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Optimal management of cardiac emergencies during pregnancy.
Developing a delivery plan for pregnant women with an acute cardiac complication.
To understand that the knowledge base is limited to expert opinion and experience, or observational cohort studies. There are no randomised trials.
Reducing maternal mortality was a major component of the fifth millennium development goal. A drop of 47% was achieved mainly through reductions in sepsis and haemorrhage.1 Maternal mortality related to cardiovascular causes did not decrease and, in developed countries, may even have increased.2 ,3 Most of these women are not known to have an underlying cardiovascular problem, and the majority die from acute events including aortic dissection, acute coronary syndrome (ACS) or an arrhythmia. Others have an underlying, pre-existing heart condition, which deteriorates with the increased demands of pregnancy, most commonly resulting in heart failure.4
In the group of women with a known cardiac condition, a preconception assessment by an experienced team of specialists is essential in order to minimise the risk of complications during pregnancy. The aim of this assessment is to identify those who may benefit from an operative intervention, to optimise medical treatment, to identify potential complications and to put in place plans to deal with these eventualities. It involves a combination of history, physical examination, VO2max exercise testing, echocardiography and, in some cases, cardiac CT or MR. In addition, the thorough evaluation informs preconception counselling, which should occur at the same time and which should consider the potential impact of the cardiac condition on pregnancy outcome and, conversely, the potential impact of the pregnancy on the cardiac condition.
The evaluation of maternal risks can be based on several risk tools.5–7 Of these, the modified WHO risk stratification model seems to be the best predictor of overall risk. Women in …
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