Cardiovascular pharmacotherapeutic considerations during pregnancy and lactation

Spontaneous coronary artery dissection in women in the generative period: clinical characteristics, treatment, and outcome-a systematic review and meta-analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall.

Materials and methods

This systematic review and meta-analysis is reported following the PRISMA guidelines and is registered in the PROSPERO database. A literature search was focused on female patients in generative period (16-55 of age) with acute coronary syndrome (ACS) caused by SCAD, and comparison from that database NP-SCAD (spontaneous coronary artery dissection in non pregnant women) and P-SCAD (spontaneous coronary artery dissection in pregnant women).

Results

14 studies with 2,145 females in the generative period with ACS caused by SCAD were analyzed. The median age was 41 years (33.4-52.3 years). The most common risk factor was previous smoking history in 24.9% cases. The most common clinical presentation of ACS was STEMI in 47.4%. Conservative treatment was reported in 41.1%. PCI was performed in 32.7%, and 3.8% of patients had CABG surgery. LAD was the most frequently affected (50.5%). The prevalence of composite clinical outcomes including mortality, non-fatal MI and recurrent SCAD was 3.3% (95% CI: 1.4-5.1), 37.7% (95% CI: 1.9-73.4) and 15.2% (95% CI: 9.1-21.3) of patients. P-SCAD compared to NP-SCAD patients more frequently had STEMI (OR = 3.16; 95% CI: 2.30-4.34; I2 = 64%); with the left main and LAD more frequently affected [(OR = 14.34; 95% CI: 7.71-26.67; I2 = 54%) and (OR = 1.57; 95% CI: 1.06-2.32; I2 = 23%)]; P-SCAD patients more frequently underwent CABG surgery (OR = 6.29; 95% CI: 4.08-9.70; I2 = 0%). NP-SCAD compared to P-SCAD patients were more frequently treated conservatevly (OR = 0.61; 95% CI: 0.37-0.98; I2 = 0%). In P-SCAD compared to NP-SCAD mortality rates (OR = 1.13; 95% CI: 0.06-21.16; I2 = not applicable) and reccurence of coronary artery dissection (OR = 2.54; 95% CI: 0.97-6.61; I2 = 0%) were not more prevalent.

Conclusion

The results of this meta-analysis indicated that patients with P-SCAD more frequently had STEMI, and events more frequently involved left main and LAD compared to NP-SCAD patients. Women with NP-SCAD were significantly more often treated conservatively compared to P-SCAD patients. P-SCAD compared to NP-SCAD patients did not have significantly higher mortality rates or recurrent coronary dissection.

Peripartum management of patient with long QT3 after successful implantable cardioverter defibrillator device discharge resulting in device failure: a case report

Background

Long QT3 syndrome type 3 (LQT3) is a gain of function mutation of the SCN5A gene that is inherited in an autosomal dominant fashion. Long QT3 syndrome type 3 results in an increase in arrhythmic events during rest, sleep, and bradycardia by extending the QT interval and inducing Torsades de pointes and sudden cardiac death. Attempting to block the sodium channel with Class I anti-arrhythmics or blocking adrenergic tone with beta-blockers especially in women has shown to be beneficial. There have been few large-scale studies on treating patients with LQT3 due to its lethality and underreported number of cases. Specifically, the safety and efficacy of pharmacologic treatment in pregnant LQT3 patients are unknown.

Case summary

This case demonstrates the safe use of Mexiletine and Propranolol in a 3rd-trimester pregnant LQT3 patient after a presumed ventricular arrhythmia and device-lead electrical short from therapy rendered her implantable cardioverter defibrillator inoperable in a VVI mode (venticular demand pacing). With appropriate medications, the patient was safely monitored through the remainder of her pregnancy and safely delivered at 36 weeks of pregnancy a healthy baby girl. The daughter, heterozygous for LQT3, showed no evidence of intrauterine growth restriction or other side effects from the medications.

