Cardiovascular Disease In Pregnancy Research Articles

Reducing late maternal death due to cardiovascular disease - A pragmatic pilot study

BackgroundLate maternal mortality (up-to 1-year postpartum) is poorly reported globally and is commonly due to cardiovascular disease (CVD). We investigated targeted interventions aiming at reducing peripartum heart failure admission and late maternal death. Methods and resultsProspective single-centre study of 269 peripartum women presenting with CVD in pregnancy, or within 6-months postpartum. Both cardiac disease maternity (CDM) Group-I and Group-II were treated by a dedicated cardiac-obstetric team. CDM Group-II received additional interventions: 1. Early (2–6 weeks) postpartum follow-up at the CDM clinic and immediate referral to dedicated CVD specialist clinics. 2. Beta-blocker therapy was continued in women with LVEF<45% while pregnant, or immediately started postpartum. Of 269 consecutive women (mean age 28.6 ± 5.9), 213 presented prepartum, 22% in NYHA groups III–IV and 79% in modified WHO groups III–IV. Patients were diagnosed with congenital heart disease (30%), valvular heart disease (25%) and cardiomyopathy (31%).The groups were similar in age, diagnosis, NYHA, modified WHO, BP and HIV, but Group-II had a higher rate of previously known CVD (p < 0.001) and a lower rate of being nulliparous (p < 0.0005). Of Group-I patients 9 died within the 12-month follow-up period versus one death in Group-II (p = 0.047). Heart failure leading to admission was 32% in Group-I versus 14% in Group-II (p = 0.0008), with Group-II having a higher beta-blocker use peripartum (p = 0.009). Perinatal mortality rate was 22/1000 live births with no differences between groups. ConclusionEarly follow-up in a dedicated CDM clinic with targeted pharmacological interventions led to a significant reduction in peripartum heart failure admission and mortality.

Valvular heart disease during pregnancy: a clinical case and a literature review.

Background.As a result of improved diagnostic and reparative techniques, congenital heart diseases are becoming a significant problem for women of childbearing age. Nowadays, more pregnant women in the West are being diagnosed with an acquired heart disease because of the tendency to delay childbearing and increasing age-related risk of developing complications of hypertension, diabetes, obesity and other diseases. According to the Lithuanian Health Information Centre, the incidence of cardiovascular diseases in pregnancy is decreasing in Lithuania, from 1.4% in 2014 to 1% in 2016 (1). Heart diseases can aggravate maternal adaptive capabilities and complications that pose a threat to mother and foetus can occur. Management of such conditions presents a serious therapeutic challenge to multidisciplinary team. The aim of this article is to discuss the course of pregnancy and peculiarities of maternal and foetal care in a woman with hemodynamically significant heart disease.Materials and methods.We present a clinical case of a 30-year-old nuliparous woman who was diagnosed with mitral valve disease with critical stenosis, grade II/III mitral valve insufficiency, moderate-severe pulmonary hypertension, heart failure stage C, and NYHA functional class II.Results and conclusions.Pregnancy in conjunction with heart disease is a complicated condition that requires multidisciplinary prenatal care (consisting of an obstetrician gynaecologist, cardiologist, anaesthesiologist). Low molecular weight heparins should be the first choice medication for antithrombotic prophylaxis. Since pregnancy can aggravate a heart disease, preconception counselling and evaluation of the heart function are recommended.

Comorbidities and Risk-Adjusted Maternal Outcomes: A Retrospective Study on Administrative Data

