Pregnant pause Wed, 24 Dec 2003 14:00:00 In the forum of this summer, doctors discussed the case of a 34year-old

woman who presented at the emergency department with sudden-onset chest pain. She had just had a baby, one week earlier. Following a full examination, diagnostic tests including an ECG and a 12-hour observation period, the patient was discharged. A week later she was brought back by ambulance after suffering a cardiac arrest; unfortunately, she died. Autopsy showed a spontaneous dissection of the left anterior descending coronary artery. High risk: Women who should not get pregnant For the most part, expect a good outcome The physiological changes that occur during pregnancy are what cause many of the problemshormonally mediated alterations in blood volume, red cell mass, and heart rate result in a 50% increase in cardiac output, increased left ventricular mass, and decreased peripheral vascular resistance and blood pressure, peaking early in the third trimester. Following delivery, there is a further transient increase in cardiac output, but most of the physiologic changes resolve by the second week postpartum, although a complete return to normal may not occur for six months. For those with congenital heart disease, outcome is related to functional NYHA class, the nature of the disease, and previous cardiac surgery. Colman says. Where appropriate, surgical correction of congenital defects is advisable before a patient contemplates pregnancy. Although this does not completely eliminate problemsand can in certain circumstances cause other complicationsit is generally the best approach. However, this is not always possibleoften women with congenital heart disease will turn up already pregnant. Patients with noncyanotic congenital heart disease tend to have a good prognosis in pregnancy, but cyanotic patients may decompensate as the pregnancy progresses. Those with small or moderate shunts without pulmonary hypertension or mild or moderate valve regurgitation benefit from the decrease of systemic vascular resistance that occurs during pregnancy, Colman says. Patients with mild or moderate left ventricular outflow tract obstruction also seem to do well, as do most patients who have had cardiac surgery early in life without mechanical valves. However, management of women with mechanical valves is very tricky during pregnancy because these women need to continue taking anticoagulants [see sidebar on anticoagulation during pregnancy]. With congenital heart disease and other conditions, "it is important to clarify the nature of the maternal cardiac problem at the beginning of pregnancy and then assess the individual risk for that woman," Colman stresses. This step is key to a good outcome, he says, and along with colleagues Dr Samuel Siu and Dr Mathew Sermer, also of the University of Toronto, Colman has devised a risk index based on a prospective study they conducted.