Heart Disease in Pregnancy

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