Discussion

There are many variants of the SCN5A gene mutations that can lead to different phenotypes and not all mutations are responsive to the same medications. In this case, Mexiletine and Propranolol, both of which have only recently shown to benefit certain variants or LQT3 respectively, were safely started during the 3rd trimester of pregnancy without harming the foetus.

[Cardiac arrhythmias in pregnancy : Epidemiology, clinical characteristics, and treatment options]

Symptomatic arrhythmias rarely occur during pregnancy and are predominantly benign. However, the increasing average age of women who are pregnant, especially in Western European countries, has contributed to a significant increase in arrhythmias in pregnant women in recent years. Previous or existing heart diseases can increase the occurrence of arrhythmias. In most cases pregnancy is safe and without consequences for the child and/or mother. Further cardiological work-up (including ECG and echocardiography, and possibly cardiac MRI) should always be performed. The indication for treatment should be made in close cooperation between obstetricians and cardiologists considering symptoms, hemodynamics and prognosis. In the absence of larger studies on efficacy and side effects of antiarrhythmic drugs, these should be administered very cautiously, under strict indication and whenever possible by avoiding the first trimester. Cardiologists with special expertise in arrhythmias should always be consulted, especially in the case of complex and relevant rhythm disturbances.

Rhythmusstörungen in der Schwangerschaft

Symptomatische Rhythmusstörungen treten während einer Schwangerschaft selten auf und sind überwiegend gutartig. Sie stellen dennoch eine besondere klinische Herausforderung dar, wobei sich diagnostische und therapeutische Möglichkeiten in Zusammenhang mit gleichzeitig älterem Durchschnittsalter bei Schwangerschaften in den vergangenen Jahren deutlich verbessert haben. In der Regel ist eine Schwangerschaft trotz Auftreten von Rhythmusstörungen sicher und ohne Folgen für das Kind. Vorbekannte oder vorhandene Herzerkrankungen können das Auftreten von Rhythmusstörungen begünstigen. Es sollte immer eine weiterführende kardiologische Diagnostik (u. a. EKG und Echokardiografie) erfolgen. Die Indikation zur Therapie sollte in enger Absprache zwischen Geburtsmediziner und Kardiologen/Rhythmologen erfolgen und dabei Symptomatik, Hämodynamik und Prognose berücksichtigen. Bei fehlenden größeren Studien zu Wirksamkeit und Nebenwirkungen von Antiarrhythmika sollten diese nur sehr zurückhaltend, unter strenger Indikation und am ehesten unter Umgehung des 1. Trimenons verabreicht werden. Insbesondere bei komplexen und prognostisch relevanten Rhythmusstörungen sollten immer Kardiologen mit besonderer rhythmologischer Erfahrung hinzugezogen werden.

Cardiovascular Medications in Pregnancy: A Primer

Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to increased rates of obesity, delayed childbearing, and improvements in medical technology, greater numbers of women are entering pregnancy with preexisting medical comorbidities. Use of cardiovascular medications in pregnancy continues to increase, and medical management of cardiovascular conditions in pregnancy will become increasingly common. Obstetricians and cardiologists must familiarize themselves with the pharmacokinetics of the most commonly used cardiovascular medications in pregnancy and how these medications respond to the physiologic changes related to pregnancy, embryogenesis, and lactation.

Over-the-counter analgesics during pregnancy: a comprehensive review of global prevalence and offspring safety

BACKGROUND

Analgesia during pregnancy is often necessary. Due to their widespread availability, many mothers opt to use over-the-counter (OTC) analgesics. Those analgesic compounds and their metabolites can readily cross the placenta and reach the developing foetus. Evidence for safety or associations with adverse health outcomes is conflicting, limiting definitive decision-making for healthcare professionals.

OBJECTIVE AND RATIONALE

This review provides a detailed and objective overview of research in this field. We consider the global prevalence of OTC analgesia during pregnancy, explain the current mechanistic understanding of how analgesic compounds cross the placenta and reach the foetus, and review current research on exposure associations with offspring health outcomes.

