4B.3 Management of valvular heart disease in pregnancy

Abstract

General principles in the management of valvular heart disease Management of valvular heart disease in pregnancy requires recognition of the physiological changes of pregnancy, the underlying cardiac condition, the consequences of various medications, and the bleeding challenges associated with miscarriage and childbirth. Pregnancy results in a 50% increase in circulating blood volume [1], a 50% increase in cardiac output [1], and a hypercoagulable state that results in a fourto five-fold increased risk of thrombosis [2]. The increased risk of thrombosis can predispose to valvular thromboses, especially in women with mechanical heart valves [3]. The need for anticoagulation can increase the risk of hemorrhage. The increased demands on the heart during pregnancy can lead to cardiac decompensation. Symptoms of fatigue, breathlessness and swelling are normal in pregnancy. The presence of these symptoms in a woman with valvular heart disease may rightly or wrongly raise suspicion of cardiac decompensation. Echocardiography, which does not require ionizing radiation, allows for the noninvasive monitoring of cardiac function during pregnancy. The outcome of pregnancy and the impact of pregnancy on cardiac function may depend on the nature of the valvular condition. Women with certain valvular conditions tolerate pregnancy poorly. These conditions include cyanotic heart disease, Eisenmenger syndrome, or severe pulmonary hypertension [1,4]. Other valvular lesions that put the mother and fetus at high risk during pregnancy include severe aortic stenosis, mitral or aortic stenosis with New York Heart Association (NYHA) class III or IV symptoms, mitral stenosis with NYHA class II to IV symptoms, Marfan syndrome with aortic root dilatation, bicuspid valves with aortic regurgitation, any condition that results in left ventricular systolic dysfunction or pulmonary hypertension, and mechanical heart valves requiring anticoagulation [1].