Review
Management of pregnancy in women with acquired
and congenital heart disease
S E Bowater, S A Thorne
University Hospital Birmingham
NHS Foundation Trust, Queen
Elizabeth Hospital, Edgbaston,
Birmingham, UK
Correspondence to
Dr Sara Thorne, University
Hospital Birmingham NHS
Foundation Trust, Queen
Elizabeth Hospital, Edgbaston,
Birmingham B15 2TH, UK;
[email protected]
Received 1 May 2009
Accepted 8 September 2009
ABSTRACT
Heart disease is the leading cause of maternal mortality
in the UK. Deaths from acquired conditions such as
ischaemic heart disease are increasing and often occur in
patients with no history of heart disease, thus
emphasising the need for vigilance for risk factors in
women of childbearing age. All women with known heart
disease should have pre-pregnancy counselling to assess
for maternal and fetal risk. Women deemed to be at
moderate or high risk should be under the care of
a specialist antenatal team with experience of managing
women with heart disease in pregnancy. Conditions that
are considered particularly high risk (mortality >10%)
include Marfan syndrome with dilated aortic root, severe
left heart obstructive lesions, pulmonary hypertension,
and severe left ventricular dysfunction. This article
reviews the management of women with heart disease
during pregnancy, labour and in the puerperium.
INTRODUCTION
Cardiac disease is now the leading cause of
maternal mortality in the UK1 and the numbers of
deaths have been increasing steadily over the past
two decades. The main cause of the rise in maternal
cardiac deaths is an increase in acquired conditions
such as ischaemic heart disease (IHD). This is due to
both trends in lifestyle which have led to increasing
numbers of pregnancies in women with risk factors
including obesity, diabetes and smoking, and also
the changing attitudes of society with older women
becoming pregnant. Furthermore, women with preexisting disease often now consider pregnancy.
Acquired heart disease is frequently undiagnosed
before pregnancy, remaining undetected until
pregnancy exposes underlying heart disease or
precipitates symptoms for the ﬁrst time. Diagnosis
may be delayed because many of the symptoms
and signs that occur in decompensated heart
disease, such as shortness of breath and ankle
swelling, are commonly experienced by the woman
in a ‘normal pregnancy’.
In contrast to acquired disease, maternal deaths
from congenital heart disease have declined despite
increasing numbers of patients reaching childbearing age and patients with higher risk conditions
now becoming pregnant. Congenital heart disease
does, however, remain a considerable cause of both
maternal and fetal morbidity. These women should
have access to specialist ‘high risk’ pre-pregnancy
counselling and antenatal care.
It is important to recognise that most women
with heart disease are able to tolerate a pregnancy
with a successful outcome and these women
should not be advised against pregnancy inappropriately. All women with known heart disease
100
should receive expert pre-pregnancy counselling
and advice on safe and effective contraception.
This article reviews the haemodynamic changes
that occur in pregnancy and discusses the approach
to the woman with heart disease in pregnancy,
including the pre-pregnancy assessment and
management during delivery and in the puerperium.
HAEMODYNAMIC CHANGES IN PREGNANCY
Circulatory changes start early on in the pregnancy
and peak towards the end of the second trimester
(ﬁgure 1). They are signiﬁcant and can have an
impact even on healthy women; the risk of pregnancy in the woman with heart disease is largely
determined by their ability to adapt to these
changes.
Plasma volume increases by 30e50% during
pregnancy, leading to an increased stroke volume.
This increased stroke volume along with an elevated
resting heart rate results in an increase in cardiac
output by up to 50%. Circulating oestrogens and
prostaglandins along with a low resistance placental
bed lead to a drop in systemic vascular resistance of
up to 30%, and as a result a mild decrease in blood
pressure despite the elevated cardiac output. There
is a 20e30% increase in red cell mass resulting in an
increased total blood volume and a relative anaemia.
Oxygen consumption increases throughout pregnancy to meet the metabolic needs of both mother
and fetus.