SEARCH METHODS

A comprehensive English language literature search was conducted using PubMed and Scopus databases. Different combinations of key search terms were used including 'over-the-counter/non-prescription analgesics', 'pregnancy', 'self-medication', 'paracetamol', 'acetaminophen', 'diclofenac', 'aspirin', 'ibuprofen', 'in utero exposure', 'placenta drug transport', 'placental transporters', 'placenta drug metabolism' and 'offspring outcomes'.

OUTCOMES

This article examines the evidence of foetal exposure to OTC analgesia, starting from different routes of exposure to evidence, or the lack thereof, linking maternal consumption to offspring ill health. There is a very high prevalence of maternal consumption of OTC analgesics globally, which is increasing sharply. The choice of analgesia selected by pregnant women differs across populations. Location was also observed to have an effect on prevalence of use, with more developed countries reporting the highest consumption rates. Some of the literature focuses on the association of in utero exposure at different pregnancy trimesters and the development of neurodevelopmental, cardiovascular, respiratory and reproductive defects. This is in contrast to other studies which report no associations.

WIDER IMPLICATIONS

The high prevalence and the challenges of reporting exact consumption rates make OTC analgesia during pregnancy a pressing reproductive health issue globally. Even though some healthcare policy-making authorities have declared the consumption of some OTC analgesics for most stages of pregnancy to be safe, such decisions are often based on partial review of literature. Our comprehensive review of current evidence highlights that important knowledge gaps still exist. Those areas require further research in order to provide pregnant mothers with clear guidance with regard to OTC analgesic use during pregnancy.

The Balance between the Safety of Mother, Fetus, and Newborn Undergoing Cystic Fibrosis Transmembrane Conductance Regulator Treatments during Pregnancy

The recent development of modulators of cystic fibrosis transmembrane conductance regulator (CFTR) has allowed the life expectancy of cystic fibrosis patients to increase substantially resulting in more women with cystic fibrosis reaching child-bearing age. This however raises the issue of whether long-term use of CFTR modulators during pregnancy and breastfeeding is safe for the fetus and newborn, especially for their developing brain. A very limited number of case reports available so far has shown that the fetus or breastfed newborn is likely to be exposed to maternally administered CFTR modulators. Potential impacts of drug exposure on the developing brain are of particular importance as the consequences might not be immediately noticeable upon birth but may manifest later in life as permanent neurobehavioral problems. In order for drugs in maternal circulation to enter the fetal brain, they must overcome the placental barrier followed by a series of brain barriers, each consisting of cellular components and physiological mechanisms such as efflux transporters. The extent of protection they offer during development will provide valuable insights into the potential entry and the effects of CFTR modulators in the developing brain. This review aims to explore the current understanding of the safety of CFTR modulators, especially ivacaftor, during pregnancy and breastfeeding, characterize the pharmacokinetics and pharmacodynamics of ivacaftor, both under normal conditions and during pregnancy, to provide context for its potential impact on the developing brain. Finally, we discuss the determinants that need to be taken into consideration when investigating the entry of drugs into the fetus and newborn.

Quetiapine dose optimisation during gestation: a pharmacokinetic modelling study

Objectives

The second-generation antipsychotic quetiapine has been demonstrated to undergo gestation-related changes in pharmacokinetics. This study applied pharmacokinetic modelling principles to investigate the mechanism of these changes and to propose new dosing strategies to counteract these changes.

Methods

A pharmacokinetic modelling approach was implemented using virtual population groups. Changes in quetiapine trough plasma concentration during gestation were quantified across all trimesters, and dose adjustment strategies were applied to counteract these changes by targeting a therapeutic range of 50–500 ng/ml throughout gestation.

Key findings

The application of the model during gestation predicted a decrease in trough concentration. A maximum decrease of 58% was predicted during trimester 2, and being associated with a statistically significant decrease in oral clearance at gestation week 25, 204 l/h ± 100.8 l/h compared with non-pregnant subjects, 121.9 l/h ± 51.8 l/h. A dosing optimisation strategy identified that dose increases to 500–700 mg twice daily would result in 32–55% of subjects possessing trough concentration in excess of 50 ng/ml.

