 |
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