These changes persist for 2e3 weeks postdelivery but may not completely resolve for up to
12 weeks, highlighting the ongoing risk of cardiovascular collapse even after delivery.3
During labour and delivery cardiac output is
further increased, due to increased stroke volume as
additional blood reaches the circulation with each
uterine contraction, and also to a raised heart rate
due to pain. Following delivery of the placenta
there is a rapid rise in preload due to the venous
return of blood to the maternal circulation, thus
putting the woman with heart disease at risk of
pulmonary oedema.
PRECONCEPTION ASSESSMENT
All women with known heart disease should be
seen preconception by a cardiologist or obstetrician
with an interest in heart disease in pregnancy,
ideally in a joint clinic. Counselling should include
the effects of pregnancy on the mother and fetus as
well.
Maternal risk
The risk of pregnancy to the mother with heart
disease ranges from very low, similar to the general
populationdfor example, in mild pulmonary
Postgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
Review
presence of maternal cyanosis, poor functional class, left heart
obstruction, anticoagulation, smoking or multiple pregnancies.4
A further risk is recurrence of congenital heart disease in the
offspring. For conditions with no chromosomal abnormality or
family history, the recurrence rate is around 5%. However, it is as
high as 50% in single gene disorders such as Marfan syndrome. If
there is dysmorphism or a family history to suggest an underlying chromosomal or genetic abnormality, referral to a clinical
geneticist is recommended.
In general, drugs known to be teratogenic should be stopped
preconception or once pregnancy is conﬁrmed and suitable
alternatives should be commenced if necessary (Box 2).
Timing of pregnancy
Figure 1 Haemodynamic changes in pregnancy and post-delivery
(PD).2
Medical or surgical intervention may be necessary before pregnancy to optimise cardiac function and minimise the risks of
pregnancy. This may include optimisation of treatment of
conditions such as hypertension, diabetes or arrhythmia, and
surgical valve repair or replacement. The age of the woman with
pre-existing heart disease should also be considered, as pregnancy is likely to be tolerated better if the mother is in her 20s
rather than late 30s.
PREGNANCY IN SPECIFIC CONDITIONS
stenosis or repaired atrial septal defectdto up to a 50% risk of life
threatening cardiovascular event in pulmonary arterial hypertension. Siu et al2 looked at 599 pregnancies in women with heart
disease and found that 13% were complicated by a cardiac event,
most commonly pulmonary oedema, arrhythmia, stroke or
cardiac death. Predictors of adverse maternal events are shown in
Box 1. The impact of pregnancy on long term status should be
discussed, including the possibility of a permanent deterioration
in their functional status. Most studies to date, however, have
only addressed the time until delivery or the early puerperium, so
the long term effect of pregnancy on many cardiac conditions is
unknown.
Pre-pregnancy assessment of haemodynamic status and
functional capacity with echocardiogram, exercise testing and, if
indicated, cardiac catheterisation or magnetic resonance imaging
(MRI), are recommended in moderate and high risk patients. It
is important to be realistic with the prospective parents and, if
pregnancy is deemed a very high risk, alternatives such as
adoption or surrogacy should be discussed and appropriate
advice about contraception given.
Fetal risk
Maternal cardiac disease is associated with an increased risk of
fetal complications such as prematurity, intrauterine growth
retardation, and fetal loss.5 They are more likely to occur in the
Box 1 Predictors of adverse maternal events (derived from
Siu et al)4
New York Heart Association (NYHA) functional class >II
Cyanosis (SaO2 <90%)
Prior cardiovascular event
Systemic ventricular ejection fraction <40%
Left heart obstruction
Estimated risk of adverse event is 5%, 27% and 75% with 0,1 or
>1 of these risk factors respectively.
<
<
<
<
<
Postgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
It is the role of the obstetrician and the cardiologist to assess the
potential risks from a pregnancy, thus allowing the mother to
make an informed decision. There are some conditions, however,
that should be considered prohibitively high risk with a $10%
risk of maternal death. In these conditions women should be
counselled against pregnancy (Box 3). In the case of an unplanned
pregnancy or failure of contraception, termination of the pregnancy should be considered as an option.