Conclusions

Quetiapine doses in pregnancy should be increased to 500–700 mg twice daily to counteract a concomitant increase in metabolic clearance, increase in volume of distribution and decrease in plasma protein binding.

Dose Optimization of Chloroquine by Pharmacokinetic Modeling During Pregnancy for the Treatment of Zika Virus Infection

The insidious nature of Zika virus (ZIKV) infections can have a devastating consequence for fetal development. Recent reports have highlighted that chloroquine (CQ) is capable of inhibiting ZIKV endocytosis in brain cells. We applied pharmacokinetic modeling to develop a predictive model for CQ exposure to identify an optimal maternal/fetal dosing regimen to prevent ZIKV endocytosis in brain cells. Model validation used 13 nonpregnancy and 3 pregnancy clinical studies, and a therapeutic CQ plasma window of 0.3-2 μM was derived. Dosing regimens used in rheumatoid arthritis, systemic lupus erythematosus, and malaria were assessed for their ability to target this window. Dosing regimen identified that weekly doses used in malaria were not sufficient to reach the lower therapeutic window; however, daily doses of 150 mg achieved this therapeutic window. The impact of gestational age was further assessed and culminated in a final proposed regimen of 600 mg on day 1, 300 mg on day 2 and 3, and 150 mg thereafter until the end of trimester 2, which resulted in maintaining 65% and 94% of subjects with a trough plasma concentration above the lower therapeutic window on day 6 and at term, respectively.

Family Planning and Pregnancy Management in Adults with Congenital Heart Disease

With advances in congenital heart disease management, there are an increasing number of women reaching reproductive age. Pregnancy results in a surge of hormones and increased demands on both the cardiovascular (CV) and respiratory systems. Depending on the heart defect and the treatments the mother has undergone, these hemodynamic changes can result in an increased risk of maternal CV events and an increased risk of fetal morbidity and mortality. Thus, it is important to have a comprehensive approach to adult congenital heart disease patients involving pre-pregnancy planning in addition to diligent peri- and post-partum care.

The effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy on placental P-glycoprotein in mice: Implications in the individualized transplacental digoxin treatment for fetal heart failure

INTRODUCTION

Placental P-glycoprotein (P-gp) plays a significant role in controlling transplacental digoxin transfer rate. Investigations on P-gp regulation in placenta of women with different pregnant pathological states are of great significance to individualized transplacental digoxin treatment for fetal heart failure (FHF). This study aimed to explore the effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy (ICP) on placental P-gp in mice.

METHODS

ICP model in mice was induced by subcutaneous injection of 17α-ethynylestradiol dissolved in propylene glycol once daily from E12.5 to E16.5. Maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations were measured. HE staining was applied for observation of maternal liver cells degeneration, necrosis and intrahepatic cholestasis. Placental Abcb1a/Abcb1b/HIF-1α mRNA and P-gp/HIF-1α protein expression were determined by real-time quantitative PCR and western-blot. Maternal plasma and fetal-unit digoxin concentrations were detected by a commercial kit assay.

RESULTS

The ICP group showed higher levels of maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations, reduction in fetal survival rates, lower placental and fetal weights, and typical liver cells degeneration, necrosis and intrahepatic cholestasis. The placental Abcb1a mRNA and P-gp expression of ICP group were significantly elevated, while transplacental digoxin transfer rates were significantly decreased. Both placental HIF-1α mRNA and protein expression was significantly elevated in the ICP group, and there was a positive correlation between Abcb1a mRNA and HIF-1α mRNA.

CONCLUSIONS

17α-ethynylestradiol induced ICP could up-regulate placental P-gp expression and reduce transplacental digoxin transfer rate in mice, which might be partly associated with higher expression of HIF-1α.

