Managing the pregnant patient with heart disease

Evaluation of antihypertensives for post partum management of hypertensive disorders of pregnancy: A systematic review and meta-analysis

BACKGROUND

There is a lack of evidence that directly shows the best antihypertensive treatment options for post partum management of the hypertensive disorders of pregnancy. Our objective was to analyze the safest and most effective antihypertensive drugs post partum for patients with hypertensive disorders of pregnancy.

METHODS

PubMed, Cochrane, and MEDLINE were searched to find relevant articles published from inception to Feb 2024. We included randomized control trials, in English, featuring a population of postnatal women with hypertensive disorders of pregnancy or postpartum women with de novo hypertension with a follow-up of up to 6 months in which any antihypertensive medication was compared with Placebo or a comparison between different doses of antihypertensives was done. The statistical analyses were conducted using Review Manager with a random-effects model.

RESULTS

Our analysis revealed that almost all antihypertensives are effective in treating postpartum hypertension. However, some medications had alternating roles in controlling specific outcomes. Using calcium channel blockers resulted in a faster time to sustain BP control than the control (SMD: -0.37; 95% CI: -0.73 to -0.01; P = 0.04). In contrast, using ACE inhibitors or ARBs demanded the use of other antihypertensives in contrast to all other drugs assessed (RR: 2.09; 95% CI: 1.07 to 4.07; P = 0.03).

CONCLUSION

Timely management of the hypertensive disorders of pregnancy postpartum is life-saving. All the traditional antihypertensives we assessed effectively manage hypertension postpartum, thus allowing the physician to tailor the particular drug regimen according to the patient's needs and comorbidities without any hindrance.

Cardiovascular Diseases in Pregnancy - A Brief Overview

Even though, there have been many advances in maternal medical care and fertility treatments, the presence of cardiovascular disease has a significant impact on pregnancy. In pregnant women, several heart conditions, such as valvular heart disease, chronic hypertension, congenital heart defects and non-ischemic cardiomyopathies are linked to increased risk of fetal as well as maternal morbidity and mortality. To date, the management of the co-existing conditions of pregnancy and heart disease has been challenging. Therefore, in-depth information may be beneficial to tackle a difficult case scenario. Towards this end, this paper provides an overview of the recent updated knowledge of pregnancy-related cardiovascular diseases in women.

Coronary artery disease and myocardial infarction in pregnancy: a review of epidemiology, diagnosis, and medical and surgical management

Ischemic heart disease is uncommon during pregnancy, occurring in approximately one in 10,000 live births. With the increasing age and fertility of mothers, the incidence of coronary artery disease in pregnancy is likely to increase. Atherosclerosis appears to be the most common cause of acute myocardial infarction, although coronary spasm, coronary dissection and thrombus have been reported, among others. The diagnosis of ischemic heart disease in the pregnant population can be challenging and not without risk to the fetus. Although there have been many reports of acute myocardial infarction and cardiopulmonary bypass surgery during pregnancy, most knowledge is based on anecdotal reports. Even less is known about the use of thrombolytics, percutaneous coronary intervention and the optimal medical management of ischemic heart disease during pregnancy. The epidemiology, diagnosis, medical and surgical treatment, and prognosis of ischemic heart disease in pregnancy are the subject of the present review.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Assessment and management of cardiac disease in pregnancy

Approximately 1% of pregnancies are affected by congenital or acquired cardiac disease. The obstetric care provider requires an understanding of the expected cardiorespiratory adaptations to pregnancy in order to anticipate when and how the cardiac patient may decompensate. Although the majority of women with cardiac disease in pregnancy can expect a positive outcome, women should be evaluated for predictors of poor perinatal outcome to aid in determining the appropriate location for and surveillance in labour. Women affected with congenital heart disease require counselling about the risk of recurrence in their offspring. The discussion of contraceptive needs for the woman with cardiac disease is critical in the appropriate planning of her family.

Acquired Heart Disease in Pregnancy

The incidence of rheumatic heart disease in most industrialized countries is decreasing. Those women who have regurgitant lesions will commonly experience an improvement in symptoms, and therapy is required only in the most severe cases. Women with mild to moderate stenotic lesions can usually expect a good outcome to pregnancy, but women with severe stenotic lesions require close monitoring by both their obstetricians and their cardiologists, especially during the third trimester, labour and delivery, and the early postpartum period. This is the third in a series of five articles reviewing in detail the assessment and management of specific cardiac disorders in pregnancy.

Labor analgesia for the parturient with cardiac disease: what does an obstetrician need to know?

Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the cooperative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for this high-risk group of patients. This article will review the current guidelines and standards pertinent to management of obstetric analgesia and anesthesia in parturients with cardiac disease.

Cardiac disease and pregnancy

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Pregnancy and heart disease: a review

About one per cent of all pregnancies are affected by maternal heart disease, which may have significant influence on the maternal and foetal outcome. In this context rheumatic heart disease is declining and congenital heart disease is becoming the dominant category. Our experience of pregnancy in the new groups of patients created by paediatric heart surgery is scant and a continuous update is required.

Pulmonary hypertension, cardiac disease and pregnancy

OBJECTIVE

To ascertain the significance of coexisting pulmonary hypertension in cardiac disease in pregnancy.

METHODS

Over a 3-year period a group of pregnant women with cardiac disease was followed until 6 weeks postpartum. Twenty women with pulmonary hypertension were compared with 20 controls without pulmonary hypertension with particular reference to maternal and fetal outcome. Analysis of data was carried out using Fisher's exact test and Student's t-test.

RESULTS

Except for Eisenmenger's syndrome, there were no differences in maternal morbidity and mortality between the two groups. There were more low birth weight babies but no significant differences in premature delivery rate, mode of delivery or perinatal mortality.

CONCLUSION

Except for Eisenmenger's syndrome, coexisting pulmonary hypertension complicating cardiac disease in pregnancy generally has a favorable outcome for both mother and fetus.