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How to deal with high-risk pregnancy

Session presentations
  • Risk stratification in congenital heart disease Presented by F Walker (London, GB)See the slides
  • Risk stratification of patients with pulmonary hypertension. Presented by R Condliffe (Sheffield, GB)See the slides
  • Management of pulmonary arterial hypertension. Presented by M Gomberg-Maitland (Chicago, US)See the slides
  • Severe aortic stenosis. Presented by P Tornos Mas (Barcelona, ES)See the slides
Pulmonary Hypertension


Based on the British confidential enquiries into the causes of maternal mortality, Dr Fiona Walker pointed out that cardiac disease is the single most prevalent cause of mortality during pregnancy.
To counsel women with known heart disease, three steps should be completed.
First, one has to review all the available data of the woman, including her clinical charts with history, co-morbidity, surgical reports and obstetric history and all information about all the available data in the literature on the specific diagnosis should be checked.
The second step is to evaluate the current clinical situation of the woman by assessing her ventricular function, exercise capacity, medication use etc by extensive pre-pregnancy testing including ECG, echocardiography, exercise testing and, if indicated, MRI or other imaging modalities.
Finally, you have to plan how and where this patient will be followed and checked during pregnancy and delivery. The CARPREG and ZAHARA risk scores were discussed as being informative, but Dr Walker stressed that common sense and experience of the doctor are also very important.
When answering a question from the audience about a woman with a bicuspid aortic valve without stenosis or regurgitation but with aortic dilatation, it was discussed that such a patient should not be counselled against pregnancy as long as the diameter of the ascending aorta is below 50mm.

The next two presentations focused on risk stratification and management of pregnancy in the case of pulmonary hypertension.
Both Dr Condiffe and Dr Gomberg showed very nicely that although mortality has declined over time, mortality is still as high as 36% in recent years, making pulmonary hypertension an extreme high risk and an absolute contraindication for pregnancy, as was also stressed in the different guidelines. In the year 1979, a first report of 70 Eisenmenger patients showed a mortality rate of 52%. When a woman is advised not to become pregnant, advice about contraceptives should be provided. Oral contraceptives carry the risk of thrombosis, while drugs with only progesterone have an interaction with warfarin and bosentan. Although tubal ligation is the method of choice, this solution can only be applied after careful counselling of the woman and her partner.
It is crucial that when a woman does become pregnant, guidance by expert cardiologists is organised. When deterioration occurs early in pregnancy, the outcome is clearly worse. During pregnancy, meticulous attention should be paid to heart rate and tachycardia is an early sign of hemodynamic deterioration. AV synchrony is crucial and therefore atrial fibrillation should be treated immediately. The use of low molecular weight heparins was advised for the duration of pregnancy, and many other drugs may be useful (diuretics, inotropes) but should be used with caution to prevent tachycardia. Specific drugs for pulmonary hypertension may be needed after careful information to the patient about possible side effects and effect on the fetus. Delivery under general anaesthesia seems to carry a higher risk than regional anaesthesia. In particular, the period directly after delivery is a high risk period and careful evaluation and management of fluid status and hemodynamics is mandatory.
 
In a recent report on pregnancy in patients with pulmonary hypertension it appeared that women who were on anticoagulants and also women taking calcium antagonists had better outcome, so maybe the women who respond well to calcium antagonists are a selected group of women with lower risk during pregnancy. Another study suggested that a good 6-minute-walk test predicted a better outcome. However, there is no safe patient.
 
The fourth presentation dealt with a woman with severe aortic stenosis. Dr Tornos Mas clearly explained that this is a rare condition during pregnancy but carries high risks, especially when the woman develops complaints. Predictors for bad outcome are calcification of the valve, more severe stenosis or an abnormal exercise test before pregnancy, including a low exercise capacity or abnormal blood pressure rise during exercise.
In all patients with mild to moderate stenosis, however, the risks are low and pregnancy should not be discouraged. Probably also women with severe stenosis but with a normal exercise test are allowed to proceed with pregnancy after having explained the risks, and only symptomatic patients should be counselled against pregnancy or have surgery first. If the patient develops symptoms during pregnancy and balloon valvotomy is discussed, one has to keep in mind that the risks of ballooning aortic valve stenosis are higher than ballooning mitral valve stenosis. When surgery is performed, a biological valve is advised.
After some very interesting questions from the active audience, this session was closed.

References


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How to deal with high-risk pregnancy

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.