An understanding of the remarkable cardiovascular changes during a normal pregnancy is important for optimal care. Failure to recognize and treat heart disease when it exists can adversely affect both the mother and the child.
The health of the developing fetus is predominantly determined by the health of the mother. When treating heart disease, the health of the fetus should be considered, but the safety of the mother is the highest priority. Ideally, treatment of the mother with drugs, diagnostic studies, or surgery should be avoided unless required for maternal safety.
Heart disease is the second most common cause of maternal death in Western countries (suicide is first).1 Sometimes the risk is sufficient to recommend avoidance or interruption of pregnancy (Table 97–1).
Table 97–1. Cardiovascular Abnormalities Placing a Mother and Infant at Extremely High Risk |Favorite Table|Download (.pdf)
Table 97–1. Cardiovascular Abnormalities Placing a Mother and Infant at Extremely High Risk
|Advise avoidance or interruption of pregnancy|
|Dilated cardiomyopathy with congestive failure|
|Marfan syndrome with dilated aortic root|
|Cyanotic congenital heart disease|
|Pregnancy counseling and close clinical follow-up required|
|Coarctation of the aorta|
|Dilated cardiomyopathy in asymptomatic women|
The maternal commitment to the fetus is exceptional, but if the mother requires a redistribution of blood flow for her own safety, blood is preferentially diverted away from the uterus. This subjects the fetus to an insufficient supply of oxygen and nutrients and ineffective removal of metabolic waste and heat. Uterine blood flow can already be compromised in a woman with heart disease, increasing the possibility of inadequate uterine perfusion. Treatment of maternal heart disease can also jeopardize the fetus. Diagnostic studies, drugs, or surgery may increase fetal loss, result in teratogenicity, or alter fetal growth.
Newborn Infant Vulnerability
The health of a newborn infant is a concern when the mother has heart disease. This fragility can be caused by a marginal uterine blood flow during pregnancy or by lingering effects of the medications used to treat the mother. Additionally, there is an increased incidence of congenital heart disease among the live-born infants of parents with congenital heart disease. Early infant nourishment may be jeopardized if maternal heart disease is severe enough to interfere with breastfeeding. Even if the mother is capable of breastfeeding, cardiovascular medications can be transmitted to the infant in the breast milk. Finally, the infant is at risk of losing a parent because life expectancy with many forms of heart disease is significantly reduced.
Effects of Previous Treatment