Objective: The aim of this study was the evaluation of maternal outcomes and of the associated risk factors occurred in Abruzzo region, Italy, from 2009 to 2013. Methods: The study considered all the deliveries performed from 2009 to 2013 in Abruzzo region, Italy. Data were collected from all hospital discharge records. Univariate logistic regression analyses were performed to calculate crude odds ratios for each comorbidity. Stepwise multiple logistic regression models with backward selection were performed to identify predictors of the most frequent outcomes. Results: 57, 260 deliveries were analyzed. Severe complication occurred in 0.9% of all deliveries. The most frequent complications were “Severe Hemorrhage”, “Hysterectomy”, “Uterine rupture” and “Severe pre-eclampsia/eclampsia”. Malignant cancer (OR=55.76), coagulation disorders (OR=37.21), acute pulmonary disease (OR=29.75), placenta previa (OR=26.51), caesarean section (OR=3.24) and age (OR=1.08) were associated with a higher risk of hysterectomy. Anemia (OR=14.64), coagulation disorders (OR=10.31), cardiac disease (OR=12.74), pregnancy hypertension (OR=2.66), major pre-eclampsia/eclampsia (OR=2.78), placenta previa (OR=9.42) and multiple pregnancy (OR=3.69) were associated to severe hemorrhage. Thrombocytopenia (OR=26.04) and diabetes (OR=5.05) were associated to uterine rupture. Overweight or obesity (OR=25.88) and pregnancy cardiovascular disease (OR=25.85) were associated to pre-eclampsia. Conclusions: Maternal comorbidities are associated with increased risk of complications and may result in substantial costs to the health care system.

Imaging of Cardiovascular Disease in Pregnancy and the Peripartum Period.

Cardiovascular disease is an important cause of morbidity and mortality during pregnancy and the postpartum period. During pregnancy, the cardiovascular system undergoes extensive hemodynamic, hormonal, and microstructural changes which may exacerbate a preexisting underlying cardiovascular condition or predispose to cardiovascular complications not typically seen in young healthy women. Such conditions include spontaneous coronary artery dissection, atherosclerotic coronary artery disease, and peripartum cardiomyopathy. When evaluating this patient population, the diagnostic strategy should be tailored to specifically assess this distinct disease spectrum. The choice of imaging techniques must also consider potential risks to both the mother and child; a unique challenge of diagnostic imaging during pregnancy. The risk of radiation from radiography, computed tomography, and nuclear medicine imaging; iodinated and gadolinium-based contrast media for computed tomography and magnetic resonance imaging respectively; and heat deposition from sonography are of special importance during pregnancy. A thorough understanding of pregnancy-specific cardiovascular complications and the capabilities and risks of available diagnostic imaging modalities is crucial to appropriately manage the pregnant patient.

The Role of Cardiac Biomarkers in Pregnancy.

Cardiovascular disease (CVD) is the leading cause of pregnancy-associated mortality, with an increasingly complex pregnant population. While our understanding of CVD in pregnancy continues to evolve, there remains a need to develop widely accessible tools to follow pregnant women both with and without preexisting disease with respect to cardiovascular risk, particularly for those presenting with symptoms suggestive of cardiovascular pathology. Thus, research is emerging with respect to the potential role of novel and established cardiac biomarkers in diagnosing and following CVD in pregnancy. Here, we review the normal hemodynamics of pregnancy and the behavior of various biomarkers in both normal and complicated pregnancies.

Perioperative management of obstetrical surgeries in women having coexisting cardiovascular disease: our experience

Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high maternal morbidity and mortality. These patients pose a great challenge to both anesthesiologist and obstetrician. Present study was aimed at reviewing the perioperative management and outcome of obstetrical surgeries in women who had coexisting cardiovascular disease in a tertiary care teaching institute. Materials and Methods: Departmental database of all pregnant patients with coexisting cardiovascular diseases who underwent obstetrical surgeries during January 2011 to August 2016 were reviewed. Patients functional status, obstetrical history, stage of labor, type of anaesthesia, monitoring, hemodynamics, post operative care and baby outcome were noted. Data are expressed in absolute number and percentage scale and INSTAT software was used for measuring central tendencies and dispersion. Results: A total of 22 women (mean + Standard deviation: SD age 26.18 + 4.78 years) were found eligible and included for analysis. 21(95.45%) patients underwent cesarean section and one medical termination of pregnancy. 68.18% cases were done under subarachnoid block. Most of the patient needed post operative high dependant unit care, one patient developed mild pulmonary edema and no maternal and fetal deaths were noted. All the babies were born with APGAR > 7 at 1 min. No patient was managed using pulmonary artery catheter or continuous cardiac output monitoring. Conclusion: Pregnant patients with coexisting cardiovascular disease need multidisciplinary approach, timely delivery and intensive therapy in perioperative period. They can be safely delivered under subarachnoid blocks. Pulmonary artery catheterization is probably not an essential for hemodynamics management of such patients in perioperative management.

