Below are useful articles in the area of obstetric cardiology.
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CVD in pregnancy guidelines
The number of women of childbearing age with cardiovascular disease (CVD) is growing because of increased survival of children with congenital heart disease. More women are also becoming pregnant at an older age, which is associated with increased rates of comorbidities including hypertension, diabetes, and acquired CVD.
Over the past decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counselling, antenatal and postpartum cardiac surveillance, and labor and delivery planning.
Prepregnancy counselling in a COP should be offered to women with suspected CVD who are of childbearing age. In women who present while pregnant, counselling should be performed in a COP as early as possible in pregnancy. The purpose of counselling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor, and delivery.
This Clinical Practice Update highlights the COP approach to prepregnancy counselling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight “red flags” that should trigger a more timely assessment in a COP. We also describe the approach to some of the cardiac emergencies that the care provider might encounter in a pregnant woman.
Haemodynamic changes in pregnancy
Gestation-Specific Vital Sign Reference Ranges in Pregnancy
The authors present widely relevant, gestation- specific reference ranges for detecting abnormal BP, heart rate, respiratory rate, oxygen saturation and temperature during pregnancy. Our findings refute the existence of a clinically significant BP drop from 12 weeks of gestation.
Preconception counselling
Pregnancy in congenital heart disease: risk prediction and counselling
Learning objectives
- How to estimate risk of pregnancy in women with congenital heart disease
- What to discuss during pre-pregnancy counselling in women with congenital heart disease
- Global overview of follow-up during pregnancy
Contraception & reproductive therapies
Lindley, C.J. et al. J Am Coll Cardiol. 2021 Apr, 77 (14) pp1823–1834
Highlights
- For women with known cardiovascular disease, pre-conception counseling and pregnancy planning are necessary to optimize the health of both mother and baby.
- Choosing a method of contraception for women with heart disease requires consideration of safety, effectiveness, patient preference and the risk of unplanned pregnancy in the context of the patient’s specific cardiovascular condition.
- Because of their effectiveness and low risk of complications, intrauterine devices and subdermal implants should generally be recommended for appropriate candidates, including adolescent and nulliparous women.
Infertility, Infertility Treatment, and Cardiovascular Disease: An Overview
Smith et al, Canadian Journal of Cardiology, 2021, 37(12) pp1959-1968
The prevalence of maternal cardiovascular disease (CVD) has risen throughout the developed world, reflecting an increase in acquired cardiovascular risk factors, such as hypertension and diabetes, and the improved life expectancy of those living with congenital and acquired heart disease owing to advances in care. Because many cardiovascular risk factors and conditions are associated with infertility, reproductive-age individuals with CVD may increasingly seek reproductive assistance. The worldwide use of assisted reproductive technologies (ART), such as in vitro fertilisation, with or without intracytoplasmic sperm injection, or intrauterine insemination after pharmacologic ovulation induction have increased steadily over the past several decades. It is incumbent on providers who care for reproductive-age individuals with preexisting CVD or CVD risk factors to understand and appreciate the types of treatments offered and inherent risks related to infertility treatments, in order to guide their patients to making safe reproductive choices in line with their values and preferences. Infertility treatments increase the risk of complicated pregnancy, but whether these risks are compounded among individuals with preexisting CVD is less well known. In this review, we summarise current available evidence regarding short-term and long-term cardiovascular implications of ART among individuals with and without CVD, as well as treatment considerations for these individuals. Existing knowledge gaps and priority areas for further study are presented.
Assisted reproduction in patients with cardiac disease: A retrospective review
Skorupskaite et al, Eur Journal of Obs and Gynaecology and Reproductive Biology, 2022, 276 pp199-203
- Data regarding the safety of assisted reproduction in patients with cardiac disease is scant.
- Increasing numbers of patients with known cardiac disease are seeking assisted reproduction.
- In most patients with cardiac disease assisted reproduction can be performed safely.
- Assisted reproduction in patients with cardiac disease requires a multi-disciplinary approach
Congenital heart disease
Lindley, K.J. et al. J Am Coll Cardiol. 2021 Apr, 77 (14) 1778–1798
Highlights
- CHD is the most common cardiovascular condition encountered in pregnant women.
- Most women with congenital and heritable conditions can be safely managed with a team-based approach throughout pregnancy.
- High-risk conditions include pulmonary hypertension, cardiomyopathy, left-sided obstructive valvular disease, and certain aortopathies.
- Long-acting reversible contraception is safe and effective for patients with congenital and heritable cardiovascular conditions.
Pregnancy in congenital heart disease: risk prediction and counselling
van Hagen IM, Roos-Hesselink JW. Heart 2020;106:1853–1861
Learning objectives
- How to estimate risk of pregnancy in women with congenital heart disease.
- What to discuss during prepregnancy counselling in women with congenital heart disease.
