Cardiovascular Disease in Pregnancy

The hemodynamic goals of valvular disease, ischemic disease, shunts, and

cardiomyopathies must be understood in the context of the physiologic changes of
pregnancy, labour, and anesthesia. Investigations are those appropriate to the lesion and
patient’s functional capacity (Typically echo and ECG, plus or minus catheterization for
congenital lesions or ischemia).

Normal Maternal Cardiovascular Changes

(CO, SV, HR, and EF go up. SVR goes down.)

1) Increased cardiac output (by 30-50%).

2) Increased stroke volume and heart rate (both by ~25%).
3) Ejection fraction increases.
4) Cardiac output more profoundly affected by maternal position (caval compression).
5) Systemic vascular resistance drops (by ~20%).
6) LVEDV is increased.
7) CVP remain about the same in healthy women.
8) PVR may decrease.

Cardiovascular Changes in Labour

(CO, SV, CVP, SVR, and usually HR go up).

1) Cardiac output increases between contractions (~10% in first stage, 25% in late first
stage, 40% in second stage). Mostly from increase in stroke volume.
2) During contractions, cardiac output is augmented by an additional 15-25% (via
increased stroke volume, increased CVP via 300-500cc autotransfusion from intervillous
space, and an increase in overall sympathetic tone).
3) Contractility, SVR, and venous return increase during labour, with an even greater
increase during a contraction.
4) Heart rate changes are variable. HR generally increases during contractions, but may
decrease in those patients receiving analgesia.
5) Pulmonary Vascular Resistance increases with contractions.

Cardiovascular Changes Postpartum

(CO, SV, CVP go up. HR goes down).

1) Relative hypervolemia and increased venous return follows vaginal delivery.

CVP rises.
2) Stroke volume and cardiac output increase as much as 75% immediately postpartum,
and slowly decrease to about 10% above prepregnant levels at 2 weeks.
3) Heart rate decreases rapidly postpartum, and goes below the prepregnant rate by about
2 weeks, and stays low for several months.
4) Stroke volume remains elevated for 48 hours, then slowly decreases over many weeks.
5) Left ventricle thickness and mass remain elevated for weeks.
6) All changes eventually revert to normal in healthy women.
Cardiovascular Changes with Anesthesia

Epidural analgesia attenuates the increase in cardiac output during labour to about 10-
15%, owing primarily to decreased sympathetic tone. Preload may be decreased, SVR
may be decreased, and the increase in heart rate which normally accompanies the
increased adrenergic state may be attenuated.

Congenital Heart Disease with Left to Right Shunt

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained Increased Normalized Increased
or
decreased.
Rate Maintain Increased Increased Generally Decrease
attenuates
increase
Rhythm Sinus
always
desirable
Contractility Maintain Increased Increased Possible Increased,
decrease then
normalizes.
Afterload Avoid Decreased. Increased A large Normalizes
extremes SVR may decrease
increase may
shunt, PVR, precipitate
and reversal of
decompensate flow through
RV. shunt.

Optimization: Avoid intravenous and epidural air bubbles, endocarditis prophylaxis when
appropriate (AHA guidelines: Not indicated for vaginal or cesarean birth, but optional in
high risk patients), pediatrician at birth due to risk of congenital defect in child, slow
titration of epidural (rapid drop in SVR may reverse shunt flow), avoid pushing (consider
forceps after progression of labour without pushing), avoid increased pulmonary
hypertension (hypoxemia, hypercapnea, acidemia, hypothermia, pain), use supplemental
oxygen.
Pulmonary hypertension and Right to Left Shunts

Parameter Goal Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained Increased Normalized Increased
or decreased.
Rate Maintain Increased Increased Generally Decrease
attenuates
increase
Rhythm Sinus
desirable as
always.
Contractility Maintain Increased Increased Possible Increased,
decrease then
normalizes.
Afterload Maintain Decreased Increased Decreased Normalizes.
SVR

Optimization: Avoid intravenous and epidural air bubbles, endocarditis prophylaxis when
appropriate, pediatrician at birth due to risk of congenital defect in child, slow titration of
epidural (rapid drop in SVR may increase shunt fraction), supplemental oxygen,
nitroglycerin, nitric oxide, calcium channel blockers, prostaglandins, endothelin
antagonists, avoid increased pulmonary hypertension (hypoxemia, hypercapnea,
acidemia, hypothermia, pain). Consider avoiding epinephrine in local anesthetics.