HIGH RISK CONDITIONS
Despite medical advice, some women with these conditions do
decide to continue with pregnancy and should be under the
exclusive care of a specialist and multidisciplinary antenatal
team. An outline of the management of these conditions in
pregnancy is given below.
Pulmonary hypertension
Pulmonary hypertension in pregnancy is associated with risk of
maternal death of between 25e40%. Standard medical treatment includes oxygen therapy, diuretics and anticoagulation, but
recently there have been case reports of successful pregnancy
outcome with the use of targeted pulmonary vasodilators such as
inhaled iloprost6 and intravenous prostacyclin,7 and referral
should be made to a pulmonary hypertension centre in early
pregnancy for consideration of these. A recent review of pregnancies in women with Eisenmenger syndrome showed that all
deaths in this group occurred after delivery with a median time to
death of 6 days postpartum.8 Thus, high dependency care is
Box 2 Cardiac drugs to avoid/use with caution
<
<
<
<
<
Angiotensin converting enzyme (ACE) inhibitors
Angiotensin II receptor antagonists
Amiodarone
Warfarin
Spironalactone
101
Review
Box 3 High risk cardiac lesionsdadvise against
pregnancy
<
<
<
<
Pulmonary hypertension
Marfan syndrome with dilated aortic root*
Severe left heart obstructive lesions*
Systemic ventricular dysfunction
*Pregnancy risk reduced following valve or aortic root replacement or repair.
essential for several days postpartum due to the ongoing risk of
cardiovascular collapse.
Marfan syndrome
A normal aorta shows mild dilatation and an increased
compliance in pregnancy due to a combination of the haemodynamic changes and hormonal inﬂuence. Aortic dissection can
occur in previously apparently normal pregnant women, but
women with a known aortopathy such as Marfan syndrome are
at higher risk, the dissection occurring most commonly near
term or postnatally. Meijboom et al9 demonstrated that patients
with Marfan syndrome and an aortic root diameter at baseline of
>4 cm are at risk of increased aortic dilatation during pregnancy
and thus an increased risk of dissection and aneurysm formation.
Any woman with Marfan syndrome who presents with chest or
intrascapular pain in pregnancy should have urgent computed
tomography (CT) or MRI of their aorta to exclude dissection.
b-Blockers slow down the rate of aortic root dilatation and
should be considered in all pregnant women with Marfan
syndrome, especially those with a dilated root.
a hypercoagulable state. Maternal deaths from IHD are
increasing in the UK despite an overall drop in coronary deaths.
This increased rate reﬂects the impact of lifestyle factors such as
smoking and obesity. Techniques such as in vitro fertilisation are
enabling older women to become pregnant which is an additional
risk factor for pregnancy related AMI, with women >40 years
being at a 30-fold greater risk compared with those <20 years.10
In the most recent UK maternal mortality data, all women who
died from IHD had identiﬁable risk factors even though none had
known pre-existing disease.1 As many of the risk factors are
avoidable or modiﬁable, it stresses the importance of both identifying and addressing them preconception.
Prompt diagnosis and treatment of AMI is vital to reduce the
morbidity and mortality of both mother and fetus. Unfortunately the diagnosis is often missed in pregnant women due to
a low level of suspicion and a failure to recognise the symptoms
or ECG changes by the obstetric team. Chest pain is also
commonly reported in a normal pregnancy. Diagnosis is made by
characteristic ECG changes and a rise in cardiac enzymes.
Percutaneous coronary intervention is the treatment of choice
for AMI in pregnancy and is the only effective treatment when
the aetiology is coronary artery dissection. This should be
performed before delivery as the risk of delivery with an
untreated AMI is so high. Bare metal stents are preferable in
pregnancy to drug eluting stents due to the lower risk of acute
stent thrombosis. Ideally aspirin and clopidogrel should be
continued for 6 weeks with clopidogrel later being stopped
1 week before delivery. If percutaneous coronary intervention is
not available then thrombolysis should be considered. The
majority of information regarding thrombolysis in pregnancy is
gained from its use in pulmonary embolism, where it is associated with a maternal death rate of 1%12 and thus is considered to
be reasonably safe.
