Assessment and Management of Cardiac Disease in Pregnancy

Approximately 1% of pregnancies are affected by congenital or acquired cardiac disease. The obstetric care provider requires an understanding of the expected cardiorespiratory adaptations to pregnancy in order to anticipate when and how the cardiac patient may decompensate. Although the majority of women with cardiac disease in pregnancy can expect a positive outcome, women should be evaluated for predictors of poor perinatal outcome to aid in determining the appropriate location for and surveillance in labour. Women affected with congenital heart disease require counselling about the risk of recurrence in their offspring. The discussion of contraceptive needs for the woman with cardiac disease is critical in the appropriate planning of her family.     

A practical approach to fetal heart scanning

Evaluation of the fetal heart can be readily incorporated into the obstetric ultrasound examination and need not add more than a few minutes to the examination. Correct analysis of the four-chamber view and both outflow tracts will exclude the majority of serious congenital heart disease. Where cardiac malformations are identified during pregnancy, parents should be referred to a pediatric cardiologist with expertise and experience of fetal heart scanning for further counseling. This allows for management of the pregnancy to be tailored to the parents wishes and the type of malformation found.     

Neonatal lupus erythematosus: results of maternal corticosteroid therapy.

OBJECTIVE: To assess the possibility of preventing cardiac or cutaneous manifestations of neonatal lupus erythematosus or treating the fetus with congenital heart block by administering corticosteroid therapy to the mother. METHODS: Eighty-seven offspring of 40 anti-Ro/SSA-positive mothers, followed up from 1979 to 1996, were evaluated. Autoantibodies against Ro/SSA and La/SSB antigens were detected by immunodiffusion and enzyme-linked immunosorbent assay. RESULTS: None of 26 neonates whose mothers received corticosteroid maintenance therapy initiated before 16 weeks' gestation demonstrated congenital heart block, whereas 15 of 61 neonates whose mothers received no corticosteroids during pregnancy or began receiving steroid therapy after 16 weeks' gestation had congenital heart block. Complete congenital heart block, once developed, did not respond to corticosteroid treatment in utero. Four infants whose mothers received steroid treatment before 16 weeks' gestation had skin lesions of neonatal lupus erythematosus. CONCLUSION: Once established, complete congenital heart block was irreversible and maternal corticosteroid therapy did not effectively prevent cutaneous lupus erythematosus. However, prenatal maintenance therapy with prednisolone or betamethasone given to the mother starting early in pregnancy (before 16 weeks' gestation) might reduce the risk of developing antibody-mediated congenital heart block in the offspring.     

妊娠期心功能不全的防治

需要根据心脏病种类和心功能状态来评判心脏病妇女是否允许妊娠或继续妊娠。目前产科仍然常用纽约心功能分级法。允许妊娠的心脏病患者要加强孕期保健,防止产科并发症的发生,去除诱发心衰的不良因素,减轻心脏负荷,增加心肌收缩力。一旦发生心力衰竭(心衰),按急性心衰和慢性心衰的不同治疗原则处理。终止妊娠是改善心功能的有效方法。     

Kardiologische Erkrankungen in der Schwangerschaft

Serious cardiac disease has a significant impact on maternal and fetal morbidity and mortality. The overall incidence is estimated at approximately 1%. In Germany, about 6000 pregnancies in women with congenital or acquired valvular lesions are expected per year. The etiology of the disease has changed during the past several years from predominantly rheumatic disease to an equal incidence of rheumatic and congenital heart disease. Normal physiologic changes during pregnancy and delivery can aggravate underlying cardiac disease and lead to the associated mortality and morbidity. Cardiovascular alterations during pregnancy are characterized by an increased vascular volume, cardiac output, and heart rate, with a fall in peripheral vascular resistance. The peripartal phase represents another critical period. Treatment and outcome will depend on the type of cardiac disease, on the functional impairment of the fetal heart and on the status of the fetus. Close interdisciplinary collaboration and tightly networked support are the prerequisite for successful management of high-risk pregnancies involving maternal heart disease.     

A case of intrauterine fetal retardation with polycythemia in a patient with a pacemaker

A case of intrauterine fetal growth retardation with polycythemia is reported on a newborn whose mother was treated five years before pregnancy by an artificial external fixed-rate pacemaker because of complete atrioventricular block with right bundle-branch block and Adams-Stokes syndrome. Obviously fixed-rate pacemaker does not meet all necessities of pregnancy. Therefore in young women who wish to have children only demand pacemaker with programmable frequency are supposed to be used. They may be better for the requirements of systemic and uterine circulation in pregnancy.     

Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center

OBJECTIVE: To evaluate contemporary perinatal and cardiac outcomes of pregnancies in women with major structural congenital heart disease. METHODS: Obstetric, neonatal, and cardiac outcomes were abstracted retrospectively from medical records of all women with congenital cardiac disease delivering at our institution from 2000-2007 and compared by type of structural defect. Predictors of adverse cardiac or obstetric events were identified. RESULTS: Over the 7-year study period, 74 deliveries occurred in 69 women with congenital heart disease, median age 28 years. There were three right-obstructive defects, 14 left-obstructive defects, four right-regurgitant defects, 19 conotruncal defects, 19 shunts, and four miscellaneous lesions. There were 21 adverse cardiac events in 15 pregnancies (20.2%); these were defined as maternal death, congestive heart failure, myocardial infarction, stroke, the need for urgent cardiac intervention, or arrhythmia requiring treatment. There were 44 adverse obstetric events in 34 pregnancies (45.9%), defined as preterm delivery, stillbirth, preeclampsia, small for gestational age, or neonatal intensive care unit admission. Patients with shunt morphology were more likely to experience adverse obstetric and cardiac outcomes. CONCLUSION: Pregnancy in women with underlying major congenital heart defects poses increased risks to both mother and fetus. Nonetheless, favorable maternal and neonatal outcomes occur in the majority of patients.     

Pregnancy outcome in women with heart disease undergoing induction of labour

OBJECTIVE: To examine the safety and outcome of induction of labour in women with heart disease. DESIGN: Prospective single-centre comparative study. SETTING: Major university-based medical centre. POPULATION/SAMPLE: One hundred and twenty-one pregnant women with heart disease. METHODS: The sample included all women with acquired or congenital heart disease who attended our High-Risk Pregnancy Outpatient Clinic from 1995 to 2001. The files were reviewed for baseline data, cardiac and obstetric history, course of pregnancy and induction of labour and outcome of pregnancy. Findings were compared between women who underwent induction of labour and those who did not. Forty-seven healthy women in whom labour was induced for obstetric reasons served as controls. MAIN OUTCOME MEASURES: Pregnancy outcome. RESULTS: Of the 121 women with heart disease, 47 (39%) underwent induction of labour. There was no difference in the caesarean delivery rate after induction of labour between the women with heart disease (21%) and the healthy controls (19%). Although the women with heart disease had a higher rate of maternal and neonatal complications than controls (17%vs 2%, P= 0.015), within the study group, there was no difference in complication rate between the patients who did and did not undergo induction of labour. CONCLUSION: Induction of labour is a relatively safe procedure in women with cardiac disease. It is not associated with a higher rate of caesarean delivery than in healthy women undergoing induction of labour for obstetric indications, or with more maternal and neonatal complications than in women with a milder form of cardiac disease and spontaneous labour.     

Maternal heart disease. A survey of a decade in a Danish university hospital

Among 87 pregnancies complicated by heart disease, delivered during the decade 1977-86, 70 (81%) had a congenital heart malformation, 7 (8%) an acquired heart disease and 10 (11%) arrhythmias or conduction disturbances. The incidence was 0.3%. The corresponding data from a report from Rigshospitalet during the 1950s were: 42%, 49%, and 9%, respectively, and an incidence of 0.9%. Ventricular septal defect (VSD) and atrial septal defect (ASD) were the most frequent malformations. The women were classified according to the NYHA before, during and after the pregnancy. All women except 4 re-entered their original functional class. In 51 cases, ECG showed completely normal sinus rhythm, while in 36, various degrees of arrhythmia or conduction disturbance were found as well as left or right ventricular hypertrophy and/or strains. Nine infants had congenital defects, 4 of which were a heart malformation (4.6%). One infant died. Gestational duration, weight and perinatal mortality did not differ significantly from that of the general population. Two women died, one of primary pulmonary hypertension and one with a rupture of the thoracic aorta. Rheumatic heart disease is no longer a significant factor in relation to pregnancy in Denmark, but congenital heart disease is still of great importance, because more survive and reach the age of fertility. Today most women can be brought safely through pregnancy, but obstetric, cardiologic and anesthesiologic expertise is still mandatory for a successful course and outcome of pregnancies complicated by heart disease.     

