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This chapter discusses cardiovascular disease in pregnancy. Cardiovascular disease complicates >1% of pregnancies and is the cause of one-fifth of nonobstetric maternal deaths. Women with cardiovascular disease should receive counseling on maternal and fetal risks prior to conceiving. Pregnancy is not advised in patients with certain high-risk conditions (see accompanying Hurst’s Central Illustration). Women with other types of cardiovascular disease should undergo a complete work-up if considering pregnancy; additionally, anticipated or potential events should be carefully planned for and medications should be reviewed for their safety in pregnancy. Up to 10% of pregnancies are complicated by hypertensive disorders, but many other types of cardiovascular disease may develop (for example, peripartum cardiomyopathy) or present particular challenges (for example, existing valvular disease, aortic dilatation, or some types of congenital heart disease). Additionally, some previously undetected cardiovascular disease can become symptomatic in pregnancy (for example, valvular heart disease or congenital heart disease). During pregnancy, distinguishing between normal pregnancy symptoms and concerning cardiac manifestations is often challenging, but various symptoms, and any that arise after 20 weeks and become progressively worse or that significantly impair performance of daily activities, should prompt further evaluation. Pregnant women with cardiovascular conditions should be cared for by expert, multidisciplinary teams. Although obstetric complications are higher in women with cardiovascular disease, most women will be able to undergo successful spontaneous vaginal delivery with careful monitoring.

eFig 103-01

Cardiovascular disease in pregnancy. Cardiovascular disease complicates >1% of pregnancies and is a major cause of nonobstetric maternal death. Medical care should begin in the preconception period in women with cardiovascular disease, and pregnant women with cardiovascular conditions should be cared for by expert, multidisciplinary teams. ECG, electrocardiogram.


Preexisting and acquired cardiovascular disease (CVD) increases maternal and fetal morbidity and mortality during pregnancy.1,2,3,4 CVD complicates more than 1% of pregnancies, accounts for 20% of nonobstetric maternal death,2 and is the leading cause of indirect maternal mortality. Congenital heart disease (CHD) comprises more than 50% of CVD in pregnancy5,6; other common etiologies include rheumatic valve disease (more common in developing countries), connective tissue disease, and cardiomyopathies. Medical care begins in the preconception period with careful planning and anticipation of the possible complications that may occur during the antepartum, intrapartum, and postpartum periods. Risk-stratification models summarizing maternal and fetal outcomes have been developed to counsel women with CVD desiring pregnancy. Optimal patient care for the pregnant woman with CVD relies on understanding of the unique hemodynamic changes of pregnancy and the pathophysiology, signs and symptoms, and natural history specific to each heart condition that may impact pregnancy. A multidisciplinary team approach involving cardiologists, maternal fetal medicine specialists, and anesthesiologists in a center with experience is strongly advised for the care of pregnant women with heart disease.



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