Severe aortic stenosis
Severe aortic stenosis is poorly tolerated in pregnancy due to the
inability to increase cardiac output through the stenotic valve.
This results in an increase in left ventricular pressure and an
increased gradient across the stenotic valve, and women often
develop symptoms for the ﬁrst time during pregnancy. Medical
treatment is aimed at decreasing heart rate with bed rest and
b-blockade to increase time for left ventricular ejection and
coronary ﬁlling. If the woman deteriorates despite medical
treatment and the gestational age is not sufﬁcient for delivery,
intervention should be considered. The options are percutaneous
balloon valvotomy, surgical valvotomy or valve replacement.
Systemic ventricular dysfunction
Ventricular dysfunction may be due to a pre-existing condition
such as dilated cardiomyopathy or new onset peripartum
cardiomyopathy. Standard heart failure should be used including
oxygen, diuretics and vasodilators, but angiotensin converting
enzyme (ACE) inhibitors should usually be withheld until after
delivery due to the risk of renal impairment in the fetus.
Thromboprophylaxis is essential due to the increased risk of
thromboembolism.
ISCHAEMIC HEART DISEASE
Acute myocardial infarction (AMI) is rare in pregnancy, with
James et al10 estimating an incidence of 6.2/100 000 deliveries in
North America between 2000 and 2002. However, pregnancy
itself is an independent risk factor for AMI, increasing the incidence by three- to fourfold even in the absence of other risk
factors,10 11 due to the altered haemodynamic situation plus
102
RHEUMATIC HEART DISEASE
Rheumatic mitral stenosis accounts for nearly all cardiac
maternal deaths in the developing world. Although rare in the
UK rheumatic heart disease is still encountered, mainly in the
immigrant population. There were two reported deaths from
mitral stenosis, both in recently arrived immigrant women, in
the most recent UK CEMACH report, the ﬁrst UK deaths for
more than a decade. Silversides et al13 reported cardiac complications in 35% of pregnancies in women with rheumatic mitral
stenosis, most commonly pulmonary oedema and arrhythmias,
and a worsening in functional class in 40%. The symptoms peak
at around 20e24 weeks as the cardiac output and plasma volume
peak. The transmitral gradient, already raised in mitral stenosis,
is further increased by the tachycardia and high stroke volume
leading to raised atrial pressures, dyspnoea and pulmonary
oedema. The presence of atrial ﬁbrillation or pulmonary hypertension will lead to further decompensation. The mainstay of
treatment is bed rest, diuretics and rate control with b-blockers.
Percutaneous balloon mitral valvuloplasty should be considered if
symptoms persist despite medical treatment.
All women with rheumatic heart disease should be referred to
a tertiary cardiac centre for assessment and a low index of
suspicion should remain for all immigrant women who develop
shortness of breath, palpitations or orthopnoea during pregnancy.
ARRHYTHMIAS
Palpitations are common during pregnancy with >50% of women
experiencing ectopic beats or non-sustained arrhythmias.14
Postgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
Review
Ectopics and supraventricular tachycardias (SVT) may occur in
a normal heart; however, atrial ﬂutter or ﬁbrillation and sustained
ventricular arrhythmias suggest underlying heart disease and
require thorough investigation. Pregnancy is associated with an
increased risk and severity of arrhythmias due to the haemodynamic and hormonal changes and increased sympathetic drive.
Women presenting with palpitations during pregnancy should
have an accurate ECG diagnosis of the arrhythmia (this may
require 24 h or longer ECG monitoring), assessment of any
structural cardiac disease, and exclusion of underlying systemic
disorders such as hyperthyroidism.
Many arrhythmias do not require pharmacological treatment
but this should be initiated in the presence of severe symptoms
or haemodynamic compromise. Drugs should be commenced at
the lowest effective dose and concentrations should be monitored closely due to the altered pharmacokinetics and increased
volume of distribution. Electrical cardioversion is safe
throughout pregnancy and should be administered, with the
woman in a left lateral position, for any arrhythmias compromising maternal and fetal circulation.