Pharmacokinetics of drugs in pregnancy

Pregnancy is a complex state where changes in maternal physiology have evolved to favor the development and growth of the placenta and the fetus. These adaptations may affect preexisting disease or result in pregnancy-specific disorders. Similarly, variations in physiology may alter the pharmacokinetics or pharmacodynamics that determines drug dosing and effect. It follows that detailed pharmacologic information is required to adjust therapeutic treatment strategies during pregnancy. Understanding both pregnancy physiology and the gestation-specific pharmacology of different agents is necessary to achieve effective treatment and limit maternal and fetal risk. Unfortunately, most drug studies have excluded pregnant women based on often-mistaken concerns regarding fetal risk. Furthermore, over two-thirds of women receive prescription drugs while pregnant, with treatment and dosing strategies based on data from healthy male volunteers and non-pregnant women, and with little adjustment for the complex physiology of pregnancy and its unique disease states. This review will describe basic concepts in pharmacokinetics and their clinical relevance and highlight the variations in pregnancy that may impact the pharmacokinetic properties of medications.

The effect of maternal obesity on the expression and functionality of placental P-glycoprotein: Implications in the individualized transplacental digoxin treatment for fetal heart failure

INTRODUCTIONS

Placental P-glycoprotein (P-gp) plays a significant role in controlling digoxin transplacental rate. Investigations on P-gp regulation in placenta of women with different pregnant pathology are of great significance to the individualized transplacental digoxin treatment for fetal heart failure (FHF). This study aimed to explore the effect of maternal obesity on the expression and functionality of placental P-gp both in human and in mice.

METHODS

Placenta tissues from obese and lean women were collected. Female C57BL mice were fed with either a normal chow diet or a high-fat diet for 12 weeks before mating and throughout pregnancy. Maternal plasma glucose, HDL-C, LDL-C, TC, TGs, insulin, IL-1β, IL-6 and TNF-α concentrations was detected. Placental ABCB1/Abcb1a/Abcb1b/IL-1β/IL-6/TNF-α mRNA and P-gp/IL-1β/IL-6/TNF-α protein expression were determined by real-time quantitative PCR and western-blot, respectively. Maternal plasma and fetal-unit digoxin concentrations were detected by a commercial kit assay.

RESULTS

Both ABCB1 gene mRNA and protein expression of obesity group was significantly lower than that of control group in human. The high-fat dietary intervention resulted in an overweight phenotype, a significant increased Lee's index, higher levels of plasma glucose, HDL-C, LDL-C, insulin and TGs, increased peri-renal and peri-reproductive gland adipose tissue weight, and larger size of adipose cell. Compared with control group at the same gestational day (E12.5, E15.5, E17.5), placental Abcb1a mRNA and P-gp expression of obese group were significantly decreased in mice, while digoxin transplacental rates were significantly increased. Higher maternal plasma IL-1β/TNF-α concentrations and placental IL-1β/TNF-α expression were observed in obesity groups in comparison with control group at the same gestational age.

CONCLUSIONS

Maternal obesity could inhibit placental P-gp expression and its functionality both in human and in mice, which might be resulted from a heightened inflammatory response.

Acute myocardial infarction during pregnancy: a clinical checkmate

Acute myocardial infarction (AMI) in pregnancy is associated with high morbidity and mortality. Management of these patients can be challenging as little is known about the optimal management strategy. Medications routinely used may have harmful effects on the pregnancy outcome. In addition, AMI could occur in the absence of atherosclerotic disease. We describe optimal management strategy by eliciting the management of a 45-year-old female with ST segment elevation myocardial infarction. We recommend early use of coronary angiography to define the pathology in such cases. Radial artery assess should be preferred. Pregnant patients with AMI due to atherosclerotic disease should be given a 325 mg of aspirin and 600 mg of clopidogrel and either balloon angioplasty or bare metal stent should be used for revascularization. Percutaneous coronary intervention with heparin is preferred over bivalirudin and later should be reserved for patients with severe heparin allergy.

Arrhythmias in pregnancy

Pregnant women have an increased risk of having the usual arrhythmias seen in women of childbearing age. Most of these are benign sinus tachycardias or bradycardias or atrial and ventricular ectopic beats. Women who have had sustained supraventricular or ventricular tachycardias before pregnancy frequently develop them during pregnancy. These arrhythmias often have enough hemodynamic significance to decrease uterine blood flow, which adds a sense of urgency for treatment. The management is similar to that of nonpregnant women, with nuances important for the protection of the developing fetus.

