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CONGENITAL HEART DISEASE
Heart disease and pregnancy
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  1. Samuel C Siu,
  2. Jack M Colman
  1. University of Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
  1. Samuel Siu MD, PMCC 3-526, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, CanadaSam.Siu{at}uhn.on.ca

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Pregnancy in most women with heart disease has a favourable maternal and fetal outcome. With the exception of patients with Eisenmenger syndrome, pulmonary vascular obstructive disease, and Marfan syndrome with aortopathy, maternal death during pregnancy in women with heart disease is rare.1-4 However, pregnant women with heart disease do remain at risk for other complications including heart failure, arrhythmia, and stroke. Women with congenital heart disease now comprise the majority of pregnant women with heart disease seen at referral centres. The next largest group includes women with rheumatic heart disease. Peripartum cardiomyopathy, though infrequent, will be discussed in view of its unique relation to pregnancy. Two groups of conditions not discussed further are coronary artery disease, infrequently encountered, and isolated mitral valve prolapse, which generally has an excellent outcome.

Cardiovascular physiology and pregnancy

Hormonally mediated increases in blood volume, red cell mass, and heart rate result in a major increase in cardiac output during pregnancy; cardiac output peaks during the second trimester, and remains constant until term. Gestational hormones, circulating prostaglandins, and the low resistance vascular bed in the placenta result in concomitant decreases in peripheral vascular resistance and blood pressure. During labour and delivery, pain and uterine contractions result in additional increases in cardiac output and blood pressure. Immediately following delivery, relief of caval compression and autotransfusion from the emptied and contracted uterus produce a further increase in cardiac output. Most haemodynamic changes of pregnancy resolve by two weeks postpartum.5

Outcomes associated with specific cardiac lesions

Congenital heart lesions

Left to right shunts

The effect of increase in cardiac output on the volume loaded right ventricle in atrial septal defect (ASD), or the left ventricle in ventricular septal defect (VSD) and patent ductus arteriosus, is counterbalanced by the decrease in peripheral vascular resistance. Consequently, the increase in volume overload is attenuated. In the absence of pulmonary hypertension, pregnancy, labour and delivery are well …

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Supplementary materials

  • Heart disease and pregnancy

    Si Siu and JM Colman

    Additional References for Website

    Pregnancy outcomes

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    2.Whittemore R. Congenital heart disease: its impact on pregnancy. Hosp Pract 1983;18:65-74.

    3.Clarkson P, Wilson N, Neutze J, et al. Outcome of pregnancy after the Mustard operation for transposition of the great arteries with intact ventricular septum. J Am Coll Cardiol 1994;24:190-3.

    4.Lao T, Sermer M, Colman J. Pregnancy following surgical correction for transposition of the great arteries. Obstet Gynecol 1994;83:665-8.

    5.Connolly HM, Warnes CA: Ebstein's Anomaly: outcome of pregnancy. J Am Coll Cardiol 1994;23:1194

    6.Witlin A, Mabie W, Sibai B. Peripartum cardiomyopathy: an ominous diagnosis. Am J Obstet Gynecol 1997;176:182-8.

    7.Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol 1999;94:311-6.

    8.Pyeritz R. Maternal and fetal complications of pregnancy in the Marfan syndrome. Am J Med 1981;71:784-90.

    Management

    1.Elkayam U. Anticoagulation in pregnant women with prosthetic heart valves: A double jeopardy. J Am Coll Cardiol 1996;27:1704-6.

    2.Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med 2000;160:191-6.

    3.Goodwin TM, Gherman RB, Hameed A, et al. Favorable response of Eisenmenger syndrome to inhaled nitric oxide during pregnancy. Am J Obstet Gynecol 1999;180:64-7.

    4.Robinson JN, Banerjee R, Landzberg MJ, et al. Inhaled nitric oxide therapy in pregnancy complicated by pulmonary hypertension. Am J Obstet Gynecol 1999;180:1045-6.

    5.Lust KM, Boots RJ, Dooris M, et al. Management of labor in Eisenmenger syndrome with inhaled nitric oxide. Am J Obstet Gynecol 1999;181:419-23.

    6.Magee LA, Downar E, Sermer M, et al. Pregnancy outcome after gestational exposure to amiodarone in Canada. Am J Obstet Gynecol 1995;172:1307-11.

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