SVTs
Both new and recurrent SVTs are encountered with increased
frequency in pregnancy. Vasovagal manoeuvres should be
attempted ﬁrst, but if unsuccessful adenosine can be used safely
in pregnancy. b-Blockers may be required in recurrent cases.
b-Blockers are safe to use in pregnancy but require fetal growth
monitoring and heart rate monitoring at delivery.
Atrial fibrillation and flutter
Atrial ﬁbrillation and ﬂutter are most commonly seen in structural or congenital heart disease. Digoxin and b-blockers may be
used if drugs are required. Verapamil has been associated with
a risk of signiﬁcant fetal bradycardia although there are little data
regarding this. If rapid conversion to sinus rhythm is not
achieved then anticoagulation may need to be considered.
Ventricular tachycardia (VT)
Idiopathic VT is uncommon and usually arises from the right
ventricular outﬂow tract with a left bundle morphology and
inferior axis. VT associated with structural heart disease is
associated with a signiﬁcant risk of sudden death and should be
promptly treated with electrical cardioversion, lidocaine or
amiodarone. Potentially toxic drugs such as amiodarone should
be avoided but may be required in refractory arrhythmias.
Women with implantable deﬁbrillators are able to have
a successful pregnancy; one study involving 44 women with
implantable deﬁbrillators during pregnancy showed no increase
in the number of shocks delivered or device complications.15
coagulation, valve position, and fetal outcome. Bioprostheses
have a low thromboembolic risk and thus avoid the need for
anticoagulation, but they are at risk of structural valve degeneration necessitating further surgery. Conversely mechanical
valves have much greater durability but are associated with
a signiﬁcantly higher risk of valve thrombosis, which is increased
further in pregnancy due to the hypercoagulable state and is
highest with single leaﬂet tilting disc mitral valves. They are also
associated with an increased incidence of adverse fetal events
and neonatal mortality secondary to mandatory anticoagulation
use.16 The risk and beneﬁts for each valve type is summarised in
Box 4.
Warfarin is teratogenic (although the risks appear small in
doses <5 mg,17) and is also associated with miscarriage, placental
bleeding, and fetal intracerebral haemorrhage. Heparin does not
affect the fetus as it does not cross the placenta due to its size,
but is associated with an increased risk of thrombotic events
compared with warfarin. This is due to difﬁculties in maintaining adequate anticoagulation, and events appear related to
inadequate dosing and lack of monitoring.18 There is currently no
consensus as to the most appropriate anticoagulation regimen
during pregnancy, although all advocate heparin from week 36 to
allow the fetus to metabolise warfarin before delivery. Different
anticoagulation regimens are shown in Box 5. The long half life of
low molecular weight heparin may allow better control of anticoagulation than unfractionated heparin, if used in conjunction
with a haematologist and ensuring close monitoring of anti-Xa
concentrations, maintaining values >1 with dose adjustment
accordingly.
The risks and beneﬁts to both mother and fetus of the possible
anticoagulation regimens should be discussed with each woman.
CONGENITAL HEART DISEASE
All women with congenital heart disease should be referred for
specialist counselling pre-pregnancy or, if pregnant, as early as
possible. As previously discussed there is a wide spectrum of
risk ranging from that similar to the general population to
prohibitively high risk as seen in pulmonary hypertension. A
full review of congenital heart disease in pregnancy is out of the
scope of this article but has been covered thoroughly in other
reviews.20 21
MANAGEMENT OF THE PREGNANT WOMAN
All women with heart disease deemed high risk for pregnancy
should be managed in a specialised unit.22 There should be
a dedicated multidisciplinary team with experience of managing
heart disease in pregnancy, including an obstetrician, cardiologist,
Bradycardias
Bradycardias are much less common during pregnancy. Isolated
congenital heart block with no symptoms does not require
pacing either during pregnancy or labour. In the presence of
symptoms or a dilated left ventricle a permanent pacemaker
should be inserted with care to minimise radiation to the fetus.
PROSTHETIC VALVES AND ANTICOAGULATION
Prosthetic valves can be either a bioprosthesis (including
homografts, heterografts and autografts) or a mechanical valve.
