Management of Management of Heart Disease in Heart Disease in

PregnancyPregnancy

It is estimated thatIt is estimated that 1% to 3% of women either have 1% to 3% of women either have cardiac disease entering pregnancycardiac disease entering pregnancy or are diagnosed or are diagnosed with cardiac disease while they are pregnant.with cardiac disease while they are pregnant.

Approximately 10% of all maternal deaths in the Approximately 10% of all maternal deaths in the United StatesUnited States can be attributed to cardiac diseasecan be attributed to cardiac disease

75% of the women with various types of cardiac 75% of the women with various types of cardiac disease had no complications during pregnancy.disease had no complications during pregnancy.

complication in 25% include :complication in 25% include :

Congestive heart failure, including pulmonary edema (12.3%)Congestive heart failure, including pulmonary edema (12.3%)

Cardiac arrhythmias (6%)Cardiac arrhythmias (6%)

Thromboembolism (1.9%)Thromboembolism (1.9%)

Angina (1.4%)Angina (1.4%)

Hypoxemia (0.7%)Hypoxemia (0.7%)

Infective endocarditisInfective endocarditis (0.5%)(0.5%)

The overall maternal mortality rate in this group was 2.7%,The overall maternal mortality rate in this group was 2.7%, and the stillbirth and and the stillbirth and spontaneous abortion rate was 7.7%.spontaneous abortion rate was 7.7%.

   -- High-Risk Pregnancies (not pregnant)

  Pulmonary hypertension

  

Dilated cardiomyopathy, ejection fraction <40%

   Symptomatic obstructive lesions

  Aortic stenosis

  Mitral stenosis

  Pulmonary stenosis

  

Coarctation of the aorta

  

Marfan syndrome with aortic root >40 mm

  Cyanotic lesions

  Mechanical prosthetic valves

MMaternal cardiac risk: (1)prior cardiac event (e.g., heart failure, transient ischemic attack,

or stroke before pregnancy) or arrhythmia; (2) baseline New York Heart Association (NYHA) class higher than

Class II or cyanosis; (3) left-sided heart obstruction

(4) reduced systemic ventricular systolic function (ejection fraction less than 40%).

-The estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively.

--It was concluded that those with a low cardiac risk of 0 could safely be delivered in a community hospital,

-but those at intermediate or high cardiac risk (risk score of 1 or more) should be delivered at a regional center.

Mode of DeliveryMode of Delivery

For most patients with cardiac disease, a vaginal delivery is feasible and preferable

a cesarean section is indicated only for obstetric reasons.

Exceptions to this include the patient who is anticoagulated with warfarin because the baby is also anticoagulated, and vaginal delivery carries an increased risk to the fetus of intracranial hemorrhage

Cesarean section may also be considered in patients who have a dilated unstable aorta (e.g., Marfan syndrome),

severe pulmonary hypertension a severe obstructive lesion such as aortic stenosis. High-risk patients should be delivered in a center where

expertise is available to monitor the hemodynamic changes of labor and delivery and to intervene when necessary

If vaginal delivery is elected, fetal and maternal electrocardiographic monitoring should be performed.

--Delivery can be accomplished with the mother in the left lateral position so that the fetus does not compress the inferior vena cava, thereby maintaining venous return.

The second stage should be assisted, if necessary (e.g., forceps or vacuum extraction), to avoid a long labor. Blood and volume loss should be replaced promptly

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