Sildenafil therapy for fetal cardiovascular dysfunction during hypoxic development: studies in the chick embryo.

Common complications of pregnancy, such as chronic fetal hypoxia, trigger a fetal origin of cardiovascular dysfunction and programme cardiovascular disease in later life. Sildenafil treatment protects placental perfusion and fetal growth, but whether the effects of sildenafil transcend the placenta to affect the fetus is unknown. Using the chick embryo model, here we show that sildenafil treatment directly protects the fetal cardiovascular system in hypoxic development, and that the mechanisms of sildenafil protection include reduced oxidative stress and increased nitric oxide bioavailability; Sildenafil does not protect against fetal growth restriction in the chick embryo, supporting the idea that the protective effect of sildenafil on fetal growth reported in mammalian studies, including humans, is secondary to improved placental perfusion. Therefore, sildenafil may be a good candidate for human translational antioxidant therapy to protect the chronically hypoxic fetus in adverse pregnancy. There is a need for developing clinically translatable therapy for preventing fetal origins of cardiovascular disease in pregnancy complicated by chronic fetal hypoxia. Evidence shows that sildenafil protects placental perfusion and fetal growth. However, whether beneficial effects of sildenafil transcend onto the fetal heart and circulation in complicated development is unknown. We isolated the direct effects of sildenafil on the fetus using the chick embryo and hypothesised that sildenafil also protects fetal cardiovascular function in hypoxic development. Chick embryos (n=11 per group) were incubated in normoxia or hypoxia (14% O2 ) from day 1 and treated with sildenafil (4mgkg-1 day-1 ) from day 13 of the 21-day incubation. Hypoxic incubation increased oxidative stress (4-hydroxynonenal, 141.1±17.6% of normoxic control), reduced superoxide dismutase (60.7±6.3%), increased phosphodiesterase type 5 expression (167±13.7%) and decreased nitric oxide bioavailability (54.7±6.1%) in the fetal heart, and promoted peripheral endothelial dysfunction (70.9±5.6% AUC of normoxic control; all P<0.05). Sildenafil treatment after onset of chronic hypoxia prevented the increase in phosphodiesterase expression (72.5±22.4%), protected against oxidative stress (94.7±6.2%) and normalised nitric oxide bioavailability (115.6±22.3%) in the fetal heart, and restored endothelial function in the peripheral circulation (89.8±2.9%). Sildenafil protects the fetal heart and circulation directly in hypoxic development via mechanisms including decreased oxidative stress and enhanced nitric oxide bioavailability. Sildenafil may be a good translational candidate for human antioxidant therapy to prevent fetal origins of cardiovascular dysfunction in adverse pregnancy.

Perinatal and neonatal outcomes of maternal heart diseases

Aims: To explore the perinatal and neonatal outcomes of patients with heart diseases. Materials Methods: Retrospective case control analysis was carried out among 10,527 deliveries, 188 pregnancies complicated by cardiovascular disease (CVD) compared with pregnancies without CVD for obstetric outcomes from January 2000 to December 2012. The effect of cardiac functional classification (NHYA) on maternal and neonatal complications was explored. Results: The incidence of CVD in pregnancy was 1.78%. About 80.3% had rheumatic heart disease (RHD). Maternal and neonatal mortality rate was 1.06% and 2.13 %, respectively. The obstetric outcomes of women in NHYA class I / II were similar to normal group. Vaginal delivery was the preferred way of birth unless deterioration of cardiac functions as in the cases of NHYA class III/IV. NHYA class III/IV had significantly decreased birth weight, premature birth, and increased maternal-neonatal mortality (p Conclusion: RHD is still prevalent. The cardiac functional capacity predicts maternal and neonatal outcomes.

