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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Pregnancy

  • History of heart disease

  • Symptoms, signs, or other objective evidence of heart disease

GENERAL CONSIDERATIONS

  • Heart disease occurs in < 5% of pregnancies

  • Congenital heart disease and valvular disease are most common

  • Hemodynamic changes of normal pregnancy challenge the diagnosis and management of heart disease

  • Risks to mother and fetus need to be considered

  • Relative contraindications to pregnancy:

    • – Occlusive pulmonary vascular disease

    • – Severe pulmonary hypertension

    • – Marfan’s syndrome with dilated aorta

    • – Severe aortic stenosis

    • – Severe left ventricular dysfunction

    • – Cyanotic congenital heart disease

    • – Loeys-Dietz syndrome

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Atrial septal defect: usually well tolerated unless significant anemia or atrial arrhythmias develop; then dyspnea and fatigue can occur

  • Pulmonic stenosis: mild to moderate stenosis is well tolerated; severe stenosis may result in congestive heart failure

  • Coarctation of the aorta: major risks are fetal underdevelopment and maternal hypertension

  • Tetralogy of Fallot: increased cyanosis, syncope, and sudden death

  • Mitral stenosis: dyspnea, fatigue, orthopnea, and syncope

  • Mitral valve prolapse with mitral regurgitation: usually well tolerated unless regurgitation is severe

  • Aortic valve disease: mild to moderate disease well tolerated

  • Peripartum cardiomyopathy: symptoms of left heart failure must be distinguished from symptoms and signs of normal pregnancy

  • Hypertrophic cardiomyopathy: usually well tolerated if asymptomatic before pregnancy

  • Coronary artery disease: angina most common presentation; myocardial infarction can occur

  • Symptomatic arrhythmias often due to underlying cardiac disease

  • Primary pulmonary hypertension: dyspnea, fatigue, chest pain, palpitation, and syncope

PHYSICAL EXAM FINDINGS

  • Findings normal in pregnancy include: increased resting heart rate, wide pulse pressure, jugular venous distention, edema, increased amplitude of left ventricular impulse, loud split S1 and S2, S3, and innocent flow murmur

  • Cervical venous hum (decreases with sitting) and mammary soufflé may be confused with pathologic findings

  • Pregnancy augments the murmurs of aortic, mitral, and pulmonic stenosis but decreases the murmurs of aortic and mitral regurgitation and hypertrophic obstructive cardiomyopathy

  • The midsystolic click and murmur of mitral valve prolapse are less prominent during pregnancy

DIFFERENTIAL DIAGNOSIS

  • Symptoms from increased cardiac output in normal pregnancy, such as fatigue, dyspnea on exertion, and reduced exercise tolerance

  • Symptoms from reduced peripheral resistance in normal pregnancy, such as orthostatic intolerance

  • Symptoms from compression of the inferior vena cava by the gravid uterus, such as orthopnea

  • Signs of increased blood volume in normal pregnancy, such as innocent systolic ejection murmur at the left sternal border

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Positive pregnancy test

  • CBC may show mild dilutional anemia

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Leftward axis shift

  • Nonspecific ST-T changes

IMAGING STUDIES

  • Chest x-ray (only if necessary), with abdominopelvic shielding

    • – Elevated diaphragm and ...

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