Cardiac Disease in Pregnancy: Hypertrophic Obstructive Cardiomyopathy and Pulmonic Stenosis

Abstract

The prevalence of cardiovascular disease in pregnancy is increasing, and cardiovascular disease is the leading cause of pregnancy-related death in the United States. 1 Petersen EE Davis NL Goodman D et al. Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429 Crossref PubMed Scopus (382) Google Scholar The physiologic adaptations to pregnancy include an increased heart rate, stroke volume, and substantial expansion in circulatory volume, which may pose significant cardiac stress to patients with cardiac disease. During labor, cardiac output increases further, and maternal expulsive efforts during the second stage of labor, with the decreased preload and increased afterload that accompany the Valsalva maneuver, may provoke decompensation in vulnerable patients. Cardiac output peaks immediately postpartum before the return to baseline over a period of several weeks; the immediate postpartum period also is associated with substantial intravascular fluid shifts. These changes, and the gradual return to baseline physiologic states, also may pose challenges to patients with preexisting cardiac disease. A multidisciplinary approach to the management of cardiac disease in pregnancy is essential, with management guided by input from cardiologists, specialists in maternal fetal medicine, anesthesiologists, and neonatologists. 2 ACOG perioperative ultrasound training in anesthesiology. Obstet Gynecol. 2019; 133: e320-e356 Crossref PubMed Scopus (153) Google Scholar In the case reports described herein, the presentation, management, and outcomes in two patients with significant cardiac disease diagnosed during pregnancy are detailed. The first case involved hypertrophic obstructive cardiomyopathy and the second pulmonic stenosis. These cases illustrate important principles of management of the physiologic stresses of pregnancy, labor, and delivery on patients with significant cardiac disease.