Management of Pregnancy in Patients with Congenital Heart Disease
Section snippets
Normal cardiovascular adaptations to pregnancy
Over the course of a normal pregnancy, profound hemodynamic changes occur (Fig 1). Chief among these changes are increases in blood volume, cardiac output, left ventricular (LV) stroke work, and oxygen consumption. While these changes are well documented, their specific causes are incompletely understood.
Assessment of maternal and fetal risk and preconception counseling
Ideally, all women of reproductive age with known CHD should undergo thoughtful evaluation prior to becoming pregnant. This evaluation should focus first on identifying and quantifying the risk to the mother. Second, it should address potential risks to the fetus, including the risk of inheriting a congenital heart defect.
Acyanotic heart defects without shunt
Congenital aortic stenosis is a common congenital lesion that may escape detection in childhood. Obstruction to aortic outflow results in LV hypertrophy and “preload dependence”, which may cause problems in accommodating the volume shifts of pregnancy. Furthermore, fixed LV outflow obstruction limits the patient's ability to augment cardiac output as needed in pregnancy. Early reports have suggested high risk of maternal and fetal complications during pregnancy. However, there is a broad
Anticoagulation
The use of warfarin during the first trimester has been associated with a risk for embryopathy, although the absolute incidence is unknown. The risk does appear to be dose-related, with a very low incidence in patients taking 5 mg per day or less.44 Multiple studies have shown that heparin therapy is associated with a higher incidence of thrombotic complications during pregnancy45 and that low-dose warfarin use throughout pregnancy is the safest approach from the maternal perspective. Although
Conclusion
Recent advances have led to improved survival and function in patients with CHD and to an increase in the population of reproductive-age women with CHD. As our experience in managing these patients during pregnancy has grown, we have learned that the majority of patients with CHD can expect to tolerate pregnancy and delivery with acceptably low risk for complications. With this realization comes the responsibility to discuss these issues directly and frankly with our patients and an opportunity
Statement of Conflict of Interest
The author declares that there are no conflicts of interest.
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Statement of Conflict of Interest: see page 310.