HOCM

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained Increased Normalized Increased
or decreased.
Rate Slow Increased Increased May offer Decreases.
important
decrease.
Rhythm Sinus is best

Contractility Avoid Increased Increased Possible Increased,

increase. decrease then
normalizes.
Afterload Maintain SVR Decreased Increased May Normalizes
decrease

Optimization: Beta blockade, pacemaker or AICD if hx of syncope, monitor

hemodynamics and rhythm, epidural analgesia accepted, single shot spinal
contraindicated, avoid oxytocin boluses. Consider avoiding epinephrine in local
anesthetics.
Aortic Stenosis

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained, Increased. Normalized Increased.
preload, but but or
avoid decreased decreased.
overload. with caval Many
compression advocate
avoiding
single shot
spinal.
Rate Avoid Increased Significant Generally HR decreases.
tachycardia HR increase. attenuates
increase in
HR
Rhythm Sinus Remains Remains Remains Remains
rhythm important. important. important. important.
important.
Contractility Maintain Increased Increased Possible Increased,
contractility decrease then
normalizes.
Afterload Maintain Decreased. Increased. Decreased. Resolving to
SVR prepregnant
levels.
Pulmonary Avoid Normal or Increase May be May remain
vascular increased increased improved. elevated
resistance. PVR independent secondary to
of hypervolemia.
pregnancy.

Optimization: Rate and rhythm control (beta blockade is used, although there are
theoretical conerns of fetal effects), artline and CVP (PA catheter debated), endocarditis
prophylaxis when appropriate (AHA guidelines state unnecessary for vaginal delivery
and c-section, but may be considered for high risk individuals. Chestnut states they are at
risk). Maintain preload, avoid single shot spinal, but titrated epidural felt to be
appropriate. Consider avoiding epinephrine in local anesthetics.
Mitral Stenosis

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained, Increased Normalized Increased.
preload, but but or decreased.
avoid decreased
overload. with caval
compression
Rate Avoid Increased Significant Generally HR decreases.
tachycardia HR increase. attenuates
increase in
HR
Rhythm Sinus Remains Remains Remains Remains
rhythm important important. important. important.
important.
Contractility Maintain Increased Increased Possible Increased,
contractility decrease then
normalizes.
Afterload Maintain Decrease. Increased. Decreased. Resolving to
SVR prepregnant
levels.
Pulmonary Avoid Normal or Increased in May be Remains
vascular increased increased the context improved by increased
resistance. PVR independent of mitral analgesia and secondary to
of stenosis. normalization stenosis and
pregnancy. of preload. hypervolemia.

Optimization: Rate and rhythm control (beta blockade is used), diuresis, valvotomy,
balloon valvuloplasty or replacement in severe cases, endocarditis prophylaxis when
appropriate, epidural analgesia, avoid increases in PVR (hypoxia, hypercapnea, acidemia,
hypothermia, pain and light anesthesia), avoid pushing (forceps or c-section), invasive
monitoring. Seriously consider not getting pregnant if you have symptomatic mitral
stenosis! Consider avoiding epinephrine in local anesthetics.
Aortic Regurgitation

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Euvolemic Maintained Increased Normalized Increased
or decreased
Rate Slightly Increased Increased Generally HR
elevated attenuates decreases
increase in
HR
Rhythm Sinus
desirable
Contractility Maintain Increased Increased Possible Increased,
decrease then
normalizes.
Afterload Decrease Decreased Increased Decreased Resolving to
(try to avoid prepregnant
this). levels.

Optimize with early epidural to avoid adrenergically mediated increase in SVR.

Mitral Regurgitation

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Euvolemia Maintained Increased Normalized Increased
or decreased
Rate Normal to Increased Increased Generally HR
slightly attenuates decreases
elevated increase in
HR
Rhythm Sinus
desirable.
Treat acute
afib
aggressively.
Contractility Maintain Increased Increased Possible Increased,
decrease then
normalizes.
Afterload Decrease Decreased Increased Decreased Resolving to
(try to avoid prepregnant
this). levels.

Main concern is coexisting mitral stenosis. Isolated MR is generally well tolerated. Think
about risk for afib and anticoagulation. Chestnut states endocarditis prophylaxis is
indicated. Prevent increased SVR with early epidural. Avoid triggers of increased
pulmonary hypertension.
Ischemic Disease

Parameter Goals Pregnancy Labour Anesthesia Postpartum

Preload Maintain Maintained Increased Normalized Increased
(may or decreased
increase wall
tension and
decrease
coronary
perfusion).
Rate Slow Increased Increased Generally Decreases.
attenuates
increase in
HR.
Rhythm Sinus
desirable
Contractility Maintain or Increased Increased Possible Increased,
decrease. decrease then
normalizes.
Afterload Avoid Decreased Increased Decreased Resolving to
increase prepregnant
levels.

Pregnancy and labour increase metabolic demand, and this is not attenuated by elective c-
section. Metabolic demand remains elevated postpartum. To optimize: Treat precipitating
factors such as thyrotoxicosis, cocaine use, anemia etc. Beta blockers, calcium channel
blockers, heparin, and nitrates may all be used. Chestnut fails to discuss ASA in the
context of ductus closure. Oxytocin may be used. Epidural analgesia is recommended.
Consider avoiding epinephrine in local anesthetics.

Peripartum Cardiomyopathy

Cardiomyopathies were covered as a separate topic. Peripartum cardiomyopathy is a

diagnosis of exclusion which, by definition, occurs during the last month of pregnancy, or
the first five months postpartum. Treatment is largely supportive, as outlined in the
previous topic.