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. (See "Natural history, screening, and management of rheumatic heart disease", section on '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".)
- Kovacs AH, Harrison JL, Colman JM, et al. Pregnancy and contraception in congenital heart disease: what women are not told. J Am Coll Cardiol 2008; 52:577.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Bamfo JE, Kametas NA, Nicolaides KH, Chambers JB. Maternal left ventricular diastolic and systolic long-axis function during normal pregnancy. Eur J Echocardiogr 2007; 8:360.
- Waksmonski CA. Cardiac imaging and functional assessment in pregnancy. Semin Perinatol 2014; 38:240.
- Jimenez-Juan L, Krieger EV, Valente AM, et al. Cardiovascular magnetic resonance imaging predictors of pregnancy outcomes in women with coarctation of the aorta. Eur Heart J Cardiovasc Imaging 2014; 15:299.
- Ducas RA, Elliott JE, Melnyk SF, et al. Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study. J Cardiovasc Magn Reson 2014; 16:1.
- Lui GK, Silversides CK, Khairy P, et al. Heart rate response during exercise and pregnancy outcome in women with congenital heart disease. Circulation 2011; 123:242.
- Tanous D, Siu SC, Mason J, et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol 2010; 56:1247.
- Kampman MA, Balci A, van Veldhuisen DJ, et al. N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease. Eur Heart J 2014; 35:708.
- Hameed AB, Chan K, Ghamsary M, Elkayam U. Longitudinal changes in the B-type natriuretic peptide levels in normal pregnancy and postpartum. Clin Cardiol 2009; 32:E60.
- Elkayam U, Bitar F. Valvular heart disease and pregnancy part I: native valves. J Am Coll Cardiol 2005; 46:223.
- John AS, Gurley F, Schaff HV, et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 2011; 91:1191.
- Elkayam U, Bitar F. Valvular heart disease and pregnancy: part II: prosthetic valves. J Am Coll Cardiol 2005; 46:403.
- Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med 1996; 335:407.
- Badduke BR, Jamieson WR, Miyagishima RT, et al. Pregnancy and childbearing in a population with biologic valvular prostheses. J Thorac Cardiovasc Surg 1991; 102:179.
- Sbarouni E, Oakley CM. Outcome of pregnancy in women with valve prostheses. Br Heart J 1994; 71:196.
- North RA, Sadler L, Stewart AW, et al. Long-term survival and valve-related complications in young women with cardiac valve replacements. Circulation 1999; 99:2669.
- Jamieson WR, Miller DC, Akins CW, et al. Pregnancy and bioprostheses: influence on structural valve deterioration. Ann Thorac Surg 1995; 60:S282.
- Salazar E, Espinola N, Román L, Casanova JM. Effect of pregnancy on the duration of bovine pericardial bioprostheses. Am Heart J 1999; 137:714.
- Avila WS, Rossi EG, Grinberg M, Ramires JA. Influence of pregnancy after bioprosthetic valve replacement in young women: a prospective five-year study. J Heart Valve Dis 2002; 11:864.
- Horstkotte D, Lengyel M, Mistiaen WP, et al. Recommendations for reporting morbid events after heart valve surgery. J Heart Valve Dis 2005; 14:1.
- El SF, Hassan W, Latroche B, et al. Pregnancy has no effect on the rate of structural deterioration of bioprosthetic valves: long-term 18-year follow up results. J Heart Valve Dis 2005; 14:481.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521.
- Siu SC, Sermer M, Harrison DA, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96:2789.
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
- Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31:2124.
- Khairy P, Ouyang DW, Fernandes SM, et al. Pregnancy outcomes in women with congenital heart disease. Circulation 2006; 113:517.
- Hameed A, Karaalp IS, Tummala PP, et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol 2001; 37:893.
- Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002; 105:2179.
- European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147.
- Thorne S, MacGregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heart disease. Heart 2006; 92:1520.
- Silversides CK, Colman JM, Sermer M, et al. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol 2003; 91:1386.
- Yap SC, Drenthen W, Pieper PG, et al. Risk of complications during pregnancy in women with congenital aortic stenosis. Int J Cardiol 2008; 126:240.
- McKellar SH, MacDonald RJ, Michelena HI, et al. Frequency of cardiovascular events in women with a congenitally bicuspid aortic valve in a single community and effect of pregnancy on events. Am J Cardiol 2011; 107:96.
- Silversides CK, Colman JM, Sermer M, Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003; 91:1382.
- de Souza JA, Martinez EE Jr, Ambrose JA, et al. Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy. J Am Coll Cardiol 2001; 37:900.
