CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
Cardiovascular disease (CVD) complicates 1% to 4% of pregnancies and is the primary cause of nonobstetric maternal mortality. Older maternal age, with associated increases in CVD risk factors such as obesity, hypertension, and diabetes, as well as improved survival of patients with congenital heart disease have increased the burden of CVD during 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 impact pregnancy. Preconception consultation of pregnant women with CVD is imperative and such individuals should be cared for by expert multidisciplinary teams in anticipation of possible complications that may arise during the antepartum, intrapartum, and postpartum periods. Pregnancy is not advised in several conditions and some medications are contraindicated during pregnancy (see Fuster and Hurst’s Central Illustration).
eFig 78-01 Chapter 78: Heart Disease in Pregnancy
Preexisting and acquired cardiovascular disease (CVD) increases maternal and fetal morbidity and mortality during pregnancy.1,2 CVD complicates 1% to 4% of pregnancies and according to a recent UK registry, accounts for 37% of nonobstetric maternal death and is the leading cause of indirect maternal mortality.3,4 There is an increase in the burden of CVD during pregnancy related to advanced maternal age, increase in cardiovascular risk factors such as obesity, hypertension, and diabetes, and the improved survival of congenital heart disease (CHD) patients. CHD comprises the majority of cases of CVD during pregnancy in the Western world, whereas rheumatic heart disease is more common in developing countries;5,6 other prevalent etiologies include connective tissue disease and cardiomyopathies.
There is evidence to suggest that most women with CVD may be able to tolerate pregnancy. However, careful preconception planning with providers experienced in high-risk pregnancy is needed. 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 (ie, pregnancy heart 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.
Women with CVD should receive counseling regarding both maternal and fetal risks prior to conceiving a pregnancy. In addition, women with heart disease should be cared for at institutions with experience in treating CVD during pregnancy. There are certain high-risk conditions for which pregnancy is contraindicated including pulmonary arterial hypertension, congenital cyanotic lesions, severe systemic ventricular ...