Heart disease during pregnancy in the KSA: A suggested plan

Abstract Objectives Congenital heart disease in pregnancy is a leading cause of maternal death in developed countries while rheumatic fever is the commonest cause of valvular disease in pregnancy in developing countries. Improvement in neonatal and paediatric cardiac surgery has increased the incidence of congenital heart disease in pregnancy worldwide. Published data regarding heart disease in pregnancy (HDP) in KSA are scant and relatively old. This study examines the current status of HDP in KSA and describes the rationale and design of the suggested plan for HDP in KSA, i.e., the Registry Of Saudi Heart Disease And Pregnancy (ROSHDAP). Methods A systematic search was conducted through the ProQuest MEDLINE® database using the keyword phrase “cardiovascular disease in pregnancy”. An extensive literature review about heart disease in pregnancywas performed. Results There are only 4 available Saudi studies of HDP. The ROSHDAP study is expected to establish a foundation for Saudi research in this field and will create an extensive database that will enrich knowledge about HDP. All Saudi women with HDP who wish to participate are eligible for enrolment in the registry. Five phases are planned for the registry, and data will be collected prospectively, confidentially, and electronically. The data will be transmitted from participating centres to a central coordinating office for data management and analysis. Conclusion The ROSHDAP study suggested in this article will provide contemporary data on HDP in KSA that will promote research and encourage evidence-based medical care of pregnant women with heart disease.

Diagnosing cardiac disease during pregnancy: imaging modalities.

Pregnant women with known or suspected cardiovascular disease (CVD) often require cardiovascular imaging during pregnancy. The accepted maximum limit of ionising radiation exposure to the foetus during pregnancy is a cumulative dose of 5 rad. Concerns related to imaging modalities that involve ionising radiation include teratogenesis, mutagenesis and childhood malignancy. Importantly, no single imaging study approaches this cautionary dose of 5 rad (50 mSv or 50 mGy). Diagnostic imaging procedures that may be used in pregnancy include chest radiography, fluoroscopy, echocardiography, invasive angiography, cardiovascular computed tomography, computed tomographic pulmonary angiography, cardiovascular magnetic resonance (CMR) and nuclear techniques.Echocardiography and CMR appear to be completely safe in pregnancy and are not associated with any adverse foetal effects, provided there are no general contra-indications to MR imaging. Concerns related to safety of imaging tests must be balanced against the importance of accurate diagnosis and thorough assessment of the pathological condition. Decisions about imaging in pregnancy are premised on understanding the physiology of pregnancy, understanding basic concepts of ionising radiation, the clinical manifestations of existent CVD in pregnancy and features of new CVD. The cardiologist/physician must understand the indications for and limitations of, and the potential harmful effects of each test during pregnancy. Current evidence suggests that a single cardiovascular radiological study during pregnancy is safe and should be undertaken at all times when clinically justified. In this article, the different imaging modalities are reviewed in terms of how they work, how safe they are and what their clinical utility in pregnancy is. Furthermore, the safety of contrast agents in pregnancy is also reviewed.

Assessing perinatal depression as an indicator of risk for pregnancy-associated cardiovascular disease.

Cardiovascular conditions associated with pregnancy are serious complications. In general, depression is a well-known risk indicator for cardiovascular disease (CVD). Mental distress and depression are associated with physiological responses such as inflammation and oxidative stress. Both inflammation and oxidative stress have been implicated in the pathophysiology of CVDs associated with pregnancy. This article discusses whether depression could represent a risk indicator for CVDs in pregnancy, in particular in pre-eclampsia and peripartum cardiomyopathy (PPCM).

Cardiovascular disease in pregnancy

Cardiovascular diseases are among the most frequent complications in pregnancies. Among them preexisting heart diseases including congenital heart disease, genetic cardiomyopathies, myocardial infarction and chemotherapy-induced cardiomyopathies display a special challenge for the mother and her physicians. Moreover, the incidence of cardiovascular disease induced by or associated with pregnancy, i.e. hypertensive disorders and peripartum cardiomyopathies, has increased over the past decades. In the present overview we explain why pregnancy is a stress model for the maternal heart and summarize the current knowledge on the influence of pregnancy on preexisting cardiomyopathies. We highlight recent advances in research with regard to hypertensive complications in pregnancy and peripartum cardiomyopathy (PPCM). Moreover, we summarize etiologies, risk factors, pathomechanisms, diagnosis, treatment, management and prognosis. Finally, interdisciplinarity between different clinical fields and basic science is a key requirement to avoid longterm damage to the cardiovascular system induced by pregnancy associated impacts and with this improve women's health in general.

