Cardiac disease in pregnancy and congenital heart disease

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Special Scenarios: I. Pre-existing Cardiac Disease: Congenital Heart Disease Repaired Congenital Heart Disease Pulmonary Hypertension Rheumatic Heart Disease Connective Tissue Disorders II. Valvular Heart Disease: Mitral Stenosis Mitral Regurgitation Aortic Insufficiency Aortic Stenosis Mechanical Prosthetic Valves Tissue Prosthetic Valves III. Cardiomyopathy: Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Peripartum Cardiomyopathy IV. Cardiac diseases that may develop During Pregnancy: Arrhythmias Acute Myocardial Infarction Hypertension
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

• Rapidly becoming most common cardiac problem among pregnant patients
  • Improved diagnostic techniques
  • Availability of corrective surgery
• Children of affected mothers at increased risk of having similar lesions
• Outcomes clearly linked to functional status pre-pregnancy

Classification of disease

Can classify lesions into 3 classes:

I. Volume Overload (L → R shunt)

• Atrial septal defect, ventricular septal defect, and patent ductus arteriosis well tolerated if pulmonary hypertension not present

• Peripheral vascular resistance and systemic vascular resistance falls to same degree
• Degree of shunting does not change

• Eisenmenger’s Syndrome

• Maternal and fetal mortality ≥50%
• 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

II. Pressure Overload

• Aortic stenosis, mitral stenosis

• Pulmonic stenosis

• Degree of obstruction determines outcome
• Gradient >80 mm Hg mandates correction

• Coarctation of 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

• Hypertrophic cardiomyopathy

• Early to mid pregnancy, ↑ cardiac output and end-diastolic dimension, ↓ outflow tract obstruction (counteracted by systemic vascular resistance)

• 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, sympathomimetics and excessive diuretics

III. Cyanotic Heart Disease (R → L shunt)

• Poor prognosticators:

• Hematocrit > 60%

• O2 sat<85%

• Livebirth 12% vs. 92% is sat >90%
• Systemic right ventricular pressures

• h/o recurrent syncope

• Tetralogy of Fallot most common unrepaired defect

• Drop in systemic vascular resistance leads to increased shunting, deeper cyanosis and rising hematocrit
• Need to avoid valsava during delivery
• Maternal mortality more than 4%

References

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