Cardiac disease in pregnancy overview
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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
Approximately 1-4% of pregnancies in the United States occur in women with maternal cardiovascular disease. In fact, pregnancy can "unmask" underlying cardiovascular disease, due to the hemodynamic changes associated with pregnancy. [1] With a careful pre-pregnancy evaluation, most women with cardiovascular disease can carry a pregnancy to term with proper care.
Epidemiology and Demographics
Increasing numbers of women with congenital heart disease are now reaching childbearing age, making congenital heart disease the most common form of heart disease complicating pregnancy in the United States. Rheumatic heart disease is still prevalent in the developing world and in immigrant populations. Overall, maternal death during pregnancy in women with heart disease is rare, but certain conditions are associated with an increased mortality.[2]
Disorders Associated with Cardiovascular Disease in Pregnancy
Maternal cardiovascular disease includes (most commonly) congenital heart disease. Other cardiovascular disorders encountered during pregnancy include cardiomyopathies, both dilated and hypertrophic, and valvular heart disease, such as bicuspid aortic valve and mitral valve prolapse. Less common cardiovascular disorders include pulmonary hypertension and, rarely, coronary artery disease. The above cardiovascular disorders require a strategy regarding the frequency of follow-up by the cardiologist and a plan for labor and delivery.[3]
Risk Factors
The following clinical characteristics are independent predictors of adverse outcomes in a risk score for maternal cardiac complications[4]:
- Prior cardiac events or arrhythmia
- Poor functional class or cyanosis
- Left ventricular outflow tract obstruction
- Left ventricular systolic dysfunction
Pulmonary hypertension is a well recognized risk factor during maternal pregnancy. In particular the presence of Eisenmenger syndrome places the mother particularly high risk.
Diagnosis
History and Symptoms
Common symptoms present during pregnancy include: fatigue, decreased exercise capacity, hyperventilation, dyspnea, tachycardia and palpitations.
Secondary to inferior vena caval compression by the gravid uterus resulting in reduced venous return from the lower extremities, patients may even experience orthostatic lightheadedness and syncope.
Pedal edema is often observed during the last trimester and may lead to an erroneous diagnosis of heart failure.
Physical Examination
Significant similarities exist between the normal signs of pregnancy and the presence of an underlying cardiac disease; hence poses a clinical challenge to differentiate between the two. However, common signs include: jugular venous distension, pulmonary rales, increased intensity of heart sounds and pedal edema.
ECG
The common electrocardiographic findings that occur secondary to physiological changes during pregnancy include: tachycardia, short PR interval and left axis deviation.
Echocardiography
Echocardiograhy does not carry the risk of fetal irradiation; hence, is a safe and preferred screening method to assess cardiac function and valvular lesions.
Treatment
References
- ↑ Roos-Hesselink JW, Duvekot JJ, Thorne SA (2009). "Pregnancy in high risk cardiac conditions". Heart. 95 (8): 680–6. doi:10.1136/hrt.2008.148932. PMID 19329725.
- ↑ Siu SC, Colman JM (2001). "Heart disease and pregnancy". Heart. 85 (6): 710–5. PMC 1729784. PMID 11359761.
- ↑ Thorne SA (2004). "Pregnancy in heart disease". Heart. 90 (4): 450–6. PMC 1768170. PMID 15020530.
- ↑ Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC; et al. (2001). "Prospective multicenter study of pregnancy outcomes in women with heart disease". Circulation. 104 (5): 515–21. PMID 11479246.