Arrhythmias in pregnancy (RCD code: VII-V)

Cardiovascular diseases in pregnancy are the most common causes of maternal mortality in developed world and an important cause of heart failure, stroke, and arrhythmia. Cardiac disease complicates 0.4–4% of all pregnancies, and arrhythmias are among the most common cardiac complications [1]. In some cases, pregnancy triggers exacerbations of pre-existing arrhythmias, whereas in others it may manifest for the first time [2]. A prior history of arrhythmias or structural heart disease and family history of sudden death are the factors that matter to risk of tachyarrhythmias during pregnancy [3]. Due to extraordinary ethical considerations in pregnant women, there are only a few randomized studies and little data on efficacy or safety of antiarrhythmic drugs applied during pregnancy [4]. Therefore, much of clinical care is guided by general knowledge about hemodynamic changes in pregnant women, universal principles of treatment of arrhythmias and finally by gained experience in that area. Multi-disciplinary approach remains the overriding principle in management of pregnant woman with arrhythmias, including collaboration with gynecological and obstetric center. JRCD 2016; 2 (6): 177–180

Perioperative Management of Obstetrical Surgeries in Women Having Coexisting Cardiovascular Disease: Our Experience

Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high maternal morbidity and mortality. These patients pose a great challenge to both anesthesiologist and obstetrician. The present study was aimed at reviewing the perioperative management and outcome of obstetrical surgeries in women who had coexisting cardiovascular disease in a tertiary care teaching institute. Materials and Methods: Departmental database of all pregnant patients with coexisting cardiovascular diseases who underwent obstetrical surgeries from January 2011 to August 2016 were reviewed. Patients functional status, obstetrical history, stage of labor, type of anaesthesia, monitoring, hemodynamics, post-operative care, and baby outcome were noted. Data are expressed in absolute number and percentage scale and INSTAT software was used for measuring central tendencies and dispersion. Results: A total of 22 women (mean + Standard deviation: SD age 26.18 + 4.78 years) were found eligible and included for analysis. 21(95.45%) patients underwent cesarean section and one medical termination of pregnancy. 68.18% of cases were done under subarachnoid block. Most of the patient needed postoperative high dependant unit care, one patient developed mild pulmonary edema and no maternal and fetal deaths were noted. All the babies were born with APGAR > 7 at 1 min. No patient was managed using a pulmonary artery catheter or continuous cardiac output monitoring. Conclusion: Pregnant patients with the coexisting cardiovascular disease need multidisciplinary approach, timely delivery and intensive therapy in the perioperative period. They can be safely delivered under subarachnoid blocks. Pulmonary artery catheterization is probably not essential for hemodynamics management of such patients in perioperative management.

Melatonin rescues cardiovascular dysfunction during hypoxic development in the chick embryo.

There is a search for rescue therapy against fetal origins of cardiovascular disease in pregnancy complicated by chronic fetal hypoxia, particularly following clinical diagnosis of fetal growth restriction (FGR). Melatonin protects the placenta in adverse pregnancy; however, whether melatonin protects the fetal heart and vasculature in hypoxic pregnancy independent of effects on the placenta is unknown. Whether melatonin can rescue fetal cardiovascular dysfunction when treatment commences following FGR diagnosis is also unknown. We isolated the effects of melatonin on the developing cardiovascular system of the chick embryo during hypoxic incubation. We tested the hypothesis that melatonin directly protects the fetal cardiovascular system in adverse development and that it can rescue dysfunction following FGR diagnosis. Chick embryos were incubated under normoxia or hypoxia (14% O2) from day 1 ± melatonin treatment (1 mg/kg/day) from day 13 of incubation (term ~21 days). Melatonin in hypoxic chick embryos rescued cardiac systolic dysfunction, impaired cardiac contractility and relaxability, increased cardiac sympathetic dominance, and endothelial dysfunction in peripheral circulations. The mechanisms involved included reduced oxidative stress, enhanced antioxidant capacity and restored vascular endothelial growth factor expression, and NO bioavailability. Melatonin treatment of the chick embryo starting at day 13 of incubation, equivalent to ca. 25 wk of gestation in human pregnancy, rescues early origins of cardiovascular dysfunction during hypoxic development. Melatonin may be a suitable antioxidant candidate for translation to human therapy to protect the fetal cardiovascular system in adverse pregnancy.

