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The scope of the problem
Cardiovascular disease is the most common cause of pregnancy-related mortality in countries with medium or higher human development index (HDI).1 2 In parallel, medical advancements in the treatment of cardiovascular disease have allowed for more women with structural and congenital heart disease to survive and reach childbearing age, and the number of pregnancies in women with congenital and acquired valvular or ischaemic heart disease is increasing.1 Women with valvular heart disease (VHD) are important to identify as the haemodynamic burden of pregnancy may be particularly difficult for them to tolerate. Starting in the first trimester, as early as 6-week to 8-week gestation, the plasma volume increases (in part due to activation of the renin-angiotensin system) as does the cardiac output, peaking in the second trimester; heart rate continues to increase into the third trimester.3 These shifts lead to an increased risk of heart failure symptoms and arrhythmias in pregnant women with VHD. Given the rapid rise in systemic vascular resistance and significant fluid shifts shortly after delivery, the early post-partum phase is also a time when women with VHD must be followed closely.
What are the risks of pregnancy for women with VHD?
In this issue, Ducas and colleagues attempt to clarify both the maternal and fetal outcomes of pregnancies in women with significant VHD from countries with medium or higher HDI by performing a systemic review and meta-analysis.4 Sufficiently robust data to assess both maternal and fetal outcomes were found only for women with mitral stenosis (MS) and aortic stenosis (AS). As expected, the rate of adverse maternal events was highest in pregnant women with severe MS and AS; however maternal and fetal adverse events were also common in women with moderate MS and AS. The outcomes of interest included all-cause maternal mortality up to 6 weeks post-partum, stillbirth (after 20 weeks of gestational age) …
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Contributors All authors contributed extensively to this editorial.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; externally peer reviewed.