Pregnancy after cardiac transplantation
- Michael R Foley, MD
Michael R Foley, MD
- University of Arizona College of Medicine - Phoenix
- Section Editors
- 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
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
Experience with pregnancy after cardiac transplantation has grown since the first report in 1988 [1,2]. The number of women of childbearing age who have received heart transplants has risen due partly to some overall increase in heart transplantation in adults and to survival of pediatric heart transplant recipients to childbearing age. Pregnancy after cardiac transplantation is associated with risks to the prospective mother and fetus and with concerns regarding maternal longevity [2-7].
The maternal and fetal risks associated with pregnancy after cardiac transplantation and recommendations for management of these patients during pregnancy will be reviewed here. The indications and complications of cardiac transplantation are discussed separately. (See "Indications and contraindications for cardiac transplantation" and "Acute cardiac allograft rejection: Diagnosis".)
Preconception counseling — Family planning and pregnancy including individualized maternal and fetal risks , alternatives, and timing should be discussed with all women of childbearing age undergoing cardiac transplantation as many transplant recipients are fertile. As recommended by the American Society of Transplantation (AST) consensus conference on reproductive issues, preconception counseling should be introduced during the pretransplant evaluation (or earlier) and should be followed up throughout the post-transplant process . Transplant recipients need to know what to expect in terms of their own outcome and that for their potential children .
The reason for the mother's cardiac transplant should be investigated and discussed in terms of risk of recurrence of the underlying cardiac disease in mother or offspring. As an example, women who have received cardiac allografts because of severe peripartum cardiomyopathy are theoretically at risk for recurrent problems in future pregnancies (see "Peripartum cardiomyopathy: Etiology, clinical manifestations, and diagnosis"). Another example is the risk of cardiac defects (concordant or discordant with the mother) in offspring of women with congenital or familial/genetic types of heart disease (eg, 20 to 50 percent of idiopathic dilated cardiomyopathy cases may be familial). (See "Genetics of dilated cardiomyopathy" and "Pregnancy in women with congenital heart disease: General principles", section on 'Inheritance'.)
Timing of pregnancy — Most experts recommend that cardiac transplant recipients avoid pregnancy during the first year post-transplantation when the risk of rejection is greatest and immunosuppressive therapy most aggressive . (See "Prognosis after cardiac transplantation".)
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- PRECONCEPTION CARE
- Preconception counseling
- Timing of pregnancy
- Baseline assessment
- MATERNAL PHYSIOLOGY AND MONITORING
- Physiologic changes
- Maternal monitoring
- MATERNAL RISKS IN PREGNANCY
- Abnormal liver function
- Hypertension and preeclampsia
- FETAL RISKS
- Maternal medications
- INTRAPARTUM RISKS AND MANAGEMENT
- Mode of delivery
- Antibiotic prophylaxis
- Stress dose steroids
- Maternal monitoring
- POSTPARTUM RISKS AND MANAGEMENT
- SUMMARY AND RECOMMENDATIONS