PP.24.15

Objective: The aim of this study was to assess the treatment (type of drugs, their doses, adherence to current ESH/ESC guidelines) in patients with hypertension in pregnancy and the impact of studied parameters (age, diabetes mellitus (DM), quantitative proteinuria, uric acid) on the treatment. Design and method: 233 patients, median age 32 (interquartile range 28–35), 16% with DM, admitted to the St. Cyril and Methodius Hospital due to hypertension in pregnancy (4% with preexisting hypertension) from June 2011 to June 2014 were included. The treatment was evaluated until the day of delivery. In case of serial measurements of quantitative proteinuria and uric acid, the highest ante-partum value was used. Results: The number of drugs needed to control hypertension was increasing with growing age (p < 0.05) and quantitative proteinuria (p < 0.005). DM and uric acid had no influence on the number of drugs used. 31% patients were treated with 1 drug, 40% with 2 drugs, 21% with 3 drugs, 8 % with 4 and only 1 patient with 5 drugs. The most frequent antihypertensive drugs, their most frequent dose/day and maximum dose/day were: methyldopa (97%, 2000 mg, 2250 mg), isradipin (50%, 5 mg, 7.5 mg), intravenous (i.v.) urapidil (27%), oral urapidil (18%, 60/90 mg, 240 mg), metoprolol (10%, 100 mg, 125 mg), amlodipin (9%, 10 mg, 15 mg), verapamil (5%, 120 mg, 360 mg). Current ESH/ESC guidelines (Management of Arterial Hypertension, 2013; Management of Cardiovascular Diseases in Pregnancy, 2011) recommend the use of methyldopa, calcium antagonists and beta-blockers. In this study, the treatment was consistent with guidelines, except for urapidil. Urapidil was predominantly used in the i.v. form, as the by guidelines recommended i.v. drugs for treatment of hypertension in pregnancy are not available in Slovakia. Conclusions: The number of drugs needed to control hypertension in pregnancy showed a correlation with increasing quantitative proteinuria and age. Most patients were concomitantly treated with 2 antihypertensive drugs. Methyldopa, isradipin and urapidil were the most frequently used drugs.

Management of valvular disease in pregnancy: a global perspective.

Valvular heart disease (VHD) in pregnant women, whether due to congenital or acquired aetiologies, poses a challenge to clinicians and their patients. Significant valve disease, which can affect a single valve or several valves, increases the risk of pregnancy to the mother and foetus and requires a careful preconception risk assessment and, subsequently during pregnancy, specialized care to minimize maternal and foetal morbidity and mortality. The goal of this paper is to provide a guide to risk assessment and to give an overview of the optimal cardiac and obstetric management, including surgical intervention, taking into consideration the resources available in higher and lower-to-middle income countries. This manuscript provides a practical approach and is not replacing comprehensive guidelines on the management of VHD or cardiovascular disease in pregnancy. It focuses on common valvular diseases and does not cover the large variety of aortic disease with and without valve disease or complex congenital heart disease in detail.

