Management of high risk cardiac conditions in pregnancy: Anticoagulation, severe stenotic valvular disease and cardiomyopathy☆

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Abstract

Cardiovascular disease contributes to approximately one third of all maternal mortality and remains a significant source of peri‑ and postpartum morbidity. As more women at risk for and with cardiovascular disease are desiring pregnancy, it is imperative that general cardiologists and obstetricians participate collaboratively in preconception counseling and are more facile with management of these lesions during peri‑ and postpartum periods. This review aims to address this growing need and highlights the management strategies for some of the major high risk cardiac conditions encountered during pregnancy including anticoagulation, cardiomyopathies as well as severe mitral and aortic stenosis; aortopathy, pulmonary hypertension, and severe congenital heart lesions will not be addressed.

Introduction

Once the most feared cause of death in young women, maternal mortality has declined dramatically in the 20th century from 50 per 100,000 live births in 1950 to 10 per 100,000 live births in 1984 [1]. Unfortunately, since 1987, we have seen a rise in pregnancy-related mortality up to a present rate of 17 per 100,000 live births (Fig. 1). Cardiovascular disease (CVD) contributes to approximately 1/3 of all maternal mortality [2]. Among cardiac conditions in pregnancy, an analysis of pregnancy-related mortality in the United States from 1987–2010 found that rates of cardiomyopathy and general cardiovascular conditions were rising, while hypertensive diseases were declining. As women are increasingly delaying childbearing or utilizing assisted reproductive technologies, the rates of cardiovascular complications during pregnancy are unsurprisingly rising [3]. Finally, with the improvement in the care of congenital heart disease (CHD) and childhood cancers, more women with CHD or women who have undergone treatment for cancer are surviving into adulthood and desiring pregnancy, introducing further complexity to the care of pregnant women today [4]. As more women with CVD are desiring pregnancy, it is imperative that general cardiologists and obstetricians become more expert in the management of high risk lesions during pregnancy. This review aims to address this growing need and highlights the management strategies for some of the major high risk cardiac conditions encountered during pregnancy; aortopathy and pulmonary hypertension will not be addressed.

Section snippets

During pregnancy

Pregnancy is a vulnerable time for women with preexisting cardiac disease and may unmask undiagnosed conditions. Cardiac output increases by 30–50%, marked by a 40% increase in plasma volume initially followed by an increase in heart rate by up to 15–20% by the third trimester. Late third trimester, cardiac output begins to fall largely due to uterine compression of the IVC and aorta (reducing preload and afterload), but does not return to baseline values until 2–4 weeks postpartum. Systemic

Anticoagulation in pregnancy

Pregnancy is a period of marked hypercoagulability resulting from the combination of increase in coagulation factors, decrease in natural anticoagulant mechanisms, and inhibition of fibrinolysis. The highest thrombotic risk occurs postpartum, and the risk does not return to baseline levels until 12 weeks postpartum. Populations at risk for thrombosis during pregnancy include women with prosthetic heart valves, venous thromboembolism, and thrombophilias. We will limit our discussion to the

Mitral stenosis

Mitral stenosis (MS) is an important source of maternal morbidity and mortality worldwide. Rheumatic disease is responsible for most cases, although congenital MS occurs as well (Fig. 3). Indeed, 67% of women with severe MS develop a maternal cardiac event during their pregnancy. The most common maternal complications include pulmonary edema, atrial tachyarrhythmias, thromboembolism, and even, death [20]. If unrecognized, MS in pregnancy can be destabilizing and even fatal. In a study of 1000

Aortic stenosis

Unlike MS, isolated aortic stenosis (MS) in pregnancy is generally better tolerated, but still associated with a high rate of adverse outcomes [29]. Most cases of AS in pregnancy are a result of congenital bicuspid aortic valve but rheumatic disease is also common outside the US. Complications include HF, tachyarrhythmias, and pulmonary edema. A 2016 analysis of 96 women with moderate to severe AS from the ROPAC registry found that 20.8% were admitted to the hospital for cardiac reasons [30].