Cardiovascular disease in pregnancy

Heart disease continues to be an important cause of maternal morbidity and mortality. This is largely because of the extensive haemodynamic changes that occur during pregnancy, namely the increase in blood volume, fluctuations in cardiac output, fall in systemic vascular resistance and the hypercoagulable state. High-risk periods include the end of the second trimester, during labour and the immediate postpartum period. Prognosis depends on the specific cardiac condition, the patient's functional class, presence of cyanosis, history of cardiac events or arrhythmia and the degree of systolic dysfunction. Pregnancy is contraindicated in women with Eisenmenger's syndrome, pulmonary hypertension, complex cyanotic congenital heart disease, Marfan's syndrome with aortic root dilatation, and those with severe left ventricular dysfunction. Women with heart disease should be thoroughly evaluated and counselled before and during pregnancy. Multidisciplinary care is essential for successful maternal and fetal outcomes.     

Pregnancy after myocardial infarction: are we playing safe?

The safety of pregnancy after myocardial infarction remains a significant dilemma for both the obstetrician and the cardiologist. Only 20 cases of pregnancy after myocardial infarction have been reported. To clarify this problem, we add our experience of four such cases in which conception occurred 9 months to 9 years after myocardial infarction with no previous consultation. Each woman had an uneventful pregnancy with no cardiac or obstetric complications related to the myocardial infarction. All patients were under the strict supervision of an obstetrician and a cardiologist during pregnancy in our conjoined antepartum-cardiologic clinic. The mode of delivery in all patients was related to the obstetric indications. Our experience and the accumulated experience in the literature demonstrate good prognosis for patients who conceive after myocardial infarction.     

Cardiovascular disease in pregnancy

Heart disease continues to be an important cause of maternal mortality. This is largely because of the extensive haemodynamic changes that occur during pregnancy, namely the increase in blood volume, increase in cardiac output, fall in systemic vascular resistance and hypercoagulable state. High-risk periods include the end of the second trimester, during labour and the immediate postpartum period. Prognosis depends on the specific heart condition, the patient's functional class and the degree of cardiac dysfunction. Conditions that are contraindications to pregnancy include Eisenmenger's syndrome, primary and secondary pulmonary hypertension, complex cyanotic congenital heart disease, and Marfan's syndrome with aortic root dilatation. Women with heart disease should be thoroughly evaluated and counselled before and during pregnancy. Multidisciplinary care is essential for successful maternal and fetal outcomes.     

围产期心功能不全59例临床分析

目的探讨围产期心功能不全的临床相关因素。方法对北京大学人民医院1990年1月至2008年12月间收治的59例围产期心功能不全患者的临床资料进行回顾性分析。结果①围产期心功能不全以妊娠高血压性心脏病发生率最高,22例（37.29%）,其次是风湿性心脏病10例（16.95%）,先天性心脏病9例（15.25%）等;②按心功能分级,Ⅱ级17例（28.81%）,Ⅲ级22例（37.29%）,Ⅳ级20例（33.90%）;③按心功能不全发生的时间：产前发生47例（79.66%）,产时2例（3.39%）,产后10例（16.95%）;④分娩方式：剖宫产44例（74.58%）,产钳5例（8.47%）,顺产10例（16.95%）;⑤孕产妇死亡1例,围产儿死亡率2例（33.9‰）。结论59例围产期心功能不全的病因以妊娠高血压性心脏病占首位,产前发生为主,分娩方式的选择以剖宫产为主。重视产时及产后心衰的预警。     

Prenatal diagnosis of a double outlet right ventricle (DORV) using *doppler echocardiography with subsequent observation of intrauterine heart failure

Doppler echocardiography was used for the prenatal diagnosis of a double outlet right ventricle and coarctation of the aorta in the 30th week of pregnancy. Heart failure with intrauterine death was observed during blood flow measurements. End-diastolic loss of flow velocity in the umbilical artery and fetal aorta occurred first and was followed by total loss of flow in both vessels, although ineffective contractions of the heart were recorded for a further three minutes. We conclude that a lock of end-diastolic flow velocity in the aorta may not only be due to strong placental resistance but can also be caused by a heart defect of by impaired cardiac function. The four-chamber-view approach makes an accurate prenatal diagnosis of severe congenital heart defects possible.     

