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    Cardiovascular morbidity and mortality in pregnancy


    Prosthetic valve disease

    Patients who have undergone prior valve replacement are a particular challenge in pregnancy.  Bioprosthetic valves may be placed in a young woman who is interested in pregnancy since pregnancy is usually well-tolerated with a normally functioning bioprosthesis. For a mother with a mechanical prosthesis, anticoagulation management is complex. Warfarin provides the greatest protection against valve thrombosis and is the only agent approved for use with mechanical valves, but full anticoagulation with the drug carries a significant risk of warfarin embryopathy, as well as increased risk of miscarriage and stillbirth.4,20,21 Switching to an alternate form of anticoagulation such as unfractionated heparin or low molecular weight heparin (LMWH) carries risk as well. While LWMH is safe in pregnancy, multiple complications have been reported when used in pregnancy with mechanical valves, including valve thrombosis, hemorrhage, and both maternal and fetal mortality. The prothrombotic state of pregnancy increases the risk of mechanical valve thrombosis and the pharmacodynamic changes in pregnancy (increased renal clearance drugs and increased volume of distribution) increase the difficulty of maintaining stable anticoagulation. While there are published guidelines for management of mechanical valves in pregnancy, the underlying data are sparse. A recent prospective registry report from the ROPAC registry indicated that women with a mechanical heart valve have only a 58% chance of having an uncomplicated pregnancy.22  


    Cardiomyopathy/ventricular dysfunction

    The term cardiomyopathy refers to a heterogeneous group of heart muscle diseases with a variety of etiologies, including genetic defects, toxic agents, infection, or most frequently, an unknown cause (idiopathic). Regardless of etiology, the presence of left ventricular (LV) dysfunction is a risk factor for maternal complications, and both ejection fraction and symptom status (often defined by New York Heart Association symptom class III or IV) are markers for increased risk.6,7 Teratogenic medications such as angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin-receptor blockers (ARBs) are commonly used to treat cardiomyopathy and heart failure symptoms and withdrawal of these medications prior to pregnancy may worsen cardiac function or symptoms. Treatment of heart failure during pregnancy usually involves use of hydralazine and long-acting nitrates (as a substitute for ACE inhibitors, or ARBs), diuretics, and beta-blockers. Inotropic agents may be required in low-output states with hypoperfusion, renal impairment or impaired mentation.

    Peripartum cardiomyopathy is now defined as an idiopathic dilated cardiomyopathy that presents with LV dysfunction and symptoms of heart failure towards the end of pregnancy (typically in the last month) or up to 6 months following delivery. The etiology is unknown and other known causes must be ruled out, including preexisting forms of dilated cardiomyopathy, valvular disease, hypertension, coronary disease, or CHD.23,24 Maternal morbidity and mortality are high, but both partial and complete recovery of LV function may be seen in some patients. The clinical course is highly variable,24 and there is a significant risk of relapse with subsequent pregnancies. Careful counseling should be given to these patients before attempting another pregnancy.25

    Coronary artery disease

    While coronary artery disease (CAD) does not often present in young women, it can be seen in older mothers and those with more CAD risk factors (diabetes, hyperlipidemia, hypertension, tobacco use). Spontaneous coronary artery dissection and spontaneous coronary thrombus can also complicate pregnancy, but are usually not associated with preexisting atherosclerotic CAD. Myocardial infarction (MI) in pregnancy usually presents as an ST elevation MI (STEMI), and revascularization with percutaneous coronary intervention (PCI) is usually recommended.  For non-ST elevation MI, a more conservative, noninvasive approach is often advised.26,27

    NEXT: Aortopathy and aortic dissection

    Beth Brickner, MD
    Dr. Brickner is co-director of the Adult Congenital Heart Disease Program at UT Southwestern Medical Center, Dallas, Texas.


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