Cardiovascular Disease in Pregnancy

Abstract

Establishing the level of maternal and fetal risk is central to the management of heart disease in pregnancy. A preconception evaluation of severity of cardiac disease, functional class, left ventricular function, pulmonary pressures, and need for anticoagulation during pregnancy should guide risk assessment. Assessment of the risk of pregnancy in heart disease should include an interdisciplinary approach with providers and patients and a detailed discussion of short- and long-term morbidity and mortality to both the mother and fetus. High-risk predictors of maternal morbidity and mortality include maternal left ventricular ejection fraction less than 40 %, New York Heart Association (NYHA) class II–IV symptoms (Table 1), or left-sided obstructive valve lesions or outflow obstruction. These factors are also known to be predictive of neonatal complications, including premature birth, intrauterine growth restriction, respiratory distress syndrome, and death. In general, treatment of any high-risk cardiac lesions should be performed when appropriate and feasible prior to conception. Most patients with relatively low-risk conditions are successfully managed throughout pregnancy, labor, and delivery with conservative treatment designed to optimize intravascular volume status, heart rate, and systemic preload and afterload. In certain conditions, where risk cannot be modified, such as cyanotic congenital heart disease, congestive heart failure with an ejection fraction <30 %, or severe pulmonary hypertension, pregnancy should be strongly discouraged as patients with these conditions do not typically tolerate the hemodynamic changes of pregnancy.