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    Cardiovascular morbidity and mortality in pregnancy


    Prediction of risk

    Several different risk scores have been developed to predict pregnancy risk in mothers with CVD, with the modified World Health Organization (WHO) classification felt to be the most reliable.30 (See “World Health Organization classification of maternal cardiovascular risk factors” at Contemporaryobgyn.net/cv-morbidity.) WHO Pregnancy category I indicates no significant maternal morbidity or mortality. Category II indicates a low risk of maternal mortality and a moderate risk of morbidity.  Category III indicates a high risk of complications with a significantly increased risk of maternal mortality or morbidity and requires careful coordinated care with ongoing monitoring throughout the pregnancy. Some patients are classified as Category II-III with an intermediate risk of maternal mortality and morbidity, depending on their specific anatomy and clinical status. Category IV indicates that pregnancy is contraindicated due to a very high risk of maternal mortality or morbidity, and termination of pregnancy is often recommended. In a validation study comparing risk models for pregnancy complications in CHD, the risk of cardiovascular complications was 0% in WHO Class I, 6.8% in Class II, 24.5% in Class III, and 100% in Class IV.9


    Coordination of care

    For patients at increased risk of cardiovascular morbidity or mortality (WHO pregnancy class II or greater), pregnancy care should be coordinated between the maternal-fetal medicine obstetrician and the cardiologist. For patients with CHD, a CHD-trained physician should be involved in the care of the patient and high-risk patients should be managed at a specialized adult CHD center. For patients with the highest mortality risks, pregnancy and delivery should be in a specialized care center as well. The frequency of follow-up depends on the perceived risk to the patient and her clinical status, with follow- up every trimester for low-risk patients (Class II) and every 1 to 2 months or more frequently for patients at highest risk (Class III or IV). In some cases where maternal risk is felt to be excessive, termination of pregnancy should be recommended. A specific plan for labor, delivery, and postpartum care should be created, involving the cardiologist, ob/gyn, and anesthesiologist. For the highest-risk patients, involvement of a cardiac anesthesiologist may be indicated, as well as cardiac interventionalists, pulmonary hypertension specialists, cardiac surgeons and other specialists. Common complications to be anticipated and planned for should include arrhythmias and heart failure. Specific plans for management of complications should include the availability of telemetry monitoring, intensive care unit-level care, availability of transcatheter interventions and cardiac surgery if needed, and the ability to perform cardiopulmonary resuscitation. Prolonged maternal monitoring after delivery is important, as cardiac complications may arise in the postpartum period after successful delivery. Careful planning and integration of care between providers are vital to optimize maternal and neonatal outcomes.


    Disclosure The author reports no potential conflicts of interest with regard to this article.


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    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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