occur during pregnancy, labor, and delivery and the postpartum period. These changes begin to take place during the first 5 to 8 weeks of pregnancy and reach their peak late in the second trimester. In patients with preexisting cardiac disease, and cardiac decompensation (worsening of heart function) often coincides with this peak.
Pre-existing maternal conditions such as congenital heart defects (ASD/VSD), valvular heart disease (mitral stenosis), cardiomyopathy (hypertrophic obstructive cardiomyopathy / left ventricular dysfunction), pulmonary artery hypertension (PAH) or coronary artery disease (CAD) may complicate the pregnancy. Also pregnant women who has undergone heart valve surgery and are on anticoagulants like warfarin need special attention. The risks associated with heart disease during pregnancy include an increased likelihood of maternal complications such as heart failure, arrhythmias, and thromboembolic events like brain strokes. Additionally, the fetus (unborn child) may be at risk for growth restriction, premature birth, or stillbirth.
Preconception planning is crucial for women with pre-existing heart disease to optimize outcomes. Specialist cardiac consultation is essential. A thorough evaluation should assess the severity of the heart disease, identify potential contraindications to pregnancy, and provide personalized counseling regarding the risks associated with pregnancy. Risk stratification tools, such as the Cardiac Disease in Pregnancy (CARPREG) score, aid in determining the level of risk for each pregnant women.
Pregnancy in women with heartdisease requires meticulous monitoring throughout until delivery. Regular assessments of heart function, blood pressure, and fluid status are essential. Close attention to symptoms like shortness of breath, swelling of legs, or palpitations is necessary to detect worsening heart function promptly. Maternal complications such as heart failure, arrhythmias, or preeclampsia (a condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and urinary protein) require immediate management to prevent adverse outcomes.
Collaboration between obstetricians, cardiologists, and other specialists is paramount in managing pregnant women with heart disease. Treatment plans must be individualized and may involve medication adjustments, lifestyle modifications, and close monitoring. Women with moderate to high-risk heart disease may require specialized care, including more frequent prenatal visits, echocardiograms, blood tests and cardiac monitoring. Echocardiography is an invaluable tool for the diagnosis and evaluation of suspected cardiac disease in the pregnant patient. In patients with artificial heart valves on anticoagulants like warfarin , special care and treatment are needed in different trimester of pregnancy (switching from warfarin to heparin and recommencing warfarin). The choice of delivery method should be carefully considered, weighing the risks and benefits of normal delivery versus cesarean section.
To conclude, pregnancy and heart disease present a delicate balance that requires comprehensive care and management. Women with such pre-existing disease can successfully navigate pregnancy with proper planning, risk assessment, and multidisciplinary collaboration. By closely monitoring mother and fetal well-being, ensuring the well-being of both mother and unborn baby demands vigilant attention throughout pregnancy.
Summary:
Heart disease during pregnancy encompasses a wide spectrum of disorders. Basic concepts to bear in mind include the following:
- Blood volume and cardiac output rise during normal pregnancy, reaching a peak during the late second trimester.
- Preexisting disease in heart should be evaluated with respect to the risk they impart during the stress of pregnancy.
- Contraindications to pregnancy include severe pulmonary hypertension or Eisenmenger’s syndrome, cardiomyopathy with severe shortness of breath at rest or minimal exertion, history of peripartum cardiomyopathy, severe uncorrected heart valve stenosis, unrepaired cyanotic congenital heart disease, and Marfan syndrome with an abnormal aorta.
- Awareness of major cardiac drug classes that are contraindicated during pregnancy is important for the treatment of high blood pressure and heart failure during pregnancy.
Anticoagulation during pregnancy presents unique challenges because of the maternal and fetal side effects of warfarin, unfractionated heparin, and LMWH (low molecular weight heparin).
