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Chapter 8: Cardiac Disease in Pregnancy

Manisha Gandhi; Stephanie R. Martin

INTRODUCTION

Cardiac disease complicates approximately 4% of all pregnancies in the United States; however, these patients are at a disproportionate increase in risk for maternal deaths (10%-25%).1,2 Congenital cardiac lesions are 3 times more common than acquired, adult-onset abnormalities in pregnant patients. Intensive care unit (ICU) admissions due to maternal cardiac disease comprise up to 15% of obstetric ICU admissions, yet these patients account for up to 50% of all maternal deaths in the ICU.3-9 The incidence of an acute coronary event is increasing during pregnancy due to older maternal age at child-bearing along with higher rates of hypertension and obesity in women.10 Pregnant cardiac patients are at risk of developing cardiac decompensation and adverse pregnancy outcomes based on the type of cardiac lesion. Pregnancy can have a negative influence on systolic and diastolic function in women with structural heart disease, which can persist 6 months after pregnancy.11 Further complicating the issue, common complaints of normal pregnancy such as dyspnea, fatigue, palpitations, orthopnea, and pedal edema mimic symptoms of worsening cardiac disease and can create challenges for the clinician when evaluating a pregnant patient with cardiac disease.

In this chapter, we will review valvular, congenital, and acquired cardiac lesions and their impact on pregnancy management. Each section will address the concerns specific to the relevant abnormality, including key points in antepartum management, as well as anesthetic and delivery issues.

PHYSIOLOGIC CHANGES OF SINGLETON PREGNANCY

Comprehensive understanding of the normal physiologic adaptations to pregnancy is essential for successful management of patients with cardiac disease. Conditions which may be asymptomatic while nonpregnant can deteriorate in the pregnant state. Table 8-1 outlines key physiologic changes in a normal singleton gestation. Multiple gestations can be expected to have even more dramatic physiologic changes. Table 8-2 provides an overview of changes in cardiovascular evaluations during pregnancy.

TABLE 8-1Expected Physiologic Changes Occurring in the Antepartum, Intrapartum, and Postpartum Periods
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TABLE 8-1 Expected Physiologic Changes Occurring in the Antepartum, Intrapartum, and Postpartum Periods

Antepartum

  • Blood volume increases by 20%-50%

  • In nonpregnant females, total blood volume is ~60-70 mL/kg

  • Systemic vascular resistance decreases by 20%

    • Accounts for majority of drop in BP

    • Accommodates increase in circulating volume without increase in BP

  • Blood pressure (taken in sitting position)

    • BP ≥140/90 abnormal at any time in gestation

    • BP decreases to lowest point at 28 wk

    • After 28 wk, BP increases to nonpregnant level by term

  • Mean arterial pressure unchanged

  • Heart rate increases by 10-15 beats/min

  • Stroke volume increases by 30%

  • Cardiac output increases by 30%-50%

    • CO = heart rate × stroke volume. Majority of increase is from stroke volume

    • Half of the expected increase occurs by 8 wk

    • Peaks end of second trimester, sustained to term

    • 6 L/min by term

  • Pulmonary capillary wedge pressure (preload to left heart) unchanged

  • Central venous pressure ...

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