Pregnancy and Heart Disease
Publication Date: April 1, 2019
Last Updated: March 14, 2022
Recommendations
Referral to a hospital setting that represents an appropriate maternal level of care dependent upon the specific cardiac lesion is recommended for all pregnant patients with moderate- to high-risk cardiac conditions (modified WHO risk classes III and IV) because outcomes are significantly better for women in these facilities.
574
It may be helpful to obtain a baseline BNP level during pregnancy in women at high risk of or with known heart disease, such as dilated cardiomyopathy and congenital heart disease.
574
All pregnant and postpartum patients with chest pain should undergo standard troponin testing and an electrocardiogram to evaluate for acute coronary syndrome.
574
Patients should be counseled to avoid pregnancy or consider induced abortion if they have severe heart disease, including an ejection fraction less than 30% or class III/IV heart failure, severe valvular stenosis, Marfan syndrome with aortic diameter more than 45 mm, bicuspid aortic valve with aortic diameter more than 50 mm, or pulmonary arterial hypertension.
574
Health care providers should become familiar with the signs and symptoms of cardiovascular disease as an important step toward improving maternal outcomes.
574
Women with known cardiovascular disease should be evaluated by a cardiologist ideally before pregnancy or as early as possible during the pregnancy for an accurate diagnosis and assessment of the effect pregnancy will have on the underlying cardiovascular disease, to assess the potential risks to the woman and fetus, and to optimize the underlying cardiac condition.
574
Patients with moderate and high-risk cardiovascular disease should be managed during pregnancy, delivery, and the postpartum period in medical centers with a multidisciplinary Pregnancy Heart Team that includes obstetric providers, maternal–fetal medicine subspecialists, cardiologists, and an anesthesiologist at a minimum.
574
Discussion of cardiovascular disease with the woman should include the possibilities that
- pregnancy can contribute to a decline in cardiac status that may not return to baseline after the pregnancy;
- maternal morbidity or mortality is possible; and
- fetal risk of congenital heart or genetic conditions, fetal growth restriction, preterm birth, intrauterine fetal demise, and perinatal mortality is higher when compared with risk when cardiovascular disease is not present.
574
A personalized approach estimating the maternal and fetal hazards related to the patient’s specific cardiac disorder and the patient’s pregnancy plans can provide anticipatory guidance to help support her decision making. For some patients, the prepregnancy evaluation may suggest a pregnancy risk that is unacceptable. For those women, reproductive alternatives, such as surrogacy or adoption, and effective contraceptive methods should be discussed.
574
All women should be assessed for cardiovascular disease in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm.
574
All pregnant and postpartum women with known or suspected cardiovascular disease should proceed with further evaluation by a Pregnancy Heart Team consisting of a cardiologist and maternal–fetal medicine subspecialist, or both, and other subspecialists as necessary.
574
Testing of maternal cardiac status is warranted during pregnancy or postpartum in women who present with symptoms such as shortness of breath, chest pain, or palpitations and known cardiovascular disease whether symptomatic or asymptomatic, or both.
574
An echocardiogram should be performed in pregnant or postpartum women with known or suspected congenital heart disease (including presumed corrected cardiac malformations), valvular and aortic disease, cardiomyopathies, and those with a history of exposure to cardiotoxic chemotherapy (eg, doxorubicin hydrochloride).
574
Congenital heart disease in the woman should prompt fetal echocardiography, and conversely, identification of congenital heart disease in a fetus or neonate may prompt screening for parental congenital heart disease.
574
Women with asymptomatic valve disease should be monitored by a cardiologist and may require additional testing or care during pregnancy. The frequency of monitoring necessary is indicated in the patient’s modified WHO classification.
574
Any pregnant woman who presents with an arrhythmia should undergo evaluation to assess the cause and the possibility of underlying structural heart disease.
574
Pregnant or postpartum women who present with shortness of breath, chest discomfort, palpitations, arrhythmias, or fluid retention should be evaluated for peripartum cardiomyopathy. An echocardiogram is generally the most important diagnostic test.
574
Every pregnant or postpartum patient with chest pain or cardiac symptoms should have consideration of acute coronary syndrome.
574
Although maternal cardiac arrest occurs infrequently, the health care provider should be prepared to manage this situation in any health care facility.
574
The infrequency of maternal cardiac arrest underscores the need for regular team training and practice of resuscitation skills and scenarios through simulation training.
574
Women with complex congenital or noncongenital heart disease should be treated by a Pregnancy Heart Team.
574
Women with stable cardiac disease can undergo a vaginal delivery at 39 weeks of gestation, with cesarean delivery reserved for obstetric indications.
574
Health care providers should be aware of cardiac medications with obstetric implications as well as obstetric medications with cardiac implications.
574
A postpartum follow-up visit (early postpartum visit) with either the primary care provider or cardiologist is recommended within 7–10 days of delivery for women with hypertensive disorders or 7–14 days of delivery for women with heart disease/cardiovascular disorders.
574
All postpartum women with cardiovascular disease and those identified as at high risk of cardiovascular disease should be educated on their individual risk.
574
Decisions regarding the most appropriate contraceptive option for a woman require discussion of her future pregnancy desires and personal preferences, as well as critical assessment of the patient’s underlying disease and the relative risks and benefits of the contraceptive option considered.
574
Intrauterine devices are the recommended nonpermanent option for women with high-risk cardiovascular conditions.
574
Recommendation Grading
Overview
Title
Pregnancy and Heart Disease
Authoring Organization
American College of Obstetricians and Gynecologists
Publication Month/Year
April 1, 2019
Last Updated Month/Year
June 9, 2022
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse midwife, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management
Diseases/Conditions (MeSH)
D006331 - Heart Diseases, D011249 - Pregnancy Complications, Cardiovascular
Keywords
cardiovascular disease, myocardial infarction (MI), arrhythmia, aortic dissection, prenatal care, Pregnancy and Heart Disease, heart dysfunction, postpartum period
Methodology
Number of Source Documents
202
Literature Search Start Date
January 1, 2010
Literature Search End Date
February 1, 2019