gynecology and obstetrics
Heart Disease in Pregnancy
Treatment of Heart Disease in Pregnancy
Avoidance ofwarfarin, angiotensin-converting enzyme (ACE) inhibitors,angiotensin IIreceptor blockers (ARBs), aldosterone antagonists, thiazide diuretics, and certain antiarrhythmics (eg,amiodarone) For New York Heart Association (NYHA) class III or IV, activity restriction and possibly bed rest after 20 weeks Most other usual treatments for heart failure and arrhythmias Frequent prenatal visits, ample rest, avoidance of excessive weight gain and stress, and treatment of anemia are required. An anesthesiologist familiar with heart disease in pregnancy should attend the labor and ideally should be consulted prenatally. During labor, pain and anxiety are treated aggressively to minimize tachycardia. Women are closely monitored immediately postpartum and are followed for several weeks postpartum by a cardiologist. Before women with NYHA class III or IV status conceive, the heart disease should be optimally treated medically and, if indicated (eg, if due to a valvular heart disease), treated surgically. Women with class III or IV heart failure or another high-risk disorder (listed above) may be advised to obtain an early therapeutic abortion. Some women with heart disease and poor cardiac function requiredigoxin0.25 mg orally once a day plus bed rest or limited activity, beginning at 20 weeks. Cardiac glycosides (eg,digoxin, digitoxin) cross the placenta, but neonates (and children) are relatively resistant to their toxicity. ACE inhibitors and ARBs are contraindicated because they may cause fetal renal damage. Aldosterone antagonists (spironolactone,eplerenone) should be avoided because they may cause feminization of a male fetus. Other treatments for heart failure (eg, nonthiazide diuretics, nitrates, inotropes) may be continued during pregnancy depending on disease severity and fetal risk, as determined by a cardiologist and a perinatologist. Atrial Fibrillation may accompany Anticoagulationmay be required because the relative hypercoagulability during pregnancy makes atrial thrombi (and subsequent systemic or pulmonary embolization) more likely. Standard or low molecular weightheparinis used. Neither standardheparinnor low molecular weight heparins cross the placenta, but low molecular weight heparins may have less risk of thrombocytopenia.Warfarincrosses the placenta and may cause fetal abnormalities (see table), particularly during the 1st trimester. However, risk is dose-dependent, and incidence is very low if the dose is ≤ 5 mg per day.Warfarinuse during the last month of pregnancy has risks. Rapid reversal ofwarfarin’s anticoagulant effects may be difficult and may be required because of fetal or neonatal intracranial hemorrhage resulting from birth trauma or because of maternal bleeding (eg, resulting from trauma or emergency cesarean delivery). Management of acute Treatment or For pregnant patients with a structural heart disorder, indications and use of Prevention for nonobstetric events are the same as those for nonpregnant patients. The American Heart Association guidelines do not recommend endocarditis prophylaxis for vaginal and cesarean deliveries because the rate of bacteremia is low. However, in the highest-risk patients (eg, those with prosthetic heart materials, a history of endocarditis, an unrepaired congenital cyanotic heart lesion, or a heart transplant with a valvulopathy), prophylaxis is often considered when the membranes rupture, even though no evidence indicates any benefit. If patients with a structural heart disorder develop Intraamniotic Infection or another infection (eg, pyelonephritis) requiring hospital admission, the antibiotics used to treat the infection should cover the pathogens most likely to cause endocarditis. 