American Heart Association updates guidelines on Managing Pregnancy in CHD Patients.

Courtesy: http://www.heartdiseaseandpregnancy.com/

AHA

With advances in surgery and medical management, more and more female children born with CHD are reaching reproductive age. The most recent statistics by AHA  estimates that 1 in 150  adults have some form of CHD.

Ability to successfully carry the pregnancy to term, intrapartum and postpartum management of these patients involve multidisciplinary coordination and monitoring.  It includes a cardiologist expert in treating CHD, a maternal-fetal medicine  specialist, heart anesthesiologists and heart surgeons. 

“Women with complex congenital heart disease were previously advised to not get pregnant because of the risk to their life,” said Mary M. Canobbio, R.N., M.N., chair of the writing committee for the new scientific statement published in the American Heart Association Journal Circulation.[1]

“Now scientific research demonstrates that with proper management in the hands of experienced cardiologists and obstetricians, these women can have successful pregnancies,” said Canobbio, who is also a lecturer at UCLA School of Nursing in Los Angeles, California.[2]

courtesy: American Heart Association.

Most common complex defects seen in practice are single ventricle, transposition of great arteries, pulmonary hypertension and aortic valve stenosis.

In pregnancy, the blood volume increases by 40%, cardiac output increases by 30-50% with heart rate increasing by 10-20 beats/min. This change in circulation dynamic is very taxing to the heart.[3] The physician needs to assess beforehand whether the heart can handle this increased load.

The strategy to manage patients with complex CHD with pregnancy begins by preconception counselling and assessing the risk to mother and fetus, which includes genetic counselling as the risk of recurrence of CHD is always real.  The clinician should assess the volume overload, tachycardia and hypercoagulable state along with the need for constant medications.

The second most important issue is the management during pregnancy, which includes the diagnostic test required, medication alteration if teratogenic and fetal screening beside the routine antenatal care in pregnancy. Blood thinners are known to be harmful to the fetus.

Low risk patients are seen by cardiologist in first and last trimester while moderate to high risk patients are evaluated each trimester at a tertiary care center by a maternal-fetal medicine specialist. Fetal echocardiography at 18-22 weeks is recommended for all patients.

Intrapartum care, access to a tertiary care center, insurance and availability of cardiologist at the time of delivery should be discussed with the patients. Each patient should have an individual plan for her delivery, according to her medical needs. Experts advice use of narcotics and epidural to limit the urge to 'push' which increases load on heart. 

Postpartum the patients should be closely monitored in a cardiac intensive care unit and monitored for volume overload in the first 24-48 hours. In some patient close monitoring is needed for 6 months because of residual effects of pregnancy.

This scientific statement also stress the need for developing and collecting data on large cohorts of patients so that preconception care outline and pregnancy complication stratified according to individual congenital malformation can be known.

“This scientific statement outlines the specific management for these high-risk patients,” Canobbio said. “What we know about the risks for these patients, what the potential complications are, what cardiologists, advanced practice nurses and other cardiac health providers should discuss in counseling these women, and once pregnant, recommendations in terms of the things we should be looking out for when caring these women.”

Full text of the article can be found here.

---

[1] http://circ.ahajournals.org/content/early/2017/01/12/CIR.0000000000000458

[2] http://newsroom.heart.org/news/women-with-high-risk-congenital-heart-disease-can-have-successful-pregnancies

[3] http://news.heart.org/successful-pregnancy-possible-for-some-women-with-high-risk-congenital-heart-disease-2/?utm_campaign=sciencenews16-17&utm_source=science-news&utm_medium=phd-link&utm_content=phd01-12-16