Cardiac Disease in Pregnancy

Transcatheter therapy for aortic coarctation with severe systemic hypertension during pregnancy

Aortic coarctation is an unusual cause of hypertension during pregnancy and its management is not clarified. We report transcatheter balloon dilatation and stenting for native aortic coarctation in a 22-year-old pregnant woman with severe and uncontrolled systemic hypertension. Arterial blood pressure could be successfully controlled with medical treatment during the rest of the pregnancy and the patient underwent uneventful delivery. No adverse events or recoarctation was observed during 24 months clinical follow-up. In conclusion, native aortic coarctation can be successfully treated during pregnancy with transcatheter therapy. More experience is needed to confirm the safety and efficacy of such management.

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.

Hemodynamic assessment in a pregnant and peripartum patient

PATHOPHYSIOLOGY

Critical care in obstetrics has many similarities in pathophysiology to the care of nonpregnant women. However, changes in the physiology of pregnant woman necessary to maintain homeostasis for both mother and fetus, especially during critical illness, result in complex pathophysiology. Understanding the normal physiologic changes during pregnancy, intrapartum, and postpartum is the key to managing critically ill obstetric patients with underlying medical diseases and pregnancy-related complications.

HEMODYNAMIC MONITORING

When the pathophysiology of critically ill obstetric patients cannot be explained by noninvasive hemodynamic monitoring and the patient fails to respond to conservative medical management, invasive hemodynamic monitoring may be helpful in guiding management. Most important, the proper interpretation of hemodynamic data is predicated on knowledge of normal values during pregnancy and immediately postpartum. Invasive hemodynamic monitoring with pulmonary artery catherization has been used in the obstetric population, particularly in patients with severe preeclampsia associated with pulmonary edema and renal failure.

Pregnancy complicated by heart disease: a review of Canadian experience

The physiological adaptations to pregnancy can potentially worsen the prognosis in women whose pregnancy is complicated by heart disease. A comprehensive systematic approach to risk identification is desirable. The ability to predict a subgroup of women that are at a particularly increased risk of pregnancy-related complications can enhance the obstetric care we provide to this population. A retrospective review of 276 pregnancies associated with pre-existing heart disease was undertaken in three Toronto teaching institutions. During the course of the pregnancy, 45 (18%) of 252 completed gestations were complicated by adverse cardiovascular events (congestive heart failure, arrhythmia and stroke). Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia and prior cardiac events were predictive of maternal cardiac complications. These predictors were converted into a point score. If a point score was 0, 1 or more than 1, the risk of a given patient running into cardiovascular complication was 3%, 30% and 66%, respectively. The Canadian Prospective Multicenter Study offered the validation of this prediction rule. In this study, 13 centres recruited prospectively 599 patients with completed gestations. Similar factors were identified in their ability to predict adverse cardiac events. In addition, neonatal complications (20% of pregnancies) were associated with poor functional class or cyanosis, left heart obstruction, anticoagulation, smoking and multiple gestation. A sample of this prospective cohort (302 pregnancies) was compared to 572 matched pregnancies with no underlying heart disease. The neonatal complication rate was higher in the study group when compared to controls, 18% versus 7%, respectively. The highest neonatal complication rate (33%) was seen in gravidas with underlying heart disease who had previously identified cardiac risk factors, were at both extremes of reproductive age, had obstetrical risk factors, smoked or received anticoagulants. Both maternal and neonatal morbidity are increased significantly in gravidas with pre-existing heart disease, although mortality is low. Factors that place the mother and the neonate at risk can be identified before pregnancy. This allows informed counselling and development of a patient-specific management plan.

Cardiac disease in pregnancy

OBJECTIVES

To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country.

METHODS

A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at >or=28 weeks of gestation from June 1994 through December 2000 at a tertiary care center.

RESULTS

Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41 women who had received anticoagulants had any congenital malformation.

CONCLUSIONS

Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.

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.

Risk and predictors for pregnancy-related complications in women with heart disease

BACKGROUND

The physiological changes of pregnancy can result in cardiovascular complications in the mother, which in turn may have fetal implications. Prior studies have focused on specific cardiac lesions or identified univariate predictors. There is a need to refine the risk stratification of women with heart disease so they can receive appropriate obstetrical counseling and care.

METHODS AND RESULTS

We examined the outcomes of 221 women with heart disease who underwent 276 pregnancies and received their obstetrical care at three Toronto hospitals from 1986 through 1994. Those who underwent therapeutic abortions were excluded. Among the study participants, there were 24 miscarriages and 252 completed pregnancies (pregnancies not ending in miscarriage). Maternal heart failure, arrhythmia, or stroke occurred in 45 completed pregnancies (18%). There were no maternal deaths. Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. These predictors were incorporated into a point score that can be used to estimate the probability of a cardiac complication in the mother. The rate of cardiac complications for a patient with 0, 1, and >1 of the above factors was 3%, 30%, and 66%, respectively. Neonatal complications occurred in 42 completed pregnancies (17%). Neonatal events included death (2), respiratory distress syndrome (16), intraventricular hemorrhage (2), premature birth (35), and small-for-gestational-age birth weight (14). Poor maternal functional class or cyanosis was predictive of neonatal events.

CONCLUSIONS

Despite low maternal and neonatal mortality, pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. The probability of maternal cardiac or neonatal events can be predicted from baseline characteristics of the mother.

Valvular heart surgery during pregnancy

The pathophysiology of mitral and valvular heart disease is presented with an emphasis on the relationship of these conditions to pregnancy. Management options are discussed. Special attention is directed to patients who have prosthetic valves in place and who become pregnant. The care of this group of patients may be difficult, and treatment strategies are presented.

Congenital aortic stenosis and pregnancy--a reappraisal

OBJECTIVE

This study was performed to determine the maternal and fetal outcome in pregnant patients with congenital aortic stenosis without previous valvular replacement.

STUDY DESIGN

A retrospective review of 25 pregnancies in 13 patients delivered at our centers from September 1976 to September 1992 was undertaken.

RESULTS

Five (38%) patients had associated congenital heart lesions, three (23%) had severe stenosis (echocardiographically estimated valve area < or = 0.7 cm2), two had prior open aortic valve commissurotomy, and one had balloon valvuloplasty during pregnancy. There were no maternal deaths. Of the 25 pregnancies, five (20%) resulted in therapeutic abortions. There was no perinatal mortality, preterm labor, or increased incidence of pregnancy complications or fetal growth retardation in the remaining 20 pregnancies. One infant (5%) had congenital heart disease.

CONCLUSION

Pregnancy outcome is generally satisfactory in patients with congenital aortic stenosis.