Elsevier

Progress in Cardiovascular Diseases

Volume 53, Issue 4, January–February 2011, Pages 305-311
Progress in Cardiovascular Diseases

Management of Pregnancy in Patients with Congenital Heart Disease

https://doi.org/10.1016/j.pcad.2010.08.001Get rights and content

Abstract

Congenital heart diseases are the most common birth defects in humans, affecting approximately 0.8% of all live births. In the past, many of the more severe defects resulted in profound disability and death during childhood, and adult survival was exceptional. The past 4 decades have seen dramatic improvements in the survival and quality of life of patients with the more severe defects. As a result of these improvements, the challenges of caring for adults with congenital heart disease are only now being realized. Most women with congenital heart disease are now expected to reach childbearing age and maternal cardiac disease is the major cause of maternal morbidity and mortality. As such, appropriate pre-pregnancy counseling and management during pregnancy are fundamental components of the care of these patients. This article describes the circulatory changes that occur during normal pregnancy and delivery, addresses the risks posed during pregnancy by specific congenital lesions, and reviews the current data on pregnancy outcomes in patients with individual congenital defects.

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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