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Chapter 103: Heart Disease in Pregnancy

What is the most common form of cardiovascular disease (CVD) among pregnant women in the developed world?

A. Rheumatic valve disease

B. Connective tissue disease

C. Congenital heart disease (CHD)

D. Cardiomyopathies

E. Congestive heart failure

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 103) Preexisting and acquired CVD increases maternal and fetal morbidity and mortality during pregnancy.1-4 Cardiovascular disease complicates > 1% of pregnancies, accounts for 20% of nonobstetric maternal death,2 and is the leading cause of indirect maternal mortality. Congenital heart disease comprises > 50% of CVD in pregnancy (option C);5,6 other common etiologies include rheumatic valve disease (option A) (more common in developing countries), connective tissue disease (option B), and cardiomyopathies (option D). 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 an understanding of the unique hemodynamic changes of pregnancy and the pathophysiology, signs and symptoms, and natural history specific to each heart condition that may affect 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.

A 27-year-old woman with previously diagnosed CVD presents to your clinic for a preconception consult. Which of the following is considered a high-risk condition in which pregnancy is not advised?

A. Pulmonary arterial hypertension

B. Congenital cyanotic lesions

C. Severe systemic ventricular dysfunction

D. Severe mitral stenosis

E. All of the above

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 103) Women with CVD should receive counseling about both maternal and fetal risks prior to conceiving a pregnancy. In addition, women with heart disease should be cared for in institutions with experience in treating CVD during pregnancy. There are extremely high-risk conditions in which pregnancy is not advised, including pulmonary arterial hypertension (option A), congenital cyanotic lesions (option B), severe systemic ventricular dysfunction (option C) (ejection fraction < 30%, New York Heart Association [NYHA] class > II), severe mitral stenosis (option D), severe symptomatic aortic stenosis, and significantly dilated aorta in connective tissue disorders in women with Marfan syndrome and above 5 cm in women with bicuspid aortic valve (BAV).1 Women ...

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