Cardiomyopathy

Cardiomyopathy (CMP) is an increasingly important source of maternal morbidity and mortality. From a 2006–2010 analysis of the Healthcare Cost and Utilization Project's National Inpatient Sample, the estimated incidence of CMP was 46.8/100,000 [34]. Among hospitalized pregnant women with CMP, 50.0% were peripartum (23.4/100,000), 2.5% were hypertrophic (1.2/100,000), and 47.5% were classified as other (largely dilated) (22.2/1000,000). The authors of this analysis examined maternal outcomes and

Mode of delivery

Historically, planned C-section was perceived to be safer than vaginal delivery in women with high-risk pregnancies. Indeed, in a 2017 retrospective study of inpatient admissions in the Healthcare Cost and Utilization Project's California State Inpatient Database, women with CHD were significantly more likely to undergo cesarean delivery as compared to women without CHD (39.3% vs. 32.0%, p < 0.001), although overall rates for both groups were staggeringly high. Increasingly, studies have

Conclusions

The advancement of cardiovascular care has made pregnancy possible for many women with complex CVD. While a tremendous opportunity for our patients, pregnancy in women with high risk CVD is associated with significant risk for adverse maternal and neonatal outcomes, even death. A multidisciplinary approach and awareness of the potential complications and management strategies for pregnant women with CVD are vitally important to the health and long-term outcomes of women with complex heart

References (57)

  • CK Silversides et al.

    Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis

    Am J Cardiol

    (2003)
  • S Orwat et al.

    Risk of pregnancy in moderate and severe aortic stenosis: from the multinational ROPAC registry

    J Am Coll Cardiol

    (2016)
  • A Black et al.

    Contraceptive use among Canadian women of reproductive age: results of a national survey

    J Obstet Gynaecol Canada

    (2009)
  • N Tzemos et al.

    Late cardiac outcomes after pregnancy in women with congenital aortic stenosis

    Am Heart J

    (2009)
  • FV Lima et al.

    Association of cardiomyopathy with adverse cardiac events in pregnant women at the time of delivery

    JACC Heart Fail

    (2015)
  • J Grewal et al.

    Pregnancy outcomes in women with dilated cardiomyopathy

    J Am Coll Cardiol

    (2009)
  • K Stergiopoulos et al.

    Pregnancy in patients with pre-existing cardiomyopathies

    J Am Coll Cardiol

    (2011)
  • U Elkayam

    Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management

    J Am Coll Cardiol

    (2011)
  • DM McNamara et al.

    Clinical outcomes for peripartum cardiomyopathy in North America: results of the IPAC study (investigations of pregnancy-associated cardiomyopathy)

    J Am Coll Cardiol

    (2015)
  • AM Amos et al.

    Improved outcomes in peripartum cardiomyopathy with contemporary

    Am Heart J

    (2006)
  • S Goland et al.

    Evaluation of the clinical relevance of baseline left ventricular ejection fraction as a predictor of recovery or persistence of severe dysfunction in women in the United States with peripartum cardiomyopathy

    J Card Fail

    (2011)
  • U Elkayam

    Risk of subsequent pregnancy in women with a history of peripartum cardiomyopathy

    J Am Coll Cardiol

    (2014)
  • K Sliwa et al.

    Outcome of subsequent pregnancy in patients with documented peripartum cardiomyopathy

    Am J Cardiol

    (2004)
  • NL Lewis et al.

    UK registry of high-risk obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan's syndrome

    Int J Obstetr Anesth

    (2003)
  • BP Sachs et al.

    Maternal mortality in Massachusetts. Trends and prevention

    N Engl J Med

    (1987)
  • AA Creanga et al.

    Pregnancy-related mortality in the United States, 2006-2010

    Obstet Gynecol

    (2015)
  • K Ueland et al.

    Circulatory changes in pregnancy

    Clin Obstet Gynecol

    (1975)
  • U Elkayam et al.

    High-risk cardiac disease in pregnancy: part II

    J Am Coll Cardiol

    (2016)

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    Disclosures: No authors have any relevant financial disclosures.

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