Is patent foramen ovale (PFO) closure required in asymptomatic pregnant women?

PFO Closure is NOT Required in Asymptomatic Pregnant Women

PFO closure should not be performed in asymptomatic pregnant women, as there is no evidence of increased stroke risk in asymptomatic individuals with PFO, and pregnancy alone is not an indication for closure. 1, 2

Key Evidence Against Routine Closure in Asymptomatic Patients

No Increased Stroke Risk in Asymptomatic PFO

• Asymptomatic individuals with PFO do not have an increased risk of stroke compared to the general population, as demonstrated in both the Northern Manhattan Study (NOMAS) and the Olmsted County SPARC study. 1
• PFO is present in approximately 25% of all adults as a normal variant, and the vast majority remain asymptomatic throughout their lives without any embolic events. 3, 2
• The longitudinal risk of stroke among asymptomatic subjects with PFO does not justify prophylactic intervention. 1

Pregnancy-Specific Considerations

Management During Pregnancy:

• Asymptomatic pregnant women with incidentally discovered PFO require no specific treatment or intervention. 1
• The European Society of Cardiology guidelines state that closure of a small ASD or persistent foramen ovale for the prevention of paradoxical emboli is not indicated. 1
• Pregnancy is generally well tolerated by women with PFO, and the only contraindication to pregnancy would be the presence of pulmonary arterial hypertension or Eisenmenger syndrome—not the PFO itself. 1

Conservative Preventive Measures:

• Prevention of venous stasis through use of compression stockings and avoiding the supine position is recommended. 1
• Early ambulation after delivery should be encouraged. 1
• For prolonged bed rest situations, prophylactic heparin administration should be considered to prevent deep venous thrombosis. 1
• Diligent care to eliminate air in intravenous lines is important to prevent potential systemic embolization. 1

When PFO Closure IS Indicated During Pregnancy

PFO closure during pregnancy is reserved exclusively for symptomatic patients with:

• Recurrent cryptogenic stroke or transient ischemic attacks despite medical therapy. 4, 5
• Evidence of paradoxical embolism with documented venous thromboembolism. 4
• Relative contraindication to anticoagulation therapy. 4

Procedural Feasibility (Only When Indicated)

• If closure becomes necessary during pregnancy, it can be performed safely during the second trimester using intracardiac echocardiography guidance with minimal radiation exposure (<0.005 mGy fetal dose). 4
• The procedure should be performed under local anesthesia to minimize fetal risk. 4

Critical Pitfalls to Avoid

Do not confuse asymptomatic PFO with symptomatic disease:

• Approximately 50% of patients aged 60 years or younger with cryptogenic stroke have a PFO, but this does not mean asymptomatic PFO carriers are at increased stroke risk. 3
• The presence of PFO on routine echocardiography during pregnancy does not warrant intervention in the absence of embolic events. 1, 2

Recognize that PFO closure carries procedural risks:

• Device or procedure-related adverse events occur in 3.6% of cases. 1
• Persistent atrial fibrillation occurs in 1.8% and transient atrial fibrillation in 1.2% of patients after closure. 1
• These risks are not justified in asymptomatic patients who have no demonstrated increased stroke risk. 1

Delivery Planning

Vaginal delivery can be planned in asymptomatic women with PFO:

• Spontaneous vaginal delivery is appropriate for most cases. 1
• No special cardiac monitoring or cesarean delivery is required solely based on PFO presence. 1
• Standard obstetric care with attention to preventing venous stasis is sufficient. 1