Acute Cardiovascular Disease in Pregnancy
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Cardiovascular disease is the leading cause of mortality during pregnancy and the postpartum period, accounting for 35% of maternal deaths worldwide. Nearly 4% of pregnancies in the United States are affected by cardiovascular disease and the incidence is rising. Risks for developing maternal cardiovascular disease include non Hispanic Black race, age older than 40 years, hypertensive disorders, diabetes mellitus, and prepregnancy obesity. Women with cardiovascular disease should be evaluated by a cardiologist before pregnancy or as soon as possible during pregnancy. Symptoms of cardiovascular ischemia or acute cardiovascular events include chest discomfort, palpitations, shortness of breath, and fluid retention. Women are more likely than men to experience atypical symptoms such as fatigue and nausea. Evaluation may include measurement of brain natriuretic peptide, troponin I, troponin T, and high-sensitivity troponin; electrocardiography; chest radiography; echocardiography; exercise stress test; computed tomography; magnetic resonance imaging; and Holter monitoring.
Causes of acute cardiovascular disease during pregnancy and the postpartum period are aortic aneurysm, arrythmia, cardiomyopathy, myocardial infarction, and cardiac arrest.
Aortic aneurysm and dissection in pregnancy usually have genetic predisposition. Aneurysm is often in the ascending aorta but can be located anywhere along the aorta. The risk of dissection is increased during pregnancy and the postpartum period because of hormonal and hemodynamic changes. During pregnancy, aneurysm is treated with β-adrenergic blocker therapy and requires regular aortic imaging. Surgical or percutaneous interventions are rarely needed in pregnancy and are reserved for aortic emergency.
Arrythmias are atrial or ventricular in nature. Atrial arrythmias cause palpitations. They should be evaluated with echocardiography to identify structural heart disease and should be managed pharmacologically. Ventricular arrythmias are rare and managed with antiarrhythmic drugs, an implantable cardioverter defibrillator, and ablation.
Peripartum cardiomyopathy is nonischemic, presenting late in pregnancy or in the first few months post partum. The left ventricular ejection fraction is typically less than 45%. Most women recover but have a high recurrence risk in subsequent pregnancies. The rate of death or cardiac transplant is 5% to 10% at 1 year post partum. Outcomes are predicted by severity of initial left ventricular dysfunction.
Acute myocardial ischemia occurs in 8 per 100,000 pregnancy hospitalizations, and maternal death occurs in 5% to 11% of cases. Acute myocardial ischemia is caused by coronary artery atherosclerosis or dissection, embolism, spasm, arteritis, and occlusive aortic dissection. Complications include heart failure, cardiogenic shock, ventricular arrhythmia, recurrent myocardial infarction, and death. Management of the maternal condition should receive priority. Coronary angiography is the diagnostic standard if there is ST-segment elevation on electrocardiography. Initial management includes oxygen supplementation, nitrates, aspirin, intravenous unfractionated heparin, and a β-adrenergic blocker. Fetal monitoring and corticosteroids for fetal lung maturity are recommended as appropriate. Percutaneous coronary intervention of coronary artery dissection is associated with propagation of dissection. Conservative therapy is preferred if the patient’s condition is stable. Patients with acute myocardial ischemia should be transferred to a medical center with interventional cardiac capabilities.
Maternal cardiac arrest is rare. Etiologies include hemorrhage, amniotic fluid embolism, acute coronary syndrome, venous thromboembolism, and magnesium toxicity. Pregnancy considerations include early intubation, manually displacing the uterus towards the maternal left, preparations for fetal delivery, chest compressions at a rate of 100 to 120 per minute, and ratio of 30:2 chest compressions/ventilation. Perimortem delivery should occur, if possible, within 4 minutes of arrest and at the site of arrest.
American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol. 2019 May;133(5):e320-e356. doi: 10.1097/AOG.0000000000003243. PMID: 31022123.
Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews. 2019 Oct;20(10):e561-e574. doi: 10.1542/neo.20-10-e561. PMID: 31575778; PMCID: PMC7377107.
Easterling T, Stout K. Heart disease. In: Gabbe SG, Niebyl JR, Galan HL, et al, eds. Obstetrics: Normal and Problem Pregnancies. 6th ed. Elsevier Saunders; 2012:825-850.
Grodzinsky A, Schmidt L. Cardiovascular Contribution to Maternal Mortality. Cardiol Clin. 2021 Feb;39(1):1-5. doi: 10.1016/j.ccl.2020.09.001. Epub 2020 Nov 2. PMID: 33222806.
Initial approval: August 2022
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