Management of pregnancy in the patient with heart disease

Dateline: 09/21/98

Pregnancy is one of the physiological conditions that places a considerable burden on the heart, forcing it to work harder for a significantly long period - nine months. While a normal heart is quite capable of taking this extra workload right in its stride, a diseased one may not be able to cope. Different kinds of heart disease may cause different problems during pregnancy. In this series of articles I plan to discuss this topic in depth.

How to manage a pregnancy in a patient with heart disease ?

Special precautions are required during pregnancy in patients with heart disease. Preferably, these patients should be examined jointly by an obstetrician and a cardiologist at each visit.

Close monitoring of the fetal development is mandatory. Ultrasonographic examination is very helpful, and allows

• making a diagnosis and planning pediatric care
• considering termination of pregnancy in highly complex cases
• providing maternal reassurance in most cases that everything is fine

The Diagnosis

Most cases of heart disease have been diagnosed before the pregnancy, and very few become apparent for the first time during gestation. Making the diagnosis on the basis of patient complaints or physical examination of the heart is very difficult since most of the changes of normal pregnancy can mimic heart disease. A chest xray is not of much help except in advanced cases of heart failure, and an EKG is too non-specific to detect anything but rhythm disturbances.

An echocardiogram is the cornerstone of diagnosis of heart disease during pregnancy. It is safe as it involves no radiation that can harm the fetus, and can provide a wealth of information in skilled hands.

Treatment - Decision making

In those who have only milder forms of heart disease with no hemodynamic problems, nothing special need be done. Some obstetricians recommend antibiotic cover during the period of delivery to prevent any risk of infective endocarditis.

However, in those who have potential or real hemodynamic problems (signs of heart failure or low cardiac output), important decisions need to be taken. The most important ones are:

• should the pregnancy be terminated
• should the patient undergo heart surgery, and if so when

What are the indications for Medical Termination of Pregnancy (MTP)?

In view of their prohibitively high risk of maternal mortality, MTP is strongly advised in

• Primary pulmonary hypertension (PPH)
• Eisenmenger syndrome
• Pulmonary veno-occlusive disease
• Severe lung disease with pulmonary hypertension - some cases

In each case, an individual assessment of the risk of pregnancy must be compared with the parent's desire to have a child.

In the next article, we will discuss aspects of management principles of heart disease patients during the pregnancy.