THE PARTURIENT WITH CARDIAC DISEASE

Abstract

The presence of significant cardiac or cardiovascular disease has traditionally been one of the great contraindications to pregnancy. The second half of the twentieth century has been witness to an explosion of advances in medical and surgical technology as well as in the management of routine medical and surgical conditions. Obstetric patients have been beneficiaries of such achievements; maternal mortality from cardiovascular causes has declined progressively since the 1950s (Fig. 1) . 32 , 42 , 75 Maternal mortality in the 1990s is less than 1% in women with mild to moderate cardiac disease. The reasons for this decrease are multifactorial: (1) the decrease in rheumatic heart disease seen with the advent of antibiotics, (2) the availability of surgical correction for many serious congenital and acquired cardiac diseases, and (3) improved medical therapy for arrhythmias, heart failure, etc. The mortality rate for pregnant women with more severe cardiac pathology (New York Heart Association [NYHA] class III–IV) is higher and reported to be 5% to 15%, and fetal mortality approaches 30% in this population of women. 17 , 27 , 33 , 37 Women with congenital heart disease, collagen vascular conditions, and rheumatic fever—historically the leading causes of cardiac disease in pregnant women 7 , 42 , 51 , 75 —now generally receive appropriate and often curative therapy early enough in the course of their disease to prevent the development of irreversible sequelae. Many more of these patients now survive to child-bearing age. The medical literature is replete with case reports and clinical investigations attesting to the success of strategies for the reduction of maternal morbidity and mortality in women with preconceptual cardiac lesions. With all of the clinical successes, it is important to note that family planning and pre-pregnancy counseling, so as to avoid pregnancy, is often appropriate for those with more severe diseases such as pulmonary hypertension, coarctation of the aorta with involvement of the aortic root, and Marfan's disease with aortic root widening. 1 , 6 , 32 , 65 The obstetrician coordinates a multidisciplinary team of health-care professionals—the anesthesiologist, cardiologist, neonatologist, and nursing staff—who help guide the gravidae with cardiac disease toward a successful perinatal outcome. Some undesired outcomes may not be preventable, as this population of patients, especially those with cyanotic congenital heart defects, experience a greater incidence of spontaneous abortion, intrauterine growth retardation and fetal demise, and preterm labor and delivery; moreover, these women have an increased chance of producing offspring with similar congenital heart defects. 60 , 66 The task of the anesthesiologist caring for the pregnant cardiac patient is made more problematic by the fact that many cardiac lesions worsen during gestation as maternal cardiovascular adaptations to pregnancy place progressively greater stresses on the heart. It is possible for a woman to deteriorate from NYHA class I or II to class III or IV (Table 1) as her physiology undergoes the changes to support the growth, development, and delivery of her baby; up to 40% of women with only mild preconceptual cardiac disease can expect to suffer some degree of cardiac compromise during the course of pregnancy despite aggressive management by the health-care team. 17