Fetal cardiac arrhythmia. Clinical outcome in 113 cases

In 113 cases of fetal cardiac arrhythmia, i.e. 94 with supraventricular arrhythmia, 5 with atrioventricular block and 14 with ventricular arrhythmia, the clinical outcome was studied and compared with the general pregnant population. The arrhythmia group was afflicted with a significantly increased frequency of congenital malformations, 6.2% vs. 2.0%; fetal distress in labor, 20.4% vs. 13.5%; perinatal mortality, 3.5% vs. 0.7%; and neonatal mortality, 1.8% vs. 0.1%. In 4 cases, pharmacological cardiac treatment was needed in utero due to fetal heart failure. Fetuses with cardiac arrhythmia thus constitute an obstetric and pediatric high-risk group that should be subjected to an intensified supervision to detect fetal heart failure or fetal distress. When indicated, these complications can be treated in utero.     

心脏矫正术对先天性心脏病妇女妊娠结局影响的Meta分析

目的：探讨孕前行心脏矫正术对先天性心脏病（先心病）孕产妇妊娠结局的影响。方法：检索2018年9月以前在中国知网（CNKI）、万方数据库（WangFang data）、维普数据库（VIP）、PubMed、Cochrane Library等数据库关于孕前心脏矫正术对先心病孕产妇妊娠结局影响的文献。对纳入文献进行质量评价及数据提取,使用RevMan 5.3软件对数据进行Meta分析。结果：共纳入17个队列研究共1 181例患者,其中手术组457例,未手术组724例。对于先心病妇女,孕前的心脏矫正术可以改善孕妇的心功能情况,心力衰竭发生率、剖宫产率、早产率、胎儿生长受限发生率、小于胎龄儿发生率、新生儿窒息发生率及围生儿死亡率与未手术组比较差异均有统计学意义（均P＜0.05）。然而,关于孕妇的死亡率及新生儿心脏病发生率,2组间比较差异无统计学意义（均P＞0.05）。结论：相比于孕前未行心脏矫正术的先心病患者,手术患者能取得较为理想的妊娠结局。     

Pregnancy in patients with heart disease

PURPOSE: The study was carried out to ascertain the experience of pregnant women with cardiac disease in one referral center. METHODS: From 1986 to 2004, 242 pregnant women with heart disease were followed by the same obstetrical and cardiology center. The cardiac diagnosis was additionally confirmed with echocardiography and heart catheterization during cardiosurgery. The subjects were classified into groups with respect to the congenital heart abnormality type, and cardiovascular insufficiency according to the NYHA classification. The results from the evaluated groups were compared to a control group. RESULTS: A significant increase in percentage of congenital heart disease was found, however acquired cardiac defects prevailed. A significant increase in rate of congenital heart disease was found. A higher incidence of cesarean sections in women with underlying heart disease with respect to the control group was also found. CONCLUSIONS: In pregnant women with underlying heart disease, congenital heart disease is presently more frequent than acquired heart disease compared to the situation in the beginning of the analysis. Pregnancy duration time depends on cardiac sufficiency and it is statistically shorter in NYHA class III and IV patients.     

Routine fetal cardiac screening: what are we doing and what should we do?

In many countries, ultrasound examination is used in the second trimester to look for congenital malformations as part of routine prenatal care. While tertiary centres scanning high-risk pregnancies have reported a high degree of accuracy in the detection of congenital heart disease, many studies have shown that cardiac abnormalities are commonly overlooked during routine obstetric evaluation and there still remains a huge variation between centres. The majority of babies with congenital heart disease are born to mothers with no identifiable high-risk factors and so will not be detected unless there is widespread screening of the low-risk population. It is feasible to achieve widespread screening for fetal congenital heart disease in low-risk groups, but this does need commitment and effort from those performing the scans and those teaching them how to examine the heart. Staff performing routine obstetric ultrasound scans should learn a simple technique for examining the fetal heart and to use this in all patients. Links to a tertiary centre can provide support for checking scans of concern as well as for providing training and for obtaining feedback. In addition, an audit system needs to be established in each centre to trace false-positive and false-negative cases as well as to confirm true positives and true negatives.