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Heart Disease in Pregnancy

Heart disease is the leading cause of death in women and third leading cause of death in individuals
who are 25 to 44 years of age. Because it is relatively common in women of childbearing age, heart
disease of varying severity complicates about 1 percent of pregnancies. Although maternal mortality
related to cardiovascular disease has decreased remarkably over the past 50 years, heart disease still
contributes significantly to maternal mortality. Between 1991 and 1997, for example, cardiomyopathy
alone was responsible for 7.7 percent of the 3201 pregnancy related maternal deaths in the United
States.
PHYSIOLOGICAL CONSIDERATIONS
The marked hemodynamic changes stimulated by pregnancy have a profound effect on underlying
heart disease in pregnant women. The most important consideration is that during pregnancy cardiac
output is increased by as much as 50 percent. Amost half of the total increase occurs by 8 weeks, and it
is maximized by midpregnancy. The early increase in cardiac output results from an augmented stroke
volume associated with decreased vascular resistance and corresponding diminished blood pressure.
Later in pregnancy there is also an increased resting pulse, and stroke volume increases even more,
presumably related to increased diastolic filling from augmented blood volume.
Because significant hemodynamic alterations are apparent early in pregnancy, women with severe
cardiac dysfunction may experience worsening of heart failure before midpregnancy. In other women,
heart failure develops in the third trimester when the normal hypervolemia of pregnancy becomes
maximal. In the majority, however, heart failure develops peripartum when there are additional
hemodynamic burdens. This is the time when the physiological capability for rapid changes in cardiac
output is frequently overwhelmed in the presence of structural cardiac disease.
DIAGNOSIS OF HEART DISEASE
As shown in Fig. 48-1, many oh the physiological changes of normal pregnancy tend to make the
diagnosis of heart disease more difficult. For example, systolic heart murmurs, accentuated respiratory
effort, and edema may occur during normal pregnancy as well as in association with cardiac disease.
Listed in Table 48-1 are symptoms and clinical findings that may be suggestive of heart disease during
pregnancy. Pregnant women who have none of these findings rarely have serious heart disease.
Diagnostic Studies
Most diagnostic cardiovascular studies are noninvasive and can be conducted safely in pregnant
women. Conventional testing typically includes electrocardiography, echocardiography, and chest
radiography. If indicated, heart catheterization can be performed with limited x-ray fluoroscopy.
Electrocardiography
There are several pregnancy-induced changes that need to be considered when interpreting an
electrocardiogram. As the diaphragm is elevated in advancing pregnancy, for example, there is an
average 15-degree left-axs deviation in the electrocardiogram, and mild ST changes may be seen in the
inferior leads. Moreover, atrial and ventricular premature contractions are relatively frequent.
Pregnancy does not alter voltage findings.
Echocardiography
The widespread use of echocardiography has allowed accurate and noninvasive diagnosis of most
heart diseases during pregnancy. Some normal pregnancy-induced changes seen on echocardiography
include tricuspid regurgitation and significantly increased left-atrial size and left-ventricular outflow
cross-sectional area.
Chest X-Ray
Anteroposterior and lateral chest radiographs may be very useful when heart disease is suspected
clinically. When used with a lead apron shield, fetal radiation exposure is minimized. Slight heart
enlargement cannot be detected accurately by x-ray because the heart silhouette normally is larger in
pregnancy; however, gross cardiomegaly can be excluded.
Clinical Classification
Two clinical classification schemes are commonly used for the evaluation of pregnant women with a
history of heart disease. Shown in Table 48-2 is the classification system developed by the New York
Heart Association. Shown in Table 48-3 is the classification scheme published in 1992 by the American
College of Obstetricians and Gynecologists that stratifies the risk of maternal mortality based upon the
specific underlying heart disease. These classification systems are useful to evaluate functional capacity
and to aid in counseling the woman regarding advisability of conception or continuation of pregnancy.
MANAGEMENT
Classes I and II
With rare exceptions, women in class I and most in class II go through pregnancy without morbidity,
and mortality is rare. Throughout pregnancy and the puerperium, however, special attention should be
directed toward both prevention and early recognition of heart failure. The onset of congestive heart
failure is generally gradual. The first warning sign is likely to be persistent basilar