Approximately 2% of pregnancies involve maternal cardiovascular disease, and as such, this poses an

increased risk to both mother and fetus. Most women with cardiovascular disease can have a
pregnancy with proper care, but a careful pre-pregnancy evaluation is mandatory. Cardiac disease may
sometimes be manifested for the first time in pregnancy because the hemodynamic changes may
compromise a limited cardiac reserve. [1] Conversely, the symptoms and signs of a normal pregnancy
may mimic the presence of cardiac disease. Lightheadedness, dizziness, shortness of breath,
peripheral edema, and even syncope often occur in the course of a normal pregnancy, and for the
unwary physician, cardiac disease may be suspected. An understanding of the normal cardiac
examination of a pregnant patient is therefore important. For those physicians counseling patients
with cardiac disease about the potential risks of a pregnancy, a comprehensive knowledge of the
underlying defect as well as of the hemodynamic changes that pregnancy will impose is imperative.
With the declining incidence of rheumatic heart disease in Western countries, most maternal cardiac
disease is now congenital in origin. Other cardiovascular problems seen include cardiomyopathies,
both dilated and hypertrophic, and valvular disease, such as bicuspid aortic valve and mitral valve
prolapse. Less common problems include pulmonary hypertension and, rarely, coronary artery
disease. Pre-pregnancy counseling is important to give prospective mothers appropriate information
about the advisability of pregnancy and to discuss the risks to her and the fetus. Such patients should
be seen in a high-risk pregnancy unit and have a clinical examination, electrocardiogram, and chest
radiograph. An echocardiogram facilitates a detailed evaluation of myocardial function, valvular
disease, and pulmonary pressures. For patients with congenital heart disease, their perception of
normal activity may be skewed, and an exercise test is helpful in delineating their true functional
aerobic capacity. In general, patients who cannot achieve more than 70% of their predicted functional
aerobic capacity are unlikely to tolerate a pregnancy safely. During this visit, it is important to take a
careful family history to assess whether there is any congenital heart disease in the family. Genetic
counseling may also be considered, if necessary. A careful discussion of the maternal and fetal risks
should be made at the time of pre-pregnancy counseling, and if the mother is going to pursue a
pregnancy, a strategy should be outlined regarding the frequency of follow-up by the cardiologist, and
a plan should be put in place for labor and delivery.[2]
A multicenter Canadian study has suggested that maternal cardiac risk may be predicted by the use of
a risk index.[3] Four predictors of maternal cardiac events are as follows: (1) prior cardiac event (e.g.,
heart failure, transient ischemic attack, or stroke before pregnancy) or arrhythmia; (2) baseline New
York Heart Association (NYHA) class higher than Class II or cyanosis; (3) left-sided heart obstruction
(mitral valve area smaller than 2 cm2, aortic valve area less than 1.5 cm2, or peak left ventricular
outflow tract gradient more than 30 mm Hg by echocardiography); and (4) reduced systemic
ventricular systolic function (ejection fraction less than 40%). Each of 599 pregnancies was assigned
1 point when each predictor was present. No pregnancy received more than 3 points. The estimated
risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%,
respectively. It was concluded that those with a low cardiac risk of 0 could safely be delivered in a
community hospital, but those at intermediate or high cardiac risk (risk score of 1 or more) should be
delivered at a regional center.
During pregnancy, a multidisciplinary team approach is recommended, with close collaboration with
the obstetrician so that the mode, timing, and location of delivery can be planned. [4] The management
should be tailored to the specific needs of the patient. During pregnancy, fetal growth is monitored by
the obstetric team, and for the woman with congenital heart disease, a fetal cardiac echocardiogram is
offered at about 22 to 26 weeks of pregnancy to determine whether the baby has a congenital cardiac
anomaly.

Hemodynamic Changes
During Pregnancy
The hemodynamic changes are profound and begin early in the first trimester. The
plasma volume begins to increase in the sixth week of pregnancy and by the second
trimester approaches 50% above baseline (Fig. 82-1). The plasma volume then tends to
plateau until delivery. This increased plasma volume is followed by a slightly lesser rise
in red cell mass, which results in the relative anemia of pregnancy. The heart rate begins
to increase to about 20% above baseline to facilitate the increase in cardiac output (Fig.
82-2). Uterine blood flow increases with placental growth, and there is a fall in
peripheral resistance. This decreased peripheral resistance may result in a slight fall in
blood pressure, which also begins in the first trimester. The venous pressure in the lower
extremities rises, which is why approximately 80% of healthy pregnant women develop
pedal edema. The adaptive changes of a normal pregnancy result in an increase in
cardiac output, which also begins in the first trimester and by the end of the second
trimester approaches 30% to 50% above baseline.

FIGURE 82-1 Plasma volume and red blood cell (RBC) increase during the trimesters of
pregnancy. The plasma volume increases to approximately 50% above baseline by the second
trimester and then virtually plateaus until delivery.

FIGURE 82-2 Hemodynamic changes during pregnancy relate to increased cardiac output and a
fall in peripheral resistance. Blood pressure in most patients remains the same or falls slightly.
Venous pressure in the legs increases, causing pedal edema in many patients.

