Heart Disease In Pregnancy
Pregnancy places extra demands on a woman's heart. During the first trimester of pregnancy a woman's blood volume increases by 40 to 50 percent and remains high for the remaining two trimesters. The amount of blood the heart pumps out each minute increases by 30 to 50 percent and the heart rate increases by 10 to 15 beats per minute. All this hard work is necessary so that the heart can supply blood and nutrients to the placenta, uterus and growing fetus. Even for a woman with a healthy heart, this can place serious demands on the heart. However, for those who already have a diagnosed heart condition such as a congenital heart disease (CAD) or a heart valve disorder, pregnancy can pose a serious health risk. In addition women with other chronic conditions such as diabetes and hypertension may be prone to developing temporary heart problems during pregnancy. According to the European Society for Cardiology, maternal heart disease has become the biggest killer of pregnant women - although it must be noted that in Western countries deaths are extremely rare (about 500 every year in the United States due to pregnancy complications). However this figure is rising along with rates of diabetes in women, obesity, hypertension and the rising age of first time mothers. Another contributory factor is that women born with congenital heart defects, who in the past may not have reached adulthood, are now reaching childbearing age.
If you do have a pre-existing heart condition and plan on having children you will need to have a pre-pregnancy consultation with a cardiologist (a doctor who specializes in treating heart problems). Your pregnancy team will need to coordinate with the cardiologist on a regular basis and you will need frequent monitoring throughout the trimesters. Some conditions may even require a coordinated approach between an obstetrician, cardiologist, anesthesiologist and pediatrician. Special arrangements may need to be made for labor and delivery. Fortunately today, with good prenatal care and management, many women with different types of cardiovascular disease are delivering healthy babies safely. Yet some types of heart problems continue to remain very high risk and pregnancy is still not recommended. These include severe congestive heart failure, pulmonary hypertension (abnormally high blood pressure) and Eisenmengers syndrome (which causes low levels of oxygen to the organs).
If you plan your pregnancy carefully, consulting with both your cardiologist and gynecologist you should be able to have a safe 9 months. First your doctor will want to carry out a full physical examination including some diagnostic tests such as an echocardiogram to assess the overall condition of your heart. He will also discuss the potential problems and tell you what symptoms you need to watch out for which could indicate an issue. You may also need to discuss your heart medications because some drugs (even over the counter meds) may not be safe to continue taking. You could be prescribed different drugs or recommended a safer dosage. You will need more frequent prenatal visits than women without heart conditions, so you should factor this into your overall schedule.
A congenital heart defect is a structural problem in the heart that is present at birth. It is also called cyanotic heart disease, congenital cardiovascular malformations and heart defects. A defect causes problems with normal blood flow through the heart; blood may slow down, go to the wrong place, flow in the wrong direction or be blocked completely. Most types of defects can be corrected or managed through surgery, drugs or special medical devices like artificial heart valves and artificial cardiac pacemakers. Most women who have had corrective surgery for congenital heart disease can have a safe pregnancy with minimum risk. They do have to be particularly careful however in the second and third trimester as symptoms of heart failure and heart arrhythmia can develop. Most women with corrected heart defects can have a regular vaginal delivery unless complications have developed in the third trimester. A C-section delivery is not typically performed just for heart reasons. One of the major concerns for expectant parents is the risk of their baby being born with a defect - defects can be genetic and the chance rises when either the mother or the father has a heart defect. In such instances it is worth talking to a genetic counselor who can help assess your risk. Additionally when you do become pregnant, you may opt for a special ultrasound called a fetal echocardiogram which can check the baby's heart for possible defects. It can be performed as early as week 18 by a pediatric cardiologist who is an expert in congenital heart disease imaging. The procedure is very similar to a pregnancy ultrasound scan.
Also known as 'hole in the heart' a septal defect is where a hole occurs in the septum (the wall which separates the right and left chambers of the heart). If there is a whole in the septum that separates the upper chambers (atria) of the heart, it is known as Atrial Septal Defect (ASD). Where there is a hole, blood can mix between chambers causing problems. Most women with a small hole can have successful pregnancies with few problems. However larger holes can cause complications such as heart failure, pulmonary hypertension and heart arrhythmia. Women with Eisenmenger syndrome, which occurs in a tiny percentage of women with ASD are strongly advised against pregnancy because there is a serious risk of death.
Valvular heart disease can affect any of the valves of the heart (the mitral and aortic valves on the left and the tricuspid and pulmonary valves on the right). A person can be born with a defect in one of the valves (congenital) or it can develop later in life due to other causes. Valve disease means that one or more of the heart's valves are not working correctly which affects the way blood is pumped around the body (one of the causes of heart failure). As the amount of pumping the heart has to do (cardiac output) increases during pregnancy, this disease can cause particular problems for pregnant women. Delivery and childbirth are even more problematic as cardiac output abruptly rises due to pain and contractions. Given these effects, women with valve disease need special care during their pregnancy. It may also mean correcting a defect by surgery before becoming pregnant.Specific Valve Diseases
Mitral Stenosis (MS)
Women with MS have a mitral valve (the valve between the left ventricle and atrium) which is narrow. This is usually caused by rheumatic fever. Although most women with MS have successful pregnancies, the increase in blood pressure caused by pregnancy can lead to worsening of symptoms, such as shortness of breath while lying down (orthopnea), breathlessness (dyspnea), dizziness, chest pain and swelling in the feet, ankles or abdomen. In addition the right atrium can enlarge in size causing irregular palpitations (heartbeats) called atrial fibrillation. If this occurs during pregnancy, medications and occasionally surgery to correct the narrow valve will be necessary. Patients with MS will need to be evaluated before becoming pregnant, and corrective surgery may be recommended beforehand.
Aortic Stenosis (AS)
Women with AS have a narrowing or stiffening of the aortic valve (the valve between the aorta and the left ventricle). If the narrowing is severe the heart has to work harder to pump blood through the narrowed valve. This can lead to enlargement of the left ventricle (hypertrophy) and over time symptoms of heart failure (similar to MS, above) worsen. Women with AS are still able to have children but need to be monitored closely. Those with severe narrowing of the aorta however have higher rates of fetal complications. They may be recommended corrective valve surgery before pregnancy.
Mitral Regurgitation (MR) and Aortic Regurgitation (AR)
MR and AR occur when the valve does not close tightly enough which allows blood to flow back when it should not. When blood cannot move efficiently through the heart or the body, the patient feels out of breath and tired. Both conditions are able to tolerate pregnancy well, although valve replacement surgery may still be recommended before conception. However, if the woman is experiencing no symptoms before pregnancy a prophylactic procedure (preventative) may not be the best course of action. This is because artificial (prosthetic) heart valves themselves can cause pregnancy complications. Women with prosthetic valves need to take anticoagulant medications for life, and certain anticoagulants can be harmful to a fetus. There is still some debate as to the best course of treatment in this situation. The most recent recommendations by the European Heart Association suggest heparin in the first trimester, followed by warfarin until week 36 and then replaced again by heparin until delivery.
Because having a baby has a profound effect on a woman's cardiovascular system, some women with healthy hearts develop problems while they are pregnant. The risk increases in women who are obese, those experiencing a pregnancy after 35, have diabetes or high blood pressure. Although there is no standard screening for this risk category, the European Society for Cardiology have suggested that heart disease testing should be introduced for women at particularly high risk.
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