Cardiac arrhythmias during pregnancy

OPINION STATEMENT

This article reviews the appropriate evaluation and management of cardiac arrhythmias in the pregnant patient. Any treatment strategy in this patient population has the inherent potential to adversely affect the health of the unborn child. As such, there is no room for empiric therapy in these patients. Adequate arrhythmia documentation is paramount, preferably by noninvasive means. The decision to treat should be based on symptom severity and the risk to both mother and fetus posed by potentially recurring arrhythmia episodes throughout the pregnancy. Minimal symptoms in the setting of a structurally normal heart call for a conservative approach. Less is better. If pharmacologic therapy is justified, drugs with historically demonstrated safety profiles in pregnancy should be tried first. The safety profiles of virtually all drugs used to treat cardiac arrhythmias during human pregnancy are based solely on an accumulation of past clinical experience. Newer antiarrhythmics therefore carry a largely unknown risk. Most inherent rhythm disorders manifest long before a woman reaches childbearing age. Women with previously diagnosed arrhythmias frequently experience a recurrence or worsening of their arrhythmia during the pregnancy. Counseling of these individuals and perhaps preemptive treatment by means such as arrhythmia ablation prior to a planned pregnancy would seem optimal.

Clinical therapeutics in pregnancy

Most drugs are not tested for use during pregnancy, consequently, labeling, which may include information about fetal safety, includes nothing about dosing, efficacy, or maternal safety. Yet these are concerns of health care providers considering treatment of disease during pregnancy. Therefore, the practitioner treats the pregnant woman with the same dose recommended for use in adults (typically men) or may decide not to treat the disease at all. However, is the choice of not treating a woman during pregnancy better than dealing with the challenges which accompany treatment? This paper, which summarizes metabolic and physiologic changes induced by pregnancy, illustrates that standard adult dosing is likely to be incorrect during pregnancy.

CARDIAC ARRHYTHMIAS DURING PREGNANCY: A CLINICAL APPROACH

Physiologic changes in maternal haemodynamics, hormones and autonomic properties contribute to arrhythmias in pregnancy. While arrhythmias most commonly occur in pregnant women with structural heart disease or those with a history of cardiac arrhythmias, they can also occur de novo in women with no documented cardiac disease.

Antibiotic Treatment of Dogs and Cats during Pregnancy

The use of pharmacological agents in pregnant females poses a major clinical challenge due to the marked physiological changes that may modify the pharmacokinetics of drugs and to the potential effects on the fetus. The purpose of this paper is to review briefly our knowledge on the use of antibacterial drugs during pregnancy and to provide information for the judicious selection of an antimicrobial treatment for use in pregnant bitches and queens. The risk to the fetus is a result of the ability of a drug to reach the fetal circulation and to produce toxic effects. The placenta functions as a barrier that protects the fetus due to the presence of transporters and metabolising enzymes; however, during pregnancy, the presence and activity of both enzymes and transporters may change. Antimicrobial agents that have been shown to be safe for use during pregnancy include betalactams, macrolides, and lincosamides. Pharmacotherapy during pregnancy in all species may affect adversely the developing fetus; therefore, it should be avoided when possible.

Congenital heart disease in pregnancy

INTRODUCTION

Pregnancy, birth, and the puerperium are associated with significant physiological changes and adaptations in the cardiovascular system, which pose a significant risk to pregnant women with congenital heart disease (CHD). Thanks to advances in pediatric cardiac surgery and cardiology the majority of children with CHD survive to adulthood, and an increasing number eventually become pregnant. In fact, cardiac disease - mostly congenital - is now a leading cause of maternal death in western industrialized countries.

METHODS

Selective literature review.

RESULTS AND DISCUSSION

Optimal care of women with CHD before, during, and after pregnancy requires a multidisciplinary team including obstetricians, cardiologists, and anaesthetists. Successful pregnancy at a minimum risk is feasible for most women with CHD when appropriate counseling and optimal care are provided.

