Cardiac disease in pregnancy and valvular heart disease
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anjan K. Chakrabarti, M.D. [2]
Overview
Rheumatic heart disease remains prevalent in developing countries but is less common in Western countries. Mitral stenosis therefore complicates pregnancy less frequently and Western countries. Bicuspid aortic stenosis, mitral regurgitation, aortic regurgitation, and prosthetic valves can all be problematic during pregnancy due to physiologic hemodynamic changes.
For a general overview of valvular heart disease, click here.
Specific Issues with Valvular Disease in Pregnancy
Mitral Stenosis
- Most hemodynamically important valvular heart disease during pregnancy
Pathophysiology:
- Increase in cardiac output coupled with the increase in heart rate shortens the diastolic filling time.
- The short and diastolic filling time in turn increases the mitral valve gradient.
Screening:
- Patients should have echocardiography prior to proceeding with pregnancy.
- Exercise echocardiography may be warranted.
Management:
- Restriction of physical activity and salt intake. Avoid supine position.
- Judicious use of diuretics and beta-blockade are appropriate in symptomatic cases to lengthen disatolic filling period.
- Consideration of invasive monitoring.
- Replace blood losses during delivery carefully.
- Percutaneous balloon mitral valvuloplasty has been utilized in symptomatic cases (Class III,IV).[1]
Complications:
- Atrial fibrillation can lead to rapid deterioration.
- Volume shifts during delivery can result in pulmonary hypertension or pulmonary edema.
- For further information, click here
Mitral Regurgitation
- Fairly well tolerated in pregnancy.
- The left ventricle tends to dilate as pregnancy progresses, and this may worsen mitral regurgitation.
- Early delivery is sometimes necessary in case of maternal hemodynamic instability.
- For further information, click here
Aortic Insufficiency
- As with mitral regurgitation, fairly well tolerated.
- Closer monitoring is warranted, early delivery may be necessary.
- For further information, click here
Aortic Stenosis
- Generally due to bicuspid aortic valve.
- Fixed cardiac output in response to stress.
- Moderate stenosis may be tolerated in a compliant patient who is monitored closely.
- Severe cases have maternal mortality up to 17% and fetal mortality up to 32%.
- Aortic root dilation > 4.5cm is a contraindication to pregnancy.
- Any reduction in preload can lead to cardiac or cerebral ischemia and compromised uterine flow.
- Aortic balloon valvuloplasty has been safely performed in a small subset of pregnancy patients with some success, as described by Myerson et al.[2]
- For further information, click here
Prosthetic Valves and Pregnancy[3]
Mechanical Prosthetic Valves
Mechanical valves can be problematic in pregnancy, due to the requirement for anticoagulation. Regardless of the strategy used, there is a higher chance of fetal loss, placental hemorrhage, and prosthetic valve thrombosis.
Recommendations from the ACC/AHA for anticoagulation during pregnancy are:[4]
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1. The decision whether to use heparin during the first trimester or to continue oral anticoagulation throughout pregnancy should be made after full discussion with the patient and her partner; if she chooses to change to heparin for the first trimester, she should be made aware that heparin is less safe for her, with a higher risk of both thrombosis and bleeding, and that any risk to the mother also jeopardizes the baby. 2. High-risk women (a history of thromboembolism or an older- generation mechanical prosthesis in the mitral position) who choose not to take warfarin during the first trimester should receive continuous unfractionated heparin intravenously in a dose to prolong the mid-interval (6 h after dosing) activated partial thromboplastin time to 2 to 3 x control value. Transition to warfarin can occur thereafter. 3. In patients receiving warfarin, the international normalized ratio should be maintained between 2.0 and 3.0 with the lowest possible dose of warfarin, and low-dose aspirin should be added. 4. Women at low risk (no history of thromboembolism, newer low- profile prosthesis) might be managed with adjusted-dose subcutaneous heparin (17,500 to 20,000 U twice daily to prolong the mid-interval (6 h after dosing) activated partial thromboplastin time to 2 to 3 x control value. 5. Warfarin should be stopped no later than week 36 and heparin substituted in anticipation of labor. 6. If labor begins during treatment with warfarin, a cesarean section should be performed. 7. In the absence of significant bleeding, heparin can be resumed 4–6 h after delivery, and warfarin begun orally. |
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Tissue Prosthetic Valves
Tissue valves have less thrombogencity than mechanical valves. As a result, they do not routinely involve the use of warfarin/anticoagulation. For a more thorough discussion on tissue valves, click here.
References
- ↑ Routray SN, Mishra TK, Swain S, Patnaik UK, Behera M (2004). "Balloon mitral valvuloplasty during pregnancy". Int J Gynaecol Obstet. 85 (1): 18–23. doi:10.1016/j.ijgo.2003.09.005. PMID 15050462.
- ↑ Myerson SG, Mitchell AR, Ormerod OJ, Banning AP (2005). "What is the role of balloon dilatation for severe aortic stenosis during pregnancy?". J Heart Valve Dis. 14 (2): 147–50. PMID 15792172.
- ↑ Elkayam U, Singh H, Irani A, Akhter MW (2004). "Anticoagulation in pregnant women with prosthetic heart valves". J Cardiovasc Pharmacol Ther. 9 (2): 107–15. PMID 15309247.
- ↑ Elkayam U, Bitar F (2005). "Valvular heart disease and pregnancy: part II: prosthetic valves". J Am Coll Cardiol. 46 (3): 403–10. doi:10.1016/j.jacc.2005.02.087. PMID 16053950.