CHAPTER 33 Pregnancy and Heart Disease
Heart disease, though rare, is in Western countries a major cause of maternal mortality. Heart disease can be present or discovered during pregnancy because of haemodynamic overload of the heart, particularly during the third trimester when cardiac output doubles.Most of the knowledge in recognition and treatment of cardiac disease during pregnancy is not based on evidence from randomized trials, but is derived from clinical experience, few case reports, and small consecutive series. These are summarized in the guidelines on ‘Management of Cardiovascular Diseases During Pregnancy’ from the European Society of Cardiology, the basis for this chapter. The physiological changes that occur during pregnancy have a different impact depending on the type and severity of cardiac anomalies. Differential diagnosis with normal pregnancy related physiological changes is also discussed.
Particular emphasis is placed on early and accurate diagnosis of congenital or acquired cardiac anomalies because often early intervention is essential for a safe pregnancy and delivery.
Women at low risk are those in New York Heart Association (NYHA) class I or II with good ventricular function, without severe left ventricular inflow or outflow obstruction or pulmonary hypertension, and who do not need to take anticoagulants. Women at high risk are those showing symptoms of severe mitral or aortic stenosis, the ones with cyanotic congenital heart disease with or without pulmonary hypertension, the ones with significantly impaired systemic ventricular function and/or life-threatening arrhythmias, the ones with wide aorta in Marfan syndrome, and finally the ones with mechanical valves. The same conditions that endanger the mother also affect fetal morbidity and mortality.
Multiple therapeutic options including percutaneous or surgical intervention are now available to allow for a safe completion of the pregnancy. Management of these patients requires teamwork from cardiologists, obstetricians, anaesthetists, neonatologists, and, sometimes, cardiac surgeons.
Chapter 28)
