Pregnancy and valve disease
- Candice Silversides, MD, MS, FRCPC
Candice Silversides, MD, MS, FRCPC
- Section Editor — Congenital Heart Disease
- Associate Professor of Medicine
- University of Toronto
- Jacob A Udell, MD, MPH, FRCPC
Jacob A Udell, MD, MPH, FRCPC
- Assistant Professor of Medicine
- Women's College Hospital
- University of Toronto
- Section Editors
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
- 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
Hemodynamic changes during pregnancy, including increases in heart rate, stroke volume, and cardiac output (see "Maternal cardiovascular and hemodynamic adaptations to pregnancy"), can result in cardiac decompensation in women with valvular heart disease (VHD). Stenotic valve lesions are generally less well tolerated during pregnancy compared with regurgitant lesions. The risk of complications varies according to the type and severity of the underlying VHD.
This topic will discuss risk assessment and management of native valve disease during pregnancy. Evaluation and management of pregnant women with bicuspid aortic valve, with mitral stenosis, with Marfan syndrome, and with prosthetic heart valves are discussed separately. (See "Pregnancy in women with a bicuspid aortic valve" and "Pregnancy in women with mitral stenosis" and "Pregnancy and Marfan syndrome" and "Management of pregnant women with prosthetic heart valves" and "Use of anticoagulants during pregnancy and postpartum".)
PRECONCEPTION OR INITIAL EVALUATION
Timing — When possible, women should undergo preconception assessment and counseling so that they are able to make informed pregnancy decisions. For women who have not had preconception counseling, a complete risk evaluation should occur at the first antenatal visit.
In developed healthcare systems, women are typically aware of significant health conditions in advance of pregnancy; however, occasionally, pregnancy unmasks a previously unrecognized valve lesion. This latter scenario may be more frequent in developing healthcare systems, for instance in women with undiagnosed rheumatic mitral stenosis who first present during pregnancy.
In general, there are many health outcome benefits to seeking preconception counseling. Women with valvular heart disease (VHD) should have a preconception evaluation by a cardiologist with expertise in pregnancy and VHD. Risk assessment for women with VHD should involve a focused evaluation of the risk for the mother and baby. Many women with heart disease are unaware of the risks of pregnancy, and patient education is an important aspect of the preconception assessment . (See "The preconception office visit".)
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- PRECONCEPTION OR INITIAL EVALUATION
- Preconception evaluation
- Echocardiographic assessment
- Exercise testing
- INTERVENTIONS PRIOR TO PREGNANCY
- GENERAL APPROACH TO RISK STRATIFICATION
- Maternal cardiac risk predictors
- Fetal and neonatal risk predictors
- LESION SPECIFIC RISKS AND MANAGEMENT
- Modified WHO classification
- Specific lesions
- - Aortic stenosis
- - Mitral stenosis
- - Pulmonic stenosis
- - Tricuspid stenosis
- - Aortic regurgitation
- - Mitral regurgitation
- - Pulmonic regurgitation
- - Tricuspid regurgitation
- - Mixed valve lesions
- - Prosthetic mechanical valves
- ANTENATAL CARDIOLOGY FOLLOW-UP
- CARDIAC SURGERY DURING PREGNANCY
- Labor and delivery management
- Endocarditis prophylaxis
- Postpartum management
- SUMMARY AND RECOMMENDATIONS