Determination of pindolol enantiomers in amniotic fluid and breast milk by high-performance liquid chromatography: Applications to pharmacokinetics in pregnant and lactating women

A method for the determination of pindolol enantiomers in amniotic fluid and breast milk was developed, validated, and applied to the investigation of six pregnant women treated with rac-pindolol (10 mg/12 h). Biological samples were extracted with tert-methyl-butyl ether, and the pindolol enantiomers were resolved on a Chiralpak AD column. Amniotic fluid/plasma and milk/plasma concentrations ratios ranged from 0.4 to 4.5 and from 0.6 to 3.7, respectively, for (+)-R-pindolol and from 0.5 to 3.5 and from 1.1 to 2.8, respectively, for (-)-S-pindolol. Preliminary data suggest that amniotic fluid and breast milk are routes of fetal exposure to pindolol enantiomers.

[Pregnancy and heart disease]

Pregnancy and delivery are associated with substantial physiological changes that require adaptations in the cardiovascular system. These changes, well-tolerated in pregnant women without heart disease, expose woman with cardiovascular disease to serious risk. In fact, heart disease is the most frequent cause of maternal death, after psychiatric disorders, and the number of pregnant women with heart disease is expected to grow in the coming years. Preventing cardiovascular complications should be the main aim of every cardiologist involved in managing pregnant woman with congenital or acquired heart disease. Unfortunately, there is a lack of data which would help in the management of these patients during pregnancy and the clinical practice guidelines are often based on assumptions regarding how a specific substrate is going to respond to the physiological changes occurring due to pregnancy.

The Team Approach to Pregnancy and Congenital Heart Disease

The successful pediatric management of congenital heart disease has resulted in increasing numbers of these patients in the reproductive age group and increasing clinical challenges for their physicians. These challenges can be met successfully, with improved results for mother and child, through a concerted comprehensive team approach that relies on a thorough understanding of the patient's underlying cardiac pathology and its anticipated interaction with the pregnancy, and ongoing close evaluation and communication with a team of trained and experienced specialist, including (but not limited to) cardiologist, obstetricians, anesthetists, pediatricians, clinical nurse specialists, and clinical geneticists. Such teams are not always available locally and it will be necessary to refer medium- and high-risk patients to a specialized tertiary care center.

Pregnancy in women with valvular heart disease

Patients with valvular disease who desire pregnancy or are already pregnant require specialised care. Ideally, women undergo preconceptual counselling that addresses any procedures needed to decrease the risks of pregnancy, including valve replacement, if the patient has symptoms at baseline. Management during pregnancy includes replacing any contraindicated medications with safer alternatives, optimising loading conditions, careful monitoring and aggressive treatment of any exacerbating factors. Rarely, percutaneous or surgical intervention is required during pregnancy. Labour and delivery often require invasive haemodynamic monitoring and a multi-disciplinary team for optimal maternal and fetal outcomes.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare cardiac disorder associated with high rates of mortality that occurs during the peripartum period. PPCM is recognized as a distinct entity, separate from preexisting cardiomyopathies that are worsened by the stressors of pregnancy. To date, its etiology is unknown, although several theories are under investigation in an effort to provide more information regarding available treatment options. A multidisciplinary review of PPCM held by the National Heart, Lung, and Blood Institute, in conjunction with the Office of Rare Disease of the National Institutes of Health, in April 1997 reviewed the current knowledge and developed recommendations for areas of further research and education about PPCM. Since then, there have been some promising research testing hypotheses regarding the etiology of PPCM and advancements in possible treatment options. However, despite these efforts, knowledge and treatment recommendations about PPCM are still generally unchanged, whereas mortality rates remain high. This article attempts to provide an updated, comprehensive review about PPCM and draw attention to areas in need of further research.

Valvular Heart Disease and Pregnancy

Pregnancy in patients with valvular heart disease (VHD) continues to pose a challenge to both physicians and their patients and could be associated with an unfavorable maternal as well as fetal outcome. The purpose of this paper is to review the available clinical data and provide recommendations for the management of patients with VHD during gestation.