Pregnancy and Cardiovascular Disease

Clinical Case Download : Download full-size image A 34-year-old, G1P1, asymptomatic woman, who grew up in Ethiopia presents for preconception counseling. She has a history of rheumatic heart disease resulting in mitral stenosis as a child. She has no cardiac symptoms, at rest or with exertion. On physical exam, she has a regular rate and rhythm, with a loud S1, and normal S2. There is an opening snap followed by a 2/6 diastolic murmur at the left ventricular apex. No other extracardiac sounds are present. Lungs are clear to auscultation. Her current echocardiogram demonstrates a mitral valve area by pressure half-time method of 1.2 cm2, mean gradient across the valve of 7 mmHg at a heart of 70 beats per minute, and a mitral valve score of 8, with trace mitral regurgitation. What are her pregnancy-associated risks and how do we optimize her preconception? Abstract Maternal mortality in the United States is rising and cardiovascular disease causes 26.5% of these pregnancy-related deaths. The rising trend appears to be secondary to acquired heart disease with many factors contributing, including increasing maternal age, rise in multifetal pregnancies, and the increased burden of preexisting cardiovascular risk factors in the pregnant population. Pregnancy itself causes a significant hemodynamic burden and may cause decompensation in a patient with preexisting cardiovascular disease. Risk stratification for pregnancy should ideally occur preconception and there are several risk assessment tools that can aid decision making. The care of the pregnant woman with heart disease also implicates several stakeholders including obstetrics, obstetric anesthesia, and cardiology. Unlike many cardiovascular diseases, there are no randomized controlled data to support decision making, and guidelines are largely built on expert consensus. It is therefore vital for cardiologists to continue to build on their knowledge on the management of cardiovascular disease during pregnancy and work in a multidisciplinary fashion to improve care.