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BACKGROUND

Pregnancy in women with heart diseases carries significant risks to the mother and her fetus. Cardiovascular conditions are the leading cause of maternal death in the United States.1 The number of women with cardiac disorders/conditions in pregnancy is increasing in the United States, due to:

  • Increased survival in patients with congenital heart diseases allowing these women to reach childbearing age.

  • The incidence of rheumatic valvular diseases is trending down, rheumatic:congenital 25:1 is now 3:1, and most of rheumatic valvular diseases is mitral stenosis (90%).2

  • Increasing incidence of coronary artery disease (CAD) because of delayed childbearing age.

  • Smoking and drug use.

The anesthesiologists can make significant contribution in the monitoring and management of pregnant women with heart diseases to improve maternal outcomes. We emphasize that epidural analgesia and anesthesia must be modified and individualized to the cardiac patients and minimize to the maximum the hemodynamic changes from analgesia and anesthesia. The decision of delivery model, cardiology care, invasive intervention, and surgical management options are beyond the scope of the current chapter.

HEART DISEASES IN PREGNANCY

High-risk conditions—these conditions are most affected by the physiologic changes during pregnancy (Box 15-1):

  • Pulmonary hypertension, primary and secondary

  • Eisenmenger syndrome

  • Complex congenital heart diseases

  • Aortic dilation/dissection—most commonly due to Marfan syndrome and congenital connective tissue diseases

  • Severe aortic valve stenosis—most commonly due to bicuspid valves, other causes include Marfan syndrome

  • Severe mitral valve stenosis

  • Ventricle dysfunction

  • Peripartum cardiomyopathy3

BOX 15-1 Predictors of Adverse Cardiac Events4,5

The modified CARPREG risk score is based on a point-value to estimate the potential of an adverse cardiac event. One point is an assessed risk of 5% or less, two or three points = 10% to 15%, the risk at four points is over 20%, and a patient with greater than four points has more than a 40% chance of a major adverse event. Points are assigned based on the woman’s current status and the type of disease.

Current status:

NYHA class III-IV adds three points:

  • The presence of maternal cyanosis equates to NYHA III.

  • Prior major cardiac event or serious arrhythmia also is valued at three points.

  • If a woman has had no cardiac work-up prior to pregnancy or the first assessment is in late pregnancy—each adds one point.

Type of disease:

A woman having a mechanical heart valve is worth three points.

Other high-risk cardiac conditions are worth two points, including ventricular dysfunction, left-sided valves disease or outflow obstruction, pulmonary hypertension (systolic pressure ≥70 mm Hg), coronary artery disease, or aortopathy (e.g., ascending aortic dilation of 4.0 cm).

CARPREG, Canadian cardiac disease in pregnancy; LVOT, left ventricular outflow tract; NYHA, New York Heart Association functional class.

Variable-risk conditions:

  • Mitral valve prolapse—most common cardiac disorder among women of childbearing age, or a congenital condition due to redundant ...

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