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Chapter 22: Cardiac Disease in Pregnancy

Sarah E. Paraghamian; Afshan B. Hameed

INTRODUCTION

KEY QUESTIONS

  • Why do the physiologic changes of pregnancy unmask underlying cardiac disease?

  • How do sign and symptoms of normal pregnancy differ from cardiac disease?

  • How does pregnancy affect cardiovascular testing?

  • How are cardiac patients managed on labor and delivery (L&D)?

CASE 22-1

A 32-year-old gravida 3 para 2 at 34 weeks of gestational age presents with dyspnea and fatigue. She reports a 15-pound weight gain over the last two weeks. Physical exam is significant for mild tachycardia at 112 beats per minute, oxygen saturations of 92%, and crackles at the bilateral lung bases. Chest x-ray reveals bilateral pulmonary infiltrates. B-type natriuretic peptide (BNP) is elevated. Echocardiogram reveals depressed left ventricular ejection fraction of 30% (normal > 50%–55%). Diagnosis of peripartum cardiomyopathy is made.

Cardiovascular conditions are the leading cause of maternal mortality in the United States, accounting for approximately 25% of all pregnancy-related deaths.1–4 In fact, cardiovascular disease (CVD) has been increasing as a cause of pregnancy-related mortality relative to prior years, while the proportion of deaths attributable to other common causes, such as hemorrhage and hypertensive disorders, has declined. African-American women are disproportionately represented among pregnancy-related deaths from cardiovascular causes.3

The number of pregnant women with CVD is likely to continue to rise in the future. Advances in healthcare allow the majority of children with congenital heart disease to reach reproductive age. While pregnancy was previously considered prohibitively high risk for many women with complex cardiac lesions, current consensus guidelines include very few conditions among those for which pregnancy is contraindicated (Table 22-1).5 In addition to women with congenital heart disease, pregnancy rates among women of advanced maternal age and other risk factors for CVD are increasing.

TABLE 22-1Risk of Morbidity and Mortality in Pregnancy by Type of CVD
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TABLE 22-1 Risk of Morbidity and Mortality in Pregnancy by Type of CVD
No significant increased risk relative to general population

  • Uncomplicated, small or mild

    • Pulmonary stenosis

    • VSD

    • PDA

    • Mitral valve prolapse with no more than trivial mitral regurgitation

  • Successfully repaired simple lesions, such as:

    • Ostium secundum ASD

    • VSD

    • PDA

    • Total anomalous pulmonary venous drainage

  • Isolated ventricular extrasystoles and atrial ectopic beats
Small increased risk of morbidity and mortality, if otherwise well and uncomplicated

  • Unoperated ASD

  • Repaired tetralogy of Fallot

  • Most arrhythmias
Small-to-moderate increased risk of morbidity and mortality, depending on the individual

  • Mild left ventricular impairment

  • Hypertrophic cardiomyopathy

  • Native tissue or valvular heart disease, other than those in which pregnancy is contraindicated

  • Marfan syndrome without aortic dilatation

  • Heart transplantation
Moderate increased risk of morbidity and mortality

  • Mechanical prosthetic valve

  • Systemic right ventricle (e.g. congenitally corrected transposition)

  • Post-Fontan operation

  • Cyanotic heart disease

  • Other complex congenital heart disease
Cardiac conditions in which pregnancy is contraindicated due to extremely high risk

  • Pulmonary arterial hypertension (any cause)

  • Severe systemic ventricular dysfunction

    • Left ventricular ejection fraction ...

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