These hemodynamic changes may cause problems for the mother with cardiac disease. The added
volume load may obviously compromise a patient who has impaired ventricular function and limited
cardiac reserve. Stenotic valvular lesions (e.g., aortic stenosis) are less well tolerated than regurgitant
lesions because the decrease in peripheral resistance exaggerates the gradient across the aortic valve.
Similarly, the tachycardia of pregnancy reduces the time for diastolic filling in a patient with mitral
stenosis, with resultant increase in left atrial pressure. In contrast, with a lesion such as mitral
regurgitation, the afterload reduction helps offset the volume load on the left ventricle that gestation
imposes.
During Labor and Delivery
The hemodynamic changes during labor and delivery are abrupt. With each uterine
contraction, up to 500 mL of blood is released into the circulation, prompting a rapid
increase in cardiac output and blood pressure. The cardiac output is often 50% above
baseline during the second stage of labor and may be even higher at the time of delivery.
During a normal vaginal delivery, approximately 400 mL of blood is lost. In contrast,
with a cesarean section, about 800 mL of blood is often lost and may pose a more
significant hemodynamic burden to the parturient. After delivery of the baby, there is an
abrupt increase in venous return, in part because of autotransfusion from the uterus but
also because the baby no longer compresses the inferior vena cava. In addition, there
continues to be autotransfusion of blood in the 24 to 72 hours after delivery, and this is
when pulmonary edema may occur.

All these abrupt changes mandate that for the high-risk patient with cardiac disease, a
multidisciplinary approach during labor and delivery is essential. The cardiologist and
obstetrician should work with the anesthesiologist to determine the safest mode of
delivery.

For most patients with cardiac disease, a vaginal delivery is feasible and preferable; a cesarean section
is indicated only for obstetric reasons. Exceptions to this include the patient who is anticoagulated
with warfarin because the baby is also anticoagulated, and vaginal delivery carries an increased risk to
the fetus of intracranial hemorrhage. Cesarean section may also be considered in patients who have a
dilated unstable aorta (e.g., Marfan syndrome), severe pulmonary hypertension, or a severe
obstructive lesion such as aortic stenosis. High-risk patients should be delivered in a center where
expertise is available to monitor the hemodynamic changes of labor and delivery and to intervene
when necessary. If vaginal delivery is elected, fetal and maternal electrocardiographic monitoring
should be performed. Delivery can be accomplished with the mother in the left lateral position so that
the fetus does not compress the inferior vena cava, thereby maintaining venous return. The second

stage should be assisted, if necessary (e.g., forceps or vacuum extraction), to avoid a long labor. Blood
and volume loss should be replaced promptly. For those patients with tenuous hemodynamics, SwanGanz catheterization before active labor facilitates optimization of the hemodynamics and should be
continued for at least 24 hours after delivery, when pulmonary edema commonly occurs.
Although there is no consensus regarding the administration of antibiotic prophylaxis at the time of
delivery for patients with lesions vulnerable to infective endocarditis, many institutions routinely give
antibiotics because of the documented bacteremia. This can occur even during an uncomplicated
delivery.[5] Patients who are most vulnerable to the deleterious effects of endocarditis are those with
cyanotic heart disease and prosthetic valves. [6]

Chest Radiography
A chest radiograph is not obtained routinely in any pregnant patient because of concern about
radiation to the fetus, but it should be considered in any patient when there are concerns about her
cardiac status and new onset of dyspnea or failure. The chest radiograph in a normal healthy patient
may show slight prominence of the pulmonary artery, and as pregnancy advances, elevation of the
diaphragm may suggest an increase in the cardiothoracic ratio.
Transthoracic Echocardiography
This is the cornerstone of cardiac evaluation in pregnancy and facilitates differentiation of the features
of cardiac disease from those of a normal pregnancy. It is used most frequently to determine the
ventricular function, to assess the status of native and prosthetic valve disease, and, by use of the
tricuspid regurgitant velocity, to assess pulmonary artery pressure. For those patients with congenital
heart disease, a detailed assessment of any shunt and complex anatomy may be made.
During pregnancy, because of the increased cardiac output, the velocities across the left and right
ventricular outflow tracts increase, which may mimic an increase in outflow tract gradient. Careful
examination of the two-dimensional anatomic appearances will help differentiate this from a true
valvular abnormality, and calculation of valve area will be helpful. Similarly, because of the increased
stroke volume, any valvular regurgitation will appear to be accentuated. Serial echocardiograms may
be particularly useful in a patient with a mechanical valve prosthesis who is vulnerable to thrombosis
during pregnancy. The valve area calculation, in addition to pressure half-time determination, may be
more helpful than a simple measurement of valve gradient; this may appear to be increased as
pregnancy advances because the circulation becomes more hyperkinetic and cardiac output increases.
In patients with impaired ventricular function, particularly those with cardiomyopathy,
echocardiography plays the most important role in assessing left ventricular function. In a normal
pregnancy, the left ventricular end-diastolic measurement is increased, and there may be similar
increases in right ventricular size as well as in the volumes of both atria. Measurement of ejection
fraction is determined by changes in preload and afterload, and in the supine position, preload may be
reduced because the fetus may compress the inferior vena cava.
Transesophageal Echocardiography
Transesophageal echocardiography is seldom performed during pregnancy but may be necessary to
provide more detailed imaging of valvular disease, the presence or absence of a shunt, or intracardiac

thrombus. In addition, it may be useful to determine the presence or absence of endocarditis to

facilitate the detection of a valvular vegetation or perivalvular abscess. Transesophageal
echocardiography can be performed safely, although careful monitoring of maternal oxygen saturation
is necessary if midazolam is used for sedation. Antibiotic prophylaxis is unnecessary.
Fetal Echocardiography
Excellent imaging of the fetal heart can usually be obtained by 20 weeks gestation. The four-chamber
view may be obtained in most pregnancies and should demonstrate two atrioventricular valves, the
crux of the heart, and whether two ventricles of equal size are present. The patent foramen ovale
should also be demonstrated. Typically, the heart should be smaller than one third of the size of the
fetal thorax.