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OBSTETRICS

OBSTETRICS

HEART DISEASE IN PREGNANCY 3

Acquired Heart Disease in Pregnancy


Gregory A.L. Davies, MD, FRCSC, FACOG,1 William N.P. Herbert, MD, FACOG2
1

Professor and Chair, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Queens University, Kingston ON

William Norman Thornton Professor and Chair, Department of Obstetrics and Gynecology University of Virginia, Charlottesville VA USA

Abstract
The incidence of rheumatic heart disease in most industrialized
countries is decreasing. Those women who have regurgitant
lesions will commonly experience an improvement in symptoms,
and therapy is required only in the most severe cases. Women
with mild to moderate stenotic lesions can usually expect a good
outcome to pregnancy, but women with severe stenotic lesions
require close monitoring by both their obstetricians and their
cardiologists, especially during the third trimester, labour and
delivery, and the early postpartum period.
This is the third in a series of five articles reviewing in detail the
assessment and management of specific cardiac disorders in
pregnancy.

Rsum
Lincidence de la cardiopathie rhumatismale est en baisse dans la
plupart des pays industrialiss. Les femmes qui prsentent des
lsions reflux connatront gnralement une amlioration des
symptmes; le traitement nest requis que dans les cas les plus
graves. Les femmes qui prsentent des lsions stnoses allant
de lgres modres peuvent habituellement sattendre de
bonnes issues de grossesse; toutefois, les femmes qui prsentent
de graves lsions stnoses ncessitent un suivi troit de la part
de leurs obsttriciens et de leurs cardiologues, particulirement
pendant le troisime trimestre, le travail et laccouchement, et les
dbuts de la priode post-partum.
Il sagit du troisime article dune srie de cinq analysant en dtail
lvaluation et la prise en charge de troubles cardiaques
particuliers au cours de la grossesse.
J Obstet Gynaecol Can 2007;29(6):507509

Key Words: Cardiac disease, pregnancy, rheumatic heart disease,


mitral stenosis, aortic stenosis
Competing Interests: None declared.
Received on December 6, 2006
Accepted on March 28, 2007

RHEUMATIC HEART DISEASE

onsistent with a reduced incidence of rheumatic fever,


the incidence of rheumatic heart disease has declined
over the last 40 years.1 The prevalence of rheumatic heart
disease in pregnancy has decreased in developed countries
such that the previous ratio of rheumatic to congenital heart
disease of 34:1 has essentially been reversed.2,3 However, a
resurgence of rheumatic fever has been reported in some
areas of the United States.4

In patients with rheumatic heart disease, the mitral valve is


most commonly affected. Mitral stenosis occurs in approximately 90% of patients and mitral regurgitation in 7%. The
aortic valve is the second most commonly affected valve,
although to a lesser degree; aortic regurgitation is present in
2.5% of patients and aortic stenosis in only 1%.5 Although
the tricuspid and pulmonic valves may also be affected,
such involvement is almost always combined with mitral or
aortic disease.6,7
MITRAL STENOSIS

Many patients with mild mitral stenosis are asymptomatic


until they become pregnant.8 At that time the prenatal physiologic changes contribute to an increase in left atrial pressure and subsequent symptoms of dyspnea and eventually
tachypnea, orthopnea, and paroxysmal nocturnal
dyspnea.1,9 Management of mitral stenosis in pregnancy
depends on the level of symptoms. Patients who are asymptomatic may continue, within reason, their normal activities
of living. Patients who develop dyspnea with exercise must
restrict their activities and, depending on the severity, may
require continuous bed rest. Other treatments include
sodium restriction to less than 2 g/day1,7,10 or oral
b-adrenergic blockers to decrease maternal tachycardia,
thereby creating a longer diastolic filling time.10,11 For
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patients who develop atrial fibrillation, digoxin therapy has


