From the Guidelines
Tricuspid regurgitation (TR) can worsen during pregnancy due to increased blood volume, cardiac output, and heart rate, which places additional strain on the right side of the heart. Pregnancy creates a state of increased hemodynamic stress, which typically peaks during the second and third trimesters, potentially exacerbating pre-existing TR or causing new TR to develop 1. Women with moderate to severe TR before pregnancy should be monitored closely with regular echocardiograms throughout pregnancy, particularly in the third trimester when cardiovascular stress is highest.
- Most cases of pregnancy-associated TR are well-tolerated and can be managed conservatively with activity modification and careful attention to fluid balance.
- Diuretics like furosemide may be used cautiously if fluid overload symptoms develop, typically starting at 20-40mg daily and titrating as needed.
- Severe, symptomatic TR causing right heart failure may require hospitalization for closer monitoring. The risk of worsening TR during pregnancy is increased in patients with severe regurgitation, and these patients should be managed at a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians who have expertise in the care of high-risk cardiac patients 1.
- The presence of severe valve regurgitation is also associated with an increased risk to the fetus.
- Timing and mode of delivery should be discussed and carried out by the Heart Valve Team, with close hemodynamic monitoring during and up to 24 hours after delivery. The good news is that TR often improves postpartum as the hemodynamic changes of pregnancy resolve. This worsening during pregnancy occurs because the right ventricle and tricuspid valve must accommodate the increased venous return and cardiac output that are normal physiological adaptations to pregnancy.
From the Research
Tricuspid Regurgitation in Pregnancy
- Tricuspid regurgitation (TR) may worsen during pregnancy due to physiologic hemodynamic changes, including higher circulating volume, heart rate, and cardiac index, as well as stress during labor 2.
- A study found that adverse cardiac events, including heart failure, occurred in 15% of pregnancies with tricuspid regurgitation, and that left ventricular systolic dysfunction, pulmonary hypertension, and cardiac events before pregnancy were important determinants of cardiac events during pregnancy 3.
- Another study found that mild tricuspid regurgitation is a benign fetal finding at various stages of pregnancy, and that it may accompany various anatomical malformations and/or dysfunction of the fetal right heart, but it may also appear in an anatomically healthy heart 4.
- The presence of tricuspid regurgitation may be associated with chromosomal and structural abnormalities, and its evaluation on first-trimester ultrasound has shown promising results regarding its role in the early detection of aneuploidies, congenital heart defects, and other adverse perinatal outcomes 5.
- A case study reported a case of acute peripartal heart failure caused by idiopathic severe tricuspid regurgitation in a 38-year-old woman, highlighting the importance of early diagnosis and management of valvular heart disease during pregnancy 2.
Risk Factors and Complications
- Women with tricuspid regurgitation are at increased risk of adverse cardiac events during pregnancy, including heart failure and arrhythmias 3.
- The risk of maternal and fetal adverse events is higher in women with valvular heart disease, including tricuspid regurgitation 2.
- Tricuspid regurgitation may be associated with other cardiac conditions, such as multivalve disease, and may increase the risk of cardiac complications during pregnancy 3.
- Lithium carbonate toxicity has been reported to cause tricuspid regurgitation and other cardiac abnormalities in newborns, highlighting the importance of careful management of medication during pregnancy 6.