- Sivadasanpillai H, Srinivasan A, Sivasubramoniam S, et al. Long-term outcome of patients undergoing balloon mitral valvotomy in pregnancy. Am J Cardiol 2005; 95:1504.
- Gamra H, Ben-Farhat M, Betbout F, et al. Long term outcome of balloon mitral commissurotomy during pregnancy: a prospective physical and mental evaluation of babies. EuroIntervention 2006; 2:302.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S.
- Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Non-cardiac complications during pregnancy in women with isolated congenital pulmonary valvar stenosis. Heart 2006; 92:1838.
- Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303.
- Greutmann M, Von Klemperer K, Brooks R, et al. Pregnancy outcome in women with congenital heart disease and residual haemodynamic lesions of the right ventricular outflow tract. Eur Heart J 2010; 31:1764.
- Presbitero P, Prever SB, Brusca A. Interventional cardiology in pregnancy. Eur Heart J 1996; 17:182.
- Hauck AJ, Freeman DP, Ackermann DM, et al. Surgical pathology of the tricuspid valve: a study of 363 cases spanning 25 years. Mayo Clin Proc 1988; 63:851.
- Daniels SJ, Mintz GS, Kotler MN. Rheumatic tricuspid valve disease: two-dimensional echocardiographic, hemodynamic, and angiographic correlations. Am J Cardiol 1983; 51:492.
- Roguin A, Rinkevich D, Milo S, et al. Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J 1998; 136:103.
- Sharma S, Loya YS, Desai DM, Pinto RJ. Percutaneous double-valve balloon valvotomy for multivalve stenosis: immediate results and intermediate-term follow-up. Am Heart J 1997; 133:64.
- Gamra H, Betbout F, Ayari M, et al. Recurrent miscarriages as an indication for percutaneous tricuspid valvuloplasty during pregnancy. Cathet Cardiovasc Diagn 1997; 40:283.
- Bahl VK, Chandra S, Mishra S. Concurrent balloon dilatation of mitral and tricuspid stenosis during pregnancy using an Inoue balloon. Int J Cardiol 1997; 59:199.
- De Santo LS, Romano G, Della Corte A, et al. Mitral mechanical replacement in young rheumatic women: analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up. J Thorac Cardiovasc Surg 2005; 130:13.
- Vural KM, Ozatik MA, Uncu H, et al. Pregnancy after mechanical mitral valve replacement. J Heart Valve Dis 2003; 12:370.
- Meijer JM, Pieper PG, Drenthen W, et al. Pregnancy, fertility, and recurrence risk in corrected tetralogy of Fallot. Heart 2005; 91:801.
- Metz TD, Hayes SA, Garcia CY, Yetman AT. Impact of pregnancy on the cardiac health of women with prior surgeries for pulmonary valve anomalies. Am J Obstet Gynecol 2013; 209:370.e1.
- Connolly HM, Warnes CA. Ebstein's anomaly: outcome of pregnancy. J Am Coll Cardiol 1994; 23:1194.
- Windram JD, Colman JM, Wald RM, et al. Valvular heart disease in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:507.
- Weiss BM, von Segesser LK, Alon E, et al. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Am J Obstet Gynecol 1998; 179:1643.
- Parry AJ, Westaby S. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 1996; 61:1865.
- Strickland RA, Oliver WC Jr, Chantigian RC, et al. Anesthesia, cardiopulmonary bypass, and the pregnant patient. Mayo Clin Proc 1991; 66:411.
- Chambers CE, Clark SL. Cardiac surgery during pregnancy. Clin Obstet Gynecol 1994; 37:316.
- Tripp HF, Stiegel RM, Coyle JP. The use of pulsatile perfusion during aortic valve replacement in pregnancy. Ann Thorac Surg 1999; 67:1169.
- Goldstein I, Jakobi P, Gutterman E, Milo S. Umbilical artery flow velocity during maternal cardiopulmonary bypass. Ann Thorac Surg 1995; 60:1116.
- Pomini F, Mercogliano D, Cavalletti C, et al. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg 1996; 61:259.
- Martin MC, Pernoll ML, Boruszak AN, et al. Cesarean section while on cardiac bypass: report of a case. Obstet Gynecol 1981; 57:41S.
- Lactmed. Available at http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~R2NQWq:2. (Accessed on January 19, 2010).
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736.
- Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008; 118:e714.
- Campuzano K, Roqué H, Bolnick A, et al. Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature. Arch Gynecol Obstet 2003; 268:251.
- 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