Acquired heart disease and pregnancy
- Carol A Waksmonski, MD
Carol A Waksmonski, MD
- Professor of Medicine
- Columbia University Medical Center
- Anita LaSala, MD
Anita LaSala, MD
- Assistant Professor of Obstetrics-Gynecology
- Columbia University Medical Center
- Michael R Foley, MD
Michael R Foley, MD
- University of Arizona College of Medicine - Phoenix
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Although cardiac disease complicates a small percentage of all pregnancies in developed countries (eg, only 1 to 4 percent of pregnancies in the United States), maternal cardiac disease is a major cause of non-obstetric maternal morbidity and mortality (figure 1). Care of the high-risk patients requires a team approach including a maternal-fetal medicine specialist, cardiologist, and obstetrical anesthesiologist.
In the past, rheumatic heart disease was the most common form of cardiac disease in pregnant women; it still predominates in developing countries and in immigrant populations in the United States. Congenital heart disease is now the most common form of heart disease complicating pregnancy in the United States, in part because advances in the treatment of congenital heart disease have made it possible for more affected children to reach adulthood and attempt pregnancy. (See "Pregnancy in women with congenital heart disease: General principles" and "Pregnancy and Marfan syndrome".)
In addition, many women are postponing childbearing until the fourth and fifth decades of life [1,2]; with advancing maternal age, underlying medical conditions such as hypertension, diabetes, and hypercholesterolemia become more common and increase the incidence of acquired heart disease complicating pregnancy.
PHYSIOLOGY OF NORMAL PREGNANCY
Pregnancy is associated with several cardiocirculatory changes that can significantly impact underlying cardiac disease. These changes begin early in pregnancy (within the first five to eight weeks), reach their peak during the late second trimester, and then remain relatively constant until delivery . Knowledge of these cardiovascular adaptations is required to correctly interpret hemodynamic and cardiovascular tests in the gravida, to predict the effects of pregnancy on the woman with underlying cardiac disease, and to understand how the fetus will be affected by maternal cardiac disorders. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes".)
Antepartum hemodynamic changes
●Cardiac output — The cardiac output rises 30 to 50 percent above baseline during normal pregnancy [4,5]. The degree of change is acutely influenced by posture, as the cardiac output is higher when the pregnant woman is in the left lateral decubitus position, particularly in the latter part of pregnancy [6,7]. In comparison, assumption of the supine position can lower the output by as much as 25 to 30 percent due to compression of the inferior cava by the gravid uterus, leading to a substantial reduction in venous return to the heart.
The increased cardiac output is the result of changes in three important factors that determine cardiac performance: preload is increased due to the associated rise in blood volume; afterload is reduced due to the decline in systemic vascular resistance; and the maternal heart rate rises by 15 to 20 beats/min . The direct effect of pregnancy on left ventricular contractility remains controversial .
Regardless of the mechanism, the stress induced by the increase in cardiac output can cause patients with underlying and often asymptomatic heart disease to decompensate during the latter half of pregnancy. This was illustrated in a series of 51 pregnant or postpartum women who developed acute pulmonary edema: 13 (25 percent) had cardiac disease and 6 of the 13 had occult structural lesions . (See "Management of heart failure during pregnancy".)
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- PHYSIOLOGY OF NORMAL PREGNANCY
- Antepartum hemodynamic changes
- Physical examination
- Electrocardiographic changes
- Hemodynamic changes during labor and delivery
- Minimizing hemodynamic effects
- ASSESSING RISK
- Predictors of cardiac events
- Measurement of BNP
- VALVULAR HEART DISEASE
- Risk according to valve lesion
- Clinical course and management of valve disease
- Valve replacement in women of childbearing age
- Infective endocarditis
- CORONARY ARTERY DISEASE
- MYOCARDIAL INFARCTION
- HEART TRANSPLANT RECIPIENTS
- MANAGEMENT OF LABOR AND DELIVERY
- Hemodynamic monitoring
- Mode of delivery
- Fetal monitoring
- Antibiotic prophylaxis
- Postpartum care
- SUMMARY AND RECOMMENDATIONS