For women who require a valve replacement but would like to
consider pregnancy in the future, a detailed discussion is needed
to select the appropriate valve type. Factors to consider are
durability of the valve, thromboembolic risk, need for antiPostgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
Box 4 Risks and benefits for prosthetic valve types
Bioprosthetic valve
e Low risk of thromboembolism
e No need for anticoagulation
e [ rate of structural valve degeneration
Mechanical prosthetic valve
e Excellent durability
e Superior haemodynamic profile
e High risk of thromboembolism
e Anticoagulation required
e Associated with fetal and neonatal complications
103
Review
Box 5 Anticoagulation regimens in pregnancy with
a prosthetic valve (adapted from Bates et al)19
Current research questions
< What is the long term effect of pregnancy on different cardiac
< Dose adjusted unfractionated heparin (UFH) throughout
pregnancy (12 h subcutaneous)
< Dose adjusted low molecular weight heparin (LMWH)
throughout pregnancy
< UFH or LMWH until week 13, warfarin until week 35, then
LMWH or UFH until delivery
Consider adjunctive antiplatelet therapy to any of above regimens
in 2nd and 3rd trimesters.
anaesthetist, haematologist, midwives, a neonatologist if the
baby is considered at risk, and an adult intensivist in very high
risk cases. The timing, place and mode of delivery should be
planned well in advance in all moderate to high risk patients.
This may require the woman delivering in a hospital at
a considerable distance from home.
DELIVERY AND POSTPARTUM CARE
The mode of delivery is generally determined by obstetric rather
than cardiac indications; vaginal delivery with a low threshold
for forceps assistance is preferable in most women. The exceptions to this are warfarin treatment within the last 2 weeks,
Marfan syndrome, aortic aneurysm of any cause, and an acutely
unwell mother.20 Vaginal delivery is generally associated with
a lower risk of maternal and fetal complications with less blood
loss, fewer rapid haemodynamic changes, and less risk of peripartum infection compared to caesarean section. There is a lack
of prospective trial data on prophylactic antibiotic administration for infective endocarditis, but there is a strong case for giving
antibiotics to high risk women undergoing procedures associated
with signiﬁcant or prolonged bacteraemia.23
Effective analgesia and anaesthesia is vital to limit the cardiac
stress arising from contractions. Regional anaesthetic techniques
such as spinal and epidural are the most commonly used in the
UK for caesarean section, but do carry the risk of profound
vasodilatation and hypotension due to autonomic paralysis. In
high risk cardiac patients who require regional anaesthesia, slow
and incremental dose epidural with invasive monitoring is
advised as this carries a lower risk of cardiovascular collapse than
spinal anaesthesia, due to the lower doses used. Speciﬁc
contraindications to regional anaesthesia in cardiac disease
Key learning points
conditions?
< What are the ways in which we can reduce the rising numbers
of deaths from heart disease?
include use of anticoagulation and severely limited or ﬁxed
cardiac output.
Monitoring during labour and delivery should be individualised with continuous ECG and intermittent blood pressures as
a minimum. Invasive blood pressure and central venous pressure
monitoring should be used in lesions where large or rapid ﬂuid
shifts are poorly tolerated, such as left sided obstructive lesions.
Pulmonary artery catheters are rarely indicated.
The risk of cardiovascular decompensation remains after
delivery due to the changes in circulating volume and elevated
cardiac output, stroke volume and heart rate. This stresses the
need for high risk patients to remain in an appropriate place
where monitoring is possible, such as a high dependency unit,
after delivery and not be immediately discharged to the general
postnatal ward.
CONCLUSIONS
The number of women with both congenital and acquired heart
disease becoming pregnant is increasing. Although heart disease
is now the leading cause of maternal mortality and a cause of
signiﬁcant morbidity, the majority of women are able to have
a successful pregnancy. Women with heart disease should be
seen in a joint obstetricecardiology clinic preconception for
assessment of risk and optimisation of their clinical status, and
should be managed by an experienced multidisciplinary team
throughout pregnancy.
