Pregnancy in Women with CHD

Pregnancy can be high risk for women with congenital heart defects. It is crucial that women with CHD obtain care from a team of experts during pregnancy.

(10) Ten points to remember regarding a recent review of pregnancy in women with congenital heart disease:

(1) One

Normal physiologic changes of pregnancy include increased stroke volume, heart rate, and cardiac output, with a decrease in total peripheral resistance. Peak hemodynamic load is reached during the second trimester.

(2) Two

The modified World Health Organization (WHO) classification of maternal pregnancy risk is a useful tool in assessing pregnancy risk. WHO Class III defects are associated with a high risk of morbidity and increased risk of maternal mortality. Such diagnoses include mechanical heart valves, systemic right ventricle lesions, the Fontan palliation, unrepaired or palliated cyanotic lesions, Marfan syndrome with aorta <40 mm, severe systemic atrioventricular (AV) valve regurgitation, asymptomatic left ventricular outflow tract stenosis with gradient >50 mm Hg, left AV valve stenosis with valve area <2.0 cm2, and systemic ventricular ejection fraction 30-40%.

(3) Three

WHO Class IV diagnoses (high maternal mortality with consensus that pregnancy should be discouraged) include severe symptomatic aortic valve stenosis, severe left AV valve stenosis, pulmonary hypertension, systemic ventricular ejection fraction <30%, New York Heart Association (NYHA) functional class III and IV, Marfan syndrome with aorta >45 mm, bicuspid aortic valve with aorta >50 mm, and severe coarctation of the aorta.

(4) Four

Prepregnancy evaluation should include review of all medications. A trial off of medications contraindicated in pregnancy should be considered prior to a decision to proceed with pregnancy.

(5) Five

Women should be counseled regarding fetal risks, including risk of miscarriage, prematurity, low birth weight, and risk for recurrence of congenital heart disease. The recurrence risk is specific to the type of maternal defect but is on average approximately 3-5%.

(6) Six

There are little data regarding long-term cardiac outcomes after pregnancy for women with heart disease. There is an increased and unpredictable risk in patients following atrial switch procedures for decline in ventricular function, which does not recover after delivery.

(7) Seven

There are two peaks for development of heart failure for women with congenital heart disease. The first is towards the end of the second trimester of pregnancy, coincident with that plateau of the hemodynamic load during pregnancy. The second peak occurs in the peri- and early postpartum period.

(8) Eight

Women with mechanical heart valves are at high risk for thromboembolic events. Anticoagulation with vitamin K agonists is the safest for the mother. Offspring of women receiving a low dose of warfarin (<5 mg) have a low risk of embryopathy and fetal loss as compared with those requiring higher doses. Women receiving low molecular weight heparin during pregnancy should have close monitoring of anti-factor Xa levels.

(9) Nine

Vaginal delivery is generally the preferred method of delivery for most women with congenital heart disease. A Caesarean section may be preferred in women with aortic diameter >45 mm, those with pre-term labor while anticoagulated, patients with symptomatic severe aortic stenosis, and those with severe heart failure.

(10) Ten

A detailed, multidisciplinary delivery plan is an important part of the care of women with congenital heart disease during pregnancy. This plan should include description of the cardiac anatomy and hemodynamics, specific recommendations (including site of blood pressure measurement), anticipated complications, precautions for commonly used obstetric drugs, recommendation for mode of delivery, anesthetic plan, and detailed plan for postpartum care.

CHDs detection for newborns with parent(s) living with congenital heart disease

Are people with a CHD more likely to have children with CHDs? How much more likely? How should CHD parent(s) advocate for their newborn for an early detection?

Parents living with CHD are more likely to have children with CHDs than those without a CHD. A newborn without a close relative with CHD has about a 1% (1 out of 110 births) chance of having a CHD. The risk increases about three-fold (3x’s) for a family in which the mother, father, or sibling has CHD. That percentage does increase if the parent has a genetic cause for their defect. Often female CHD patients who are pregnant receive fetal echocardiograms, but it is recommended a heart screen (echocardiogram) is offered to their newborn after birth. This discussion should take place with their team of experts.

Medical Articles

Pregnancy in women with congenital heart disease

Pregnancy is a major life event for almost every woman. However, for women with heart disease pregnancy is associated with additional risks and deserves special attention.

Congenital Heart Defects-Know the Facts

Congenital heart defects (CHDs) are problems present at birth that affect the structure or function of the heart. They can affect how blood flows through the heart and out to the rest of the body.