heart disease during pregnancy

Etiology

• congenital heart disease
  • bicuspid aortic valve most common
• acquired heart disease
  • peripartum cardiomyopathy

Clinical manifestations

• altered hemodynamics of pregnancy may reveal murmurs not previously heard
  • most murmurs are grade 1-2 mid-systolic murmurs without radiation
  • systolic murmur grade 1-2 present in 80% of pregnancies
  • other murmurs not normal
• mild dyspnea with exertion
  • orthopnea, paroxysmal nocturnal dyspnea, cough not normal
• palpitations, atrial premature beats, ventricular premature beats
  • atrial fibrillation, atrial flutter, ventricular tachycardia not normal
• no chest pain or chest pressure
• 20-30% increase in heart rate
  • heart rate > 100/min not normal
• drop in blood pressure of ~10 mm Hg
  • symptomatic hyptension is not normal
• mild peripheral edema
  • pulmonary edema is not normal
• S3 heart sound
  • S4 heart sound is not normal

Diagnostic procedures

• 12-lead EKG & echocardiograpy as determined by history & physical exam
• uncomplicated small patent ductus arteriosus, mild pulmonary stenosis & successfully repaired simple congenital lesions are not associated with increased morbidity or mortality during pregnancy
• asymptomatic & mild mitral valve prolapse with mild mitral regurgitation is low risk for complications during pregnancy
• symptomatic palpitations & premature atrial contractions are common with mitral valve prolapse & do not indicate significant cardiac disease

Complications

Independent predictors of maternal cardiac complications:

• left ventricular systolic dysfunction, LVEF < 40%
  • high risk of fetal & maternal complications
  • contraindication to pregnancy
• left heart obstruction*
  • mitral valve stenosis, valve area < 2.0 cm2
  • aortic valvular stenosis, valve area < 1.5 cm2
• poor NYHA functional class (3 or 4) or cyanosis
• prior cardiac events or arrhythmias

* valvular regurgitation tolerated better than valvular stenosis

Management

• pregnancy or planned pregnancy in patients with severe mitral stenosis, is an indication for mitral valve surgery regardless of symptoms
  • mitral valve balloon angioplasty for most patients
  • advise against pregnancy when mitral valve surgery is not an option
  • do not perform transesophageal echocardiography to determine valve area < 2.0 cm2

Notes

• women with severe pulmonary hypertension (systolic pressure 2/3 that of systemic circulation) have maternal mortality of 30-50%

More general terms

• pregnancy disorder; obstetric disorder; pregnancy complication
• heart disease (cardiac disease)

More specific terms

• arrhythmia during pregnancy

Additional terms

• peripartum/postpartum cardiomyopathy