Cardiac disease in pregnancy risk factors
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Women with acquired or congenital heart disease have a higher risk of cardiac complications during pregnancy than the general population. In general, a full evaluation including history, physical examination, echocardiogram, and electrocardiogram should be considered in the patient maternla patient with underlying heart disease. Further risk stratification and monitoring are dictated by a number of factors, including the presence of prior cardiac events, heart failure, valvular heart disease, and systolic or diastolic dysfunction.
Cardiac Risk Score in Pregnancy
A prospective study performed by Siu and colleagues identified four predictors of maternal cardiac events. These include:
- A prior cardiac event (e.g., heart failure, transient ischemic attack, arrhythmia or stroke) before pregnancy
- A baseline New York Heart Association (NYHA) class higher than Class II heart failure or cyanosis
- A 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
- Reduced left (or systemic) ventricular systolic function (ejection fraction) less than 40%
Based on this study of approximately 600 patients, the estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively. The authors recommended 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.
It should be noted that severe pulmonary hypertension is associated with a 30-50% risk of maternal mortality.
High Risk Valvular Lesions
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines designate the following valvular lesions as high risk during pregnancy:
- Severe aortic stenosis
- Symptomatic mitral stenosis
- Aortic regurgitation or mitral regurgitation with NYHA class III to IV symptoms
- Aortic and/or mitral valve disease with left ventricular dysfunction (left ventricular ejection fraction < 40%)
- Aortic and/or mitral valve disease with severe pulmonary hypertension (pulmonary artery (PA) pressure > 75% of systemic pressure)
- Marfan syndrome
- Mechanical prosthetic valve requiring anticoagulation
- Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC; et al. (2001). "Prospective multicenter study of pregnancy outcomes in women with heart disease". Circulation. 104 (5): 515–21. PMID 11479246.
- Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.