Does the management of atrial septal defects during pregnancy and delivery also apply to patients with patent foramen ovale (PFO)?

Management of Patent Foramen Ovale During Pregnancy and Delivery

No, the management of atrial septal defects (ASD) during pregnancy does NOT fully apply to patent foramen ovale (PFO), and specifically, closure of PFO for prevention of paradoxical emboli is NOT indicated during pregnancy. 1

Key Distinction Between ASD and PFO in Pregnancy

PFO closure is explicitly not recommended for prevention of paradoxical emboli during pregnancy, whereas hemodynamically significant ASDs should be closed before pregnancy. 1 This represents a fundamental difference in management approach between these two interatrial communications.

Why PFO Management Differs

• PFO is a normal anatomical variant present in 25-30% of adults, not a true congenital defect requiring routine intervention 2, 3
• ASDs cause hemodynamic consequences (right heart volume overload) that PFOs typically do not 2
• Pregnancy is generally well tolerated with isolated PFO, unlike large or unrepaired ASDs which carry specific maternal risks 1

Shared Management Principles That DO Apply

Despite the closure recommendation difference, several preventive strategies for paradoxical embolism apply to both conditions:

Thromboembolic Prevention (Critical for Both)

• Prevention of venous stasis is essential: use compression stockings and avoid supine positioning 1
• Early ambulation after delivery reduces thromboembolism risk 1
• Prophylactic heparin should be considered for prolonged bed rest 1
• Meticulous elimination of air in IV lines is mandatory to prevent systemic embolization during labor 1

Delivery Planning

• Spontaneous vaginal delivery is appropriate in most cases with isolated PFO, similar to repaired or small ASDs 1
• Standard obstetric care without specific cardiac restrictions for uncomplicated PFO 1

When PFO Closure During Pregnancy May Be Considered

Percutaneous device closure during pregnancy is feasible but reserved for highly selected cases with recurrent embolic events despite anticoagulation or when anticoagulation is contraindicated. 4

Specific Criteria for Intervention

• Recurrent ischemic stroke during pregnancy despite medical therapy 4, 5
• Relative contraindication to anticoagulation in the setting of embolic events 4
• Procedure timing: second trimester preferred if intervention necessary 4
• Technical modifications: intracardiac echocardiography guidance without fluoroscopy can achieve fetal radiation exposure <0.001 mGy 4

High-Risk PFO Features During Pregnancy

PFO-related stroke peaks in first and second trimester (60% of cases), unlike other pregnancy stroke etiologies. 5 Additional risk factors include:

• Atrial septal aneurysm (high-risk morphology) 5
• Large right-to-left shunt 5
• Multiple gestation 5
• Concurrent hypercoagulability disorders 5

Clinical Outcomes

• Most PFO-related strokes during pregnancy have good neurological outcomes (77%) and uneventful deliveries (93%) with healthy babies 5
• This contrasts with ASDs, where unrepaired defects carry 5% thromboembolic complication rate and increased risk of pre-eclampsia and small-for-gestational-age births 1

Common Pitfalls to Avoid

• Do not routinely close PFO for embolic prevention during pregnancy—this is explicitly not indicated and differs from ASD management 1
• Do not assume all interatrial communications require the same management—PFO and ASD have fundamentally different hemodynamic significance 2
• Do not neglect venous thromboembolism prophylaxis—pregnancy's hypercoagulable state increases paradoxical embolism risk through any right-to-left shunt 1, 5