Due to the relatively small number of pregnancies in women
with some cardiac conditions, there is a need for large multicentre
studies looking at the long term impact of pregnancy on survival
and clinical status to enable us to give an accurate assessment of
the risks involved to all women with heart disease.
Key references
< Royal College Obstetrics Gynaecology. Saving mothers’
<
< Heart disease is the leading cause of maternal mortality in the
UK.
<
< Deaths from IHD have shown the biggest increase and risk
factors in women of childbearing age should be actively sought
and modified before pregnancy.
< All women with heart disease should have preconception
counselling.
< Appropriate contraceptive advice should be offered to women
deemed high risk for pregnancy.
< Moderate and high risk women should be managed by
a specialist antenatal team.
104
<
<
lives: reviewing maternal deaths to make motherhood safer.
7th report of the Confidential Enquiries into Maternal Deaths in
the UK. London: CEMACH, 2007.
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter
study of pregnancy outcomes in women with heart disease.
Circulation 2001;104:515e21.
Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome
of pregnancy in women with congenital heart disease:
a literature review. J Am Coll Cardiol 2007;49:2303e11.
Thorne SA. Pregnancy in heart disease. Heart
2004;90:450e6.
Task Force on the Management of Cardiovascular
Diseases During Pregnancy of the European Society of
Cardiology. Expert consensus document on management of
cardiovascular diseases during pregnancy. Eur Heart J
2003;24:761e81.
Postgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
Review
The majority of cardiac deaths in pregnancy occur in women
with no previously diagnosed heart disease. Vigilance is needed to
identify at risk patients for targeted antenatal and postnatal care.
Deaths from ischaemic heart disease have seen the biggest increase
and have now overtaken congenital heart disease as the leading
cause of death in pregnancy. Obesity and smoking are major public
health issues that should be addressed early in life to ensure that
deaths from IHDdboth during pregnancy and in the general
populationddo not continue to rise and reach epidemic
proportions.
MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F)); ANSWERS
AFTER THE REFERENCES
1. In normal pregnancy
A. Haemodynamic changes peak during ﬁrst trimester
B. Cardiac output increases by 50%
C. Systemic vascular resistance increases
D. Blood pressure decreases
E. Haemodynamic changes resolve within 1 week of delivery
B. Slow and incremental dose epidural may be used in most high
risk women
C. After delivery women with PHTcan be managed on a general
ward
D. Elective caesarean section should be performed if there is an
aortic aneurysm
E. Effective analgesia is important to limit cardiac stress
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
REFERENCES
1.
2.
3.
4.
5.
2. Regarding maternal and fetal risk
A. Maternal risk is not increased in NYHA III
B. Women with severe PHT should be advised against pregnancy
C. Women with severe aortic stenosis should be managed in
a specialised centre
D. Maternal cyanosis does not affect fetal outcome
E. Recurrence of congenital heart disease in the offspring is 20%
3. Regarding IHD in pregnancy
A. Pregnancy is an independent risk factor for AMI
B. Increasing maternal age does not increase the risk of AMI
during pregnancy
C. Pregnancy is an absolute contraindication to thrombolysis
D. Primary PCI is the treatment of choice for AMI during
pregnancy
E. Women who have AMI during pregnancy usually have
identiﬁable risk factors
4. Regarding mitral stenosis in pregnancy
A. Symptoms peak towards the end of second trimester
B. It is more common in immigrant population
C. Dyspnoea arises due to a fall in transmitral gradient
D. Rate control with beta-blockers can improve symptoms
E. Balloon valvuloplasty is never indicated during pregnancy
5. The following are true regarding drugs in pregnancy
A. ACE inhibitors are safe in pregnancy
B. Fetal growth monitoring should be performed if beta-blockers
are used
C. Warfarin should be avoided in the ﬁrst trimester
D. LMWH may be used with mechanical valves but anti-Xa
levels must be monitored
E. Warfarin may be used safely in the third trimester
6. The following are true regarding delivery and postpartum
management in women with heart disease
A. Caesarean section is the mode of delivery of choice for women
with heart disease
Postgrad Med J 2010;86:100e105. doi:10.1136/pgmj.2008.078030
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Royal College Obstetrics Gynaecology. Saving mothers’ lives: reviewing maternal
deaths to make motherhood safer. 7th report of the Confidential Enquiries into
Maternal Deaths in the UK. London: CEMACH, 2007.