- Global overview of follow-up during pregnancy.
Inherited cardiac conditions
Highlights
- CHD is the most common cardiovascular condition encountered in pregnant women.
- Most women with congenital and heritable conditions can be safely managed with a team-based approach throughout pregnancy.
- High-risk conditions include pulmonary hypertension, cardiomyopathy, left-sided obstructive valvular disease, and certain aortopathies.
- Long-acting reversible contraception is safe and effective for patients with congenital and heritable cardiovascular conditions.
Heart failure
Peripartum Cardiomyopathy JACC State-of-the-Art Review
Highlights:
- Medications used to treat HF during pregnancy and lactation require special considerations.
- Severe HF may require advanced therapies and mechanical circulatory support.
- Subsequent pregnancies carry risk of relapse, and dedicated counseling and monitoring are essential.
- Future research about long-term outcomes, continued drug therapy, use of bromocriptine, device therapy, and genetics are needed.
This updated position statement summarizes the knowledge about:
- pathophysiological mechanisms
- risk factors
- clinical presentation
- diagnosis and management of PPC
Highlights
- Acquired forms of cardiovascular disease account for considerable morbidity and mortality among pregnant women.
- Interdisciplinary, team-based care is critical to managing complex acquired cardiovascular disease in pregnant women.
- Optimizing maternal outcomes in pregnant women with cardiovascular disease is crucial to promoting fetal health
Ischaemic heart disease
Highlights
- Acquired forms of cardiovascular disease account for considerable morbidity and mortality among pregnant women.
- Interdisciplinary, team-based care is critical to managing complex acquired cardiovascular disease in pregnant women.
- Optimizing maternal outcomes in pregnant women with cardiovascular disease is crucial to promoting fetal health.
Pregnancy heart team
Highlights
Cardio-obstetrics involves clinicians from multiple specialties focused on pregnant patients from preconception through the postpartum period.
Risk assessment tools can guide conversations about maternal and fetal risks in women with cardiovascular disease who are pregnant or considering pregnancy.
The cardio-obstetrics team should anticipate potential cardiovascular complications of pregnancy, labor and delivery, and the postpartum period.
Postpartum care is an ongoing, integral component of cardio-obstetrical patient management
Valvular heart disease
Highlights
- Acquired forms of cardiovascular disease account for considerable morbidity and mortality among pregnant women.
- Interdisciplinary, team-based care is critical to managing complex acquired cardiovascular disease in pregnant women.
- Optimizing maternal outcomes in pregnant women with cardiovascular disease is crucial to promoting fetal health
Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach
Cupido et al, Canadian Journal of Cardiology, 2021, 37(12) pp2045-2055
Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy
Imaging and therapeutics in pregnancy & breastfeeding
Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy: JACC Focus Seminar 4/5
Bello et al, Journal of the American College of Cardiology, 2021, 77(14) pp1813-1822
Highlights
- Pregnant women represent a complex but not necessarily vulnerable population.
- Ultrasound and magnetic resonance without gadolinium-based contrast are preferred over other imaging modalities for pregnant woman to avoid radiation exposure.
- When imaging that involves ionizing radiation is necessary during pregnancy, the strategy should be designed to minimize exposure.
- Although almost every drug administered to a mother crosses the placenta, fetal drug concentration may be similar to, higher than, or lower than the maternal concentration.
Cardiovascular imaging in pregnancy
Windram & Grewal, Canadian Journal of Cardiology, 2021, 37(12) pp 2080-208Cardiovascular disease (CVD) has become increasingly prevalent in women of childbearing age in the western world. This has led to CVD now being the leading cause of maternal morbidity and mortality. In the modern era optimal cardiology care is dependent on cardiovascular imaging and this is especially so in the appropriate management of the pregnant woman with CVD. CVD imaging allows for accurate risk assessment before pregnancy and guides appropriate management during pregnancy. In this article we outline the hemodynamic and structural changes that occur in the cardiovascular system in pregnancy. We examine the role of echocardiography, cardiac magnetic resonance imaging, computed tomography, and coronary angiography within the care of the pregnant patient and highlight the strengths and weaknesses of each.
Anaesthesia & critical care
Anaesthetic considerations and anticoagulation in pregnant patients with mechanical heart valve
Bhatia et al, British Journal of Anaesthesia, 22(7) pp273-281
- List the anticoagulation regimens recommended for use in pregnant patients with mechanical heart valves (MHVs)
- Describe the significant maternal and fetal morbidity in pregnancies with MHVs.
- Discuss the peripartum anaesthetic challenges in a pregnant patient taking therapeutic doses of anticoagulant drugs.
- Highlight the need for a multidisciplinary team approach in the management of pregnant patients with MHVs
A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient
Kidson et al, Canadian Journal of Cardiology, 37(12) pp1979-2000
Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care