been recommended.7,9 Digoxin is also recommended by
some11 as prophylaxis for atrial fibrillation in mitral stenosis
during pregnancy. Diuretic therapy, usually with
furosemide, is recommended by some, but others caution
against use in patients with severe mitral stenosis without
the concurrent use of invasive hemodynamic monitoring,
because sudden death has been reported.11,12
For patients with marked symptoms before pregnancy,
relief of the stenosis should be considered.10 Patients with
severe symptoms during pregnancy that cannot be controlled by medical therapy have been successfully treated by
balloon valvuloplasty1316 or open or closed mitral
valvotomy.7,10,13,17,18
Intrapartum care of patients with severe mitral stenosis
should include invasive hemodynamic monitoring. Pulmonary capillary wedge pressures may be misleading in
patients with mitral stenosis. Clark recommends that severe
mitral stenosis be managed with high-normal or elevated
pulmonary capillary wedge pressures to maintain adequate
ventricular filling pressure and cardiac output.11 Epidural
anaesthesia should be used to reduce stress-induced tachycardia.11,14 Delivery by Caesarean section should be
reserved for obstetrical indications.11,14 Close monitoring
for the first 48 hours after delivery is advised, as this
remains a time of high risk for pulmonary edema secondary
to the normal postpartum increase in cardiac output.10
Silversides et al. described a series of 74 women with mitral
stenosis who experienced 80 pregnancies. Eighty-nine percent of the women were classified as New York Heart Association (NYHA) functional class I, and the remainder were
class II at the beginning of pregnancy. Fifty-three percent
had mild mitral stenosis, 36% had moderate, and 11% had
severe mitral stenosis. Forty percent of pregnancies were
associated with a worsening of the womens NYHA functional classification by two or more classes. Thirty-five percent of these women experienced pulmonary edema,
arrhythmias (mild 26%, moderate 38%, severe 67%), or
both. The mean gestational age when pulmonary edema
developed was 30 weeks. In women who developed
arrhythmias, atrial fibrillation was the most common (70%),
followed by supraventricular tachycardia (30%). An adverse
fetal or neonatal outcome occurred in 30% of pregnancies;
the most common was preterm birth. Seventy-four percent
of deliveries were vaginal. Only one of the 21 Caesarean
sections was performed for cardiac indications. By the time
of discharge following delivery, 68% of women were receiving digoxin, b-adrenergic blockers, or diuretics. There were
no maternal deaths, and none of the symptomatic women
failed to respond to medical therapy.8
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The maternal mortality associated with mitral stenosis is


stratified by NYHA classification: class I, 0.1%; class II,
0.3%; class III, 5.5%; and class IV, 6.0%.1 Most patients are
in class I or II at presentation, but 12% to 25% of patients
are in class III or IV.19
MITRAL REGURGITATION

Mitral regurgitation occurs in 7% of patients with rheumatic


heart disease.5 Many patients have associated mitral stenosis
and should be treated and counselled as described above.
Although rheumatic heart disease is not the most common
cause of mitral regurgitation in pregnancy,14 it represents
the most clinically significant lesions.11 Pregnancy is generally well tolerated by patients with mitral regurgitation, and
it has been theorized that mitral regurgitation may actually
improve in pregnancy because of the physiologic reduction
in systemic vascular resistance.9 Previously asymptomatic
women may worsen immediately after delivery because of
sudden increases in systemic vascular resistance.20 It has
also been suggested that these patients are at increased risk
of left atrial enlargement and subsequent atrial fibrillation.11
For this reason, prophylactic digoxin has been suggested
for patients with severe regurgitation.11 Lesniak-Sobelga
et al.21 described the pregnancies of 44 women with isolated
mitral regurgitation. Six women had severe regurgitation
and the remainder had moderate regurgitation. All six
women with severe regurgitation and one with moderate
regurgitation experienced cardiac complications. Three
required diuresis for pulmonary edema, and four required
antiarrhythmic therapy for supraventricular tachycardia.
Eighty-nine percent of women delivered vaginally. One
baby was born prematurely, and three others had
intrauterine growth restriction.21
AORTIC STENOSIS

Aortic stenosis in pregnancy is described in detail in the article on congenital heart disease.22 Most patients with aortic
stenosis of rheumatic origin also have associated mitral stenosis.10 Some authors have found that a higher maternal
mortality is associated with aortic stenosis of rheumatic origin than with aortic stenosis of congenital origin.11 The rate
of maternal mortality associated with severe aortic stenosis
in pregnancy is most commonly cited as 17%, with a fetal
mortality of 32%.23 This series also identified a maternal
mortality of 40% associated with termination of pregnancy.23 This widely quoted statistic was derived from a
description of two maternal deaths in five patients undergoing termination of pregnancy and may not represent the
total population with aortic stenosis. Decisions regarding
anaesthesia and mode of delivery for patients with aortic
stenosis must be individualized on the basis of severity of
symptoms and urgency of delivery.

Acquired Heart Disease in Pregnancy

AORTIC REGURGITATION

As with aortic stenosis, most patients with aortic regurgitation of rheumatic origin have associated mitral valve disease.11 Their clinical course, therefore, is probably determined more by the extent of their mitral valve disease than
by their aortic regurgitation. When aortic regurgitation is
the predominant lesion, pregnancy is usually well tolerated.9
It has been suggested that aortic regurgitation may actually
improve in pregnancy because of the decrease in systemic
vascular resistance.9 Also, the physiologic tachycardia of
pregnancy may reduce regurgitant flow as diastolic filling
times are shortened.1,11 It has also been recognized that the
murmurs normally associated with both aortic and mitral
regurgitation may be reduced in pregnancy.24
For patients with severe aortic regurgitation and symptoms
of left-sided heart failure, the mainstay of therapy is
decreasing cardiac work. Patients should limit their activity,
and bed rest may be necessary. Sodium restriction may also
be helpful.10 Diuresis and inotropic therapy with digitalis
have been suggested in difficult cases.14 Despite aggressive
medical therapy, some patients will require aortic valve
replacement in pregnancy.25,26 Case reports suggest that
pulsatile perfusion at bypass may help preserve placental
hemodynamic function.2729
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