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==General Principles of Managing the Pregnant Patient with Congenital Heart Disease==
==General Principles of Managing the Pregnant Patient with Congenital Heart Disease==
There are five major maternal risk factors for maternal and fetal complications of pregnancy:
===Pulmonary Hypertension===
The maternal presence of [[pulmonary hypertension]] is the poorest prgnostic factor. The presence of Eisenmenger syndrome carries a particularly poor prognosis and is a contraindication to pregnancy.  Mortality is up to 25% in patients with Eisenmenger syndrome.


==Management of the Pregnant Patient with Congenital Heart Disease Based Upon Their Hemodynamic Status==
==Management of the Pregnant Patient with Congenital Heart Disease Based Upon Their Hemodynamic Status==

Revision as of 01:40, 20 May 2010

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Given that more patients with congenital heart disease are living into adulthood, congenital heart disease is now rapidly becoming the most common cardiac problem among pregnant patients. There are also improved diagnostic techniques to aid in the management of these patients. Outcomes clearly linked to functional status pre-pregnancy. Children of affected mothers at increased risk of having similar lesions.

General Principles of Managing the Pregnant Patient with Congenital Heart Disease

There are five major maternal risk factors for maternal and fetal complications of pregnancy:

Pulmonary Hypertension

The maternal presence of pulmonary hypertension is the poorest prgnostic factor. The presence of Eisenmenger syndrome carries a particularly poor prognosis and is a contraindication to pregnancy. Mortality is up to 25% in patients with Eisenmenger syndrome.

Management of the Pregnant Patient with Congenital Heart Disease Based Upon Their Hemodynamic Status

Classification of Congenital Heart Disease Into Three Classes

Volume Overload (L-->R shunt)
  • Consider termination if detected early
  • Careful medical management
-Supplemental O2 during pregnancy
-Hospitalization at 20 weeks gestation
-Prompt treatment of CHF
-Avoid shifts in preload/afterload
Atrial Septal Defect (ASD): Arrhythmias, thromboembolism may develop among pregnant women with an ASD. However, there is no available evidence to suggest that pregnant patients should be managed differently from nonpregnant patients with respect to the indications for ASD closure are no different in pregnant women compared to non-pregnant women.
Pressure Overload
  • AS, MS
  • Pulmonic Stenosis
    • Degree of obstruction determines outcome
    • Gradient >80 mm Hg mandates correction
  • Coarctation of the aorta
    • Accounts for 9% of all congenital disease in adults
    • Class I or II patients usually do well
    • Overall 3.5% mortality in unoperated patients (aortic dissection/rupture, CVA, CHF, endocarditis)
    • HTN needs careful management
  • HOCM
    • Early to mid pregnancy,  C.O. and end-diastolic dimension ↓ outflow tract obstruction (counteracted by SVR)
  • Avoid Valsalva
  • Encourage left lateral decubitus position
    • Maximum risk period during delivery when blood loss can result in increased gradient + systemic hypotension
  • Keep well hydrated
  • Avoid digoxin, simpathomimetics and excessive diuretics
Cyanotic Heart Disease (R-->L shunt)[1]
  • Poor prognosticators:
    • Hematocrit > 60%
    • O2 sat<85%
  • Livebirth 12% vs. 92% is sat >90%
    • Systemic RV pressures
    • h/o recurrent syncope
  • Tetralogy of Fallot most common unrepaired defect
    • Drop in SVR leads to increased shunting, deeper cyanosis and rising HCT
    • Need to avoid Valsava during delivery
    • Maternal mortality more than 4%

Management of the Patient with Specific Congenital Heart Disease States

Aortic Stenosis

  • Most commonly bicuspid valve
  • Fixed cardiac output in response to stress
  • Patients with mild to moderate severity do very well
  • Severe cases have maternal mortality up to 17% and fetal mortality up to 32%
  • Critical cases need surgery / valvuloplasty
  • Any reduction in preload can lead to cardiac / cerebral ischemia and compromised uterine flow

Marfan's Syndrome

  • Autosomal dominant inheritance pattern (counseling is essential)
  • Major risk is aortic dissection
  • Most common in 3rd trimester or 1st stage of labor
  • Increases with enlarging aortic root diameter
  • Surgery recommended pre-conception if root diameter >40 mm
  • Surgery recommend during gestation if > 55 mm
  • Close follow-up with serial echo

Mitral Stenosis

Overview

  • Most hemodynamically important valvular problem during pregnancy
  • Physiologic changes result in increased pulse and C.O. with augmentation of diastolic gradient
  • Atrial fibrillation can lead to rapid deterioration
  • Volume shifts during delivery can result in pulmonary hypertension or pulmonary edema

Management of MS in Pregnancy

  • Restriction of physical activity and salt intake. Avoid supine position
  • Beta-blockade to lengthen disatolic filling period
  • Diuretics if necessary (gentle)
  • Consideration of invasive monitoring
  • Replace blood losses during delivery carefully
  • Percutaneous Balloon Mitral Valvuloplasty can be performed during pregnancy if necessary (Class III,IV)

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  1. Presbitero P. et al. Circulation 1994;89:2673-6.