Oakley C. Heart disease in pregnancy. 1st edn. London: BMJ Publishing Group; 1997.
Abbas AE, Lester SJ, Connolly H. Pregnancy and the cardiovascular system. Int J
Cardiol 2005;98:179e89.
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy
outcomes in women with heart disease. Circulation 2001;104:515e21.
Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome of pregnancy in women
with congenital heart disease: a literature review. J Am Coll Cardiol
2007;49:2303e11.
Elliot CA, Stewart P, Webster VJ, et al. The use of iloprost in early pregnancy in
patients with pulmonary arterial hypertension. Eur Respir J 2005;26:168e73.
Stewart R, Tuazon D, Olson G, et al. Pregnancy and primary pulmonary hypertension:
successful outcome with epoprostenol therapy. Chest 2001;119:973e5.
Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on
pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart
J 2009;30:256e65.
Meijboom LJ, Vos FE, Timmermans J, et al. Pregnancy and aortic root growth in the
Marfan syndrome: a prospective study. Eur Heart J 2005;26:914e20.
James AH, Jamison MG, Biswas MS, et al. Acute myocardial infarction in pregnancy:
a United States population-based study. Circulation 2006;113:1564e71.
Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll
Cardiol 2008;52:171e80.
Ahearn GS, Hadjiliadis D, Govert JA, et al. Massive pulmonary embolism during
pregnancy successfully treated with recombinant tissue plasminogen activator: a case
report and review of treatment options. Arch Intern Med 2002;162:1221e7.
Silversides CK, Colman JM, Sermer M, et al. Cardiac risk in pregnant women with
rheumatic mitral stenosis. Am J Cardiol 2003;91:1382e5.
Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias during
pregnancy. Heart 2007;93:1630e6.
Natate A, Davidson T, Geiger MJ, et al. Implantable cardioverter-defibrillators and
pregnancy: a safe combination? Circulation 1997;96:2808e12.
Elkayam U, Bitar F. Valvular heart disease and pregnancy: part ii: prosthetic valves.
J Am Coll Cardiol 2005;46:403e10.
Cotrufo M, De Feo M, De Santo LS, et al. Risk of warfarin during pregnancy with
mechanical valve prostheses. Obstet Gynecol 2002;99:35e40.
Stout KK, Otto CM. Pregnancy in women with valvular heart disease. Heart
2007;93:552e8.
Bates SM, Greer IA, Hirsh J, et al. Use of antithrombotic agents during pregnancy.
Chest 2004;126(3 Suppl):627Se44S.
Thorne SA. Pregnancy in heart disease. Heart 2004;90:450e6.
Head CEG, Thorne SA. Congenital heart disease in pregnancy. Postgrad Med J
2005;81:292e8.
Task Force on the Management of Cardiovascular Diseases During
Pregnancy of the European Society of Cardiology. Expert consensus document
on management of cardiovascular diseases during pregnancy. Eur Heart J
2003;24:761e81.
Steer PJ, Gatzoulis MA, Baker P. Heart disease and pregnancy. 1st edn. London:
RCOG Press, 2006.
ANSWERS
1.
2.
3.
4.
5.
6.
(A)
(A)
(A)
(A)
(A)
(A)
F; (B) T; (C) F; (D) T; (E) F
F; (B) T; (C) T; (D) F; (E) F
T; (B) F; (C) F; (D) T; (E) T
T; (B) T; (C) F; (D) T; (E) F
F; (B) T; (C) T; (D) T; (E) F
F; (B) T; (C) F; (D) T; (E) T
105
Management of pregnancy in women with
acquired and congenital heart disease
S E Bowater and S A Thorne
Postgrad Med J 2010 86: 100-105
doi: 10.1136/pgmj.2008.078030
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