Should I have this on my bookshelf? A review of Cardiac Drugs in Pregnancy

“Cardiac drugs in pregnancy” is a pocket-sized book published by Springer as part of their “Current Cardiovascular Therapy” series. The book is a 130 page synopsis of cardiovascular therapy in the setting of pregnancy, edited by two South African cardiologists, Drs. Karen Sliwa and John Anthony. There are six chapters in the book, beginning with General Principles and then proceeding through a series of common cardiovascular problems such as hypertension, heart failure, and arrhythmias written by a series of experienced South African and European cardiologists. The title and topic seem unusual at first glance—after all, how common is cardiovascular therapy in pregnancy? The editors make the case—and this reviewer agrees with them—that cardiovascular disease is pregnancy is in fact relatively common, notably in the era of older and older women having children, and that cardiologists need an approach to these problems. As well, some of the few well-described human teratogens include drugs commonly used by cardiologists, notably the angiotensin-converting inhibitors and warfarin. The book is an easy and enjoyable read, clearly written, and intended for practicing clinicians. The editors and chapter authors have focused on the common and important rather than the esoteric and arcane, which this reviewer thoroughly agrees with. As an example, fetal therapy is not discussed, being beyond the scope of this book. The first chapter deals with how the cardiovascular system adapts during pregnancy and how this may impact on therapy. Succeeding chapters are disorder-specific. The authors take care to ensure that their chapters provide not only a conceptual overview but also recommendations to guide therapy. The authors address what is confirmed by the literature and, of equal importance, areas where there is paucity of evidence based medicine (or data) to guide therapy decisions of cardiovascular disease in pregnancy. That being said, the book is not perfect and one wonders if perhaps the inclusion of one of small but active community of human teratogen investigators or a consulting obstetrician as a chapter author might have been useful. As an example, the concept of baseline risk and the importance of a fulsome discussion on baseline risk as part of the evaluation and therapeutic planning for pregnancy is understated, which is regrettable given the clear and compelling evidence as to the importance of this—and the consequences of misinformation—in the setting of pregnancy and drug therapy. There is also a somewhat uncritical view of some important issues in the care of the pregnant woman. As an example, more than one chapter cites the US Food and Drug Administration classification of drug teratogenicity in terms of assessment of pregnancy risk without a deeper discussion as to the very real limitations—acknowledged by the FDA - of this classification system in terms of real world evidence. The chapter on cardiovascular adjustments during pregnancy is there but is somewhat light on some issues such as drug transfer across the placenta, which is an increasingly interesting and complex area of study. An increasing population of cardiac patients—adult survivors of congenital cardiac disease—is not covered in a separate chapter but is dealt with piece-meal. It seems to this reviewer that this is not the best way to address the complex problems of a new and growing population of cardiac patients, and the addition of a chapter on pregnancy in adult survivors of congenital cardiac disease would be a useful addition to the next edition of this book. These reservations aside, the book does bring together in a single small volume a large amount of highly relevant and practical material covering those conditions and problems most likely to be encountered by cardiologists and consulting internists. The advantages and limitations of current therapy are concisely outlined and the recommendations provided will be very useful in guiding therapy. The inclusion of a final chapter on the use of obstetrical drugs in the management of cardiovascular disease is both novel and very interesting. In summary, this small volume is a useful and practical book that would be a very useful part of the library of cardiologists as well as internists whose consulting practices include the care of pregnant women.

Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa

BackgroundLack of evidence-based data on the spectrum of cardiovascular disease (CVD) in pregnancy or in the postpartum period, as well as on maternal and fetal outcome, provides challenges for treating...

Cardiovascular physiology of pregnancy.

Pregnancy is a dynamic process associated with significant physiological changes in the cardiovascular system. These changes are mechanisms that the body has adapted to meet the increased metabolic demands of the mother and fetus and to ensure adequate uteroplacental circulation for fetal growth and development. Insufficient hemodynamic changes can result in maternal and fetal morbidity, as seen in preeclampsia and intrauterine growth retardation. In addition, maternal inability to adapt to these physiological changes can expose underlying, previously silent, cardiac pathology, which is why some call pregnancy nature’s stress test. Indeed, cardiovascular disease in pregnancy is the leading cause of maternal mortality in North America.1 We therefore review here the normal cardiovascular physiology of pregnancy to provide clinicians with a basis for understanding how the presence of cardiovascular disease may compromise the mother and fetus and how their decisions about medical care may need adjustment. Pregnancy is associated with vasodilation of the systemic vasculature and the maternal kidneys. The systemic vasodilation of pregnancy occurs as early as at 5 weeks and therefore precedes full placentation and the complete development of the uteroplacental circulation.2 In the first trimester, there is a substantial decrease in peripheral vascular resistance, which decreases to a nadir during the middle of the second trimester with a subsequent plateau or slight increase for the remainder of the pregnancy3 (Figure 1). The decrease is ≈35% to 40% of baseline. Systemic vascular resistance increases to near-prepregnancy levels postpartum,4 and by 2 weeks after delivery, maternal hemodynamics have largely returned to nonpregnant levels.5 Increased vascular distensibility, or compliance, has been observed in normal human pregnancy starting in the first trimester.6 Systemic vascular resistance increases to near-prepregnancy levels postpartum.4 Vasodilation of the kidneys results in a 50% increase in renal plasma flow and glomerular filtration …