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Pregnancy and heart disease

FOCUS Cardiology Practice

Pregnancy and Heart Disease

Read the ESC Press release

Heart disease is present in 0.5-1% of all pregnant woman and is the biggest killer of pregnant women in the developed world. Surprisingly, there are no signs of decline of this incidence over the past decades.
During pregnancy, important maternal cardiovascular changes occur, such as an increase in blood volume, heart rate, stroke volume, cardiac output, left ventricular wall mass, and end-diastolic dimensions, which starts as early as the fifth week.

In the FOCUS session on Pregnancy and Heart disease three interesting cases were presented.
The first one, presented by Carina Blomstrom-Lundqvist from Sweden was a lady with arrhythmias. Supraventricular and ventricular arrhythmias requiring treatment are rarely seen during pregnancy in healthy women. We learned that echocardiography should be used with low threshold to rule out structural heart disease in patients with arrhythmias during pregnancy. In the case presented, the woman was diagnosed with ventricular tachycardia based on arrhythmogenic right ventricular cardiomyopathy. It was discussed that DC cardioversion is the preferred method to treat an acute VT and is safe during pregnancy. In addition the use of MRI is considered safe after the first trimester. Only the use of gadolinium may be harmful to the baby and should be used only if absolutely necessary, although some animal research did not show any negative effect on the foetus of gadolinium.
The second case was presented by Giacomo Boccuzzi from Italy and this was a lady with two mechanical valves (mitral and aortic position) who wanted to become pregnant. Worldwide, many prosthetic valves are yearly implanted in girls and young women with rheumatic or congenital heart disease. Sooner or later many of them wish to become pregnant. It was stressed that counselling is of utmost importance in the significantly increased maternal risk situation in a patient with a mechanical valve. During pregnancy and postpartum period, all pregnant patients are at risk for thrombo-embolic complications due to the presence of all three components of Virchow's triad: venous stasis, endothelial injury, and a hypercoagulable state. Nevertheless, thrombo-embolic events are normally seen only once per 1000 to 2000 pregnancies. In the current case, valve thrombosis with TIA occurred after delivery. The new guidelines provide clear and practical information on the best way to anticoagulate these patients during pregnancy. Pregnancy in women with mechanical valve prostheses has a high maternal complication rate including valve thrombosis and death. Coumarin derivatives are relatively safe for the mother with a lower incidence of valve thrombosis than un-fractionated and low-molecular-weight heparin, but carry the risk of embryopathy, which is probably dose-dependent. The different anticoagulation regimens are discussed.
This embroypathy risk of warfarin is dose dependent and if the mother is taking more than 5mg warfarin per day it is preferred to switch to low molecular weight heparin in the period from 6-12 weeks gestation. It was also clear that intensive follow-up in a specialized center is crucial with antiXa level checks every week. Although the new guidelines promote peak level assessment of antiX A, as there is no other evidence in the literature, it may be wise to also check low levels. Especially changes in the anticoagulant treatment are risky periods and patients should be hospitalized.
 The third case was presented by Antonia Pijuan Domenech from Spain. She presented a congenital case of severe pulmonary regurgitation and a right to left shunt through a patent foramen ovale. Progress in the fields of diagnostic techniques and surgical intervention has dramatically improved long-term outcome in congenital heart disease. As a consequence, most patients with congenital cardiac malformations reach childbearing age and many of these women wish to become pregnant. Antonia described a patient who developed cyanosis and heart failure during pregnancy. It was explained that treatment of this patient could not include ACE-inhibitors, as this medication is not safe during pregnancy. The mode of delivery was topic of a long discussion resulting in the conclusion that there a clear need for more data as at this moment we do not know what is the optimal mode of delivery.
The two panellists Gerhard Diller and obstetrician Mark Johnson (both from Great Britain) carefully explained their ideas based on expertise in the field. The room was over crowded and indeed a lot of interest from the audience made this a clinical relevant and exciting session.




Pregnancy and heart disease
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.