What is the management approach for a pregnant woman with gravidocardiac disease?

Management of Gravidocardiac Disease in Pregnancy

Pregnant women with heart disease should be managed by a multidisciplinary team in specialized centers with expertise in cardiac disease during pregnancy to reduce morbidity and mortality.1

Risk Assessment and Diagnosis

• All women with cardiac diseases should undergo risk assessment before conception and immediately after pregnancy is confirmed 1
• Echocardiography should be performed in any pregnant patient with unexplained or new cardiovascular signs or symptoms 1
• MRI without gadolinium should be considered if echocardiography is insufficient for diagnosis 1
• Chest radiography with fetal shielding may be considered when other methods fail to clarify the cause of dyspnea 1
• Cardiac catheterization may be considered with strict indications and proper shielding of the fetus 1

High-Risk Cardiac Conditions in Pregnancy

• Pulmonary hypertension carries a high maternal mortality risk (17-33% in recent studies) 1
• Severe left-sided obstructions (mitral stenosis, aortic stenosis) can cause problems even when asymptomatic before pregnancy 1
• Dilated poorly functioning left ventricles and fragile aortas (as in Marfan syndrome) are dangerous conditions during pregnancy 1
• Women in NYHA functional class III or IV have significantly higher risk 1
• Peripartum cardiomyopathy (PPCM) requires special attention with a reported mortality rate of 6-27.6% 1

Management During Pregnancy

• High-risk patients should be monitored by a multidisciplinary team including cardiologists, obstetricians, and anesthesiologists 1, 2, 3
• Medication management must consider both maternal and fetal effects:
  • ACE inhibitors, ARBs, and renin inhibitors are contraindicated during pregnancy 1
  • Beta-blockers and low-dose aspirin are considered relatively safe 1
  • For anticoagulation in patients with mechanical valves, careful planning is required 3
• Regular assessment of maternal cardiac status and fetal well-being throughout pregnancy 4
• Continuous invasive hemodynamic monitoring may be necessary for women with severe cardiac disease 1

Labor and Delivery Planning

• Vaginal delivery is recommended as first choice in most patients with cardiac disease 1
• Spontaneous onset of labor is appropriate for women with normal cardiac function 1, 4
• For induced labor with favorable Bishop score, oxytocin and artificial rupture of membranes are indicated 1, 5
• Epidural analgesia is preferred during labor as it stabilizes cardiac output 1, 4
• Caesarean delivery should be considered for:
  • Obstetric indications 1
  • Patients with dilatation of ascending aorta >45 mm 1
  • Severe aortic stenosis 1
  • Pre-term labor while on oral anticoagulants 1
  • Eisenmenger syndrome 1
  • Severe heart failure 1
• The second stage of labor should be shortened with assisted vaginal delivery (forceps or vacuum) to reduce maternal exertion 1, 4

Intrapartum Management

• Continuous monitoring of maternal vital signs and fetal heart rate is essential 4
• Positioning in lateral decubitus or sitting-up position as needed for cardiac status 1, 4
• Avoid fluid overload during intravenous infusions 1
• For the third stage, a single dose of intramuscular oxytocin is recommended; ergometrine is contraindicated 1

Postpartum Care

• Close monitoring for at least 24-48 hours after delivery due to significant hemodynamic changes 4
• Auto-transfusion of blood from the lower limbs and contracted uterus may significantly increase preload 1
• A single IV dose of furosemide is commonly given after delivery to manage increased preload 1
• Anticoagulants should be restarted in consultation with the obstetrician and anesthesiologist when post-partum bleeding has stopped 1
• For patients with PPCM, breastfeeding may not be advised due to potential negative effects of prolactin subfragments 1

Special Considerations

• For acute coronary syndrome during pregnancy, primary PCI is preferred over thrombolysis 1
• Bare metal stents are preferred over drug-eluting stents during pregnancy 1
• For women with mechanical heart valves, anticoagulation management requires careful planning 3
• Continuous cardiac monitoring is essential for women with arrhythmias 6

By implementing these recommendations through a coordinated multidisciplinary approach, maternal and fetal outcomes can be significantly improved in women with gravidocardiac disease.