Cardiac risk in pregnant women with rheumatic mitral stenosis

Physiological changes during pregnancy cause complications in mothers with mitral stenosis and their infants. This study was designed to assess maternal and fetal pregnancy outcomes in women with rheumatic mitral valve stenosis and compare them with the control group.

This study is a case-control study on 153 pregnant women, including 51 with mitral stenosis (MS) and 102 without MS as the control group, between 2007–2022. For each studied patient, two control participants were selected and matched in residence, age, and year of pregnancy. SPSS version 22 was used for data analysis.

The mean age was 31.7 ± 4.6 years in cases and 31.6 ± 4.7 in the healthy controls. Demographic variables were not significantly different between the case and control groups. The rate of stillbirth (5.9% vs. 0.0%), %), NICU admission (13.7% vs. 2.0%), and IUGR (5.9% vs. 0.0%) were higher in the fetal case group compared with the control group. On the other hand, maternal outcomes, including pulmonary edema (13.7% vs. 0.0%), ICU admission (23.5% vs. 0.0%), limb edema (15.7% vs. 0.0%), dyspnea (37.3% vs. 0.0%), pulmonary hypertension (9.8% vs. 0.0%), palpitations (21.1% vs. 0.0%) and hospital admission during pregnancy (37.2% vs. 4.9%) were statistically more common in the case groups.

Pregnancy is associated with significant fetomaternal morbidities in women with mitral valve heart disease. So they need a multidisciplinary approach in preconception and antenatal care.

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

From atrial septal defects to cardiac tamponade, the management of the myriad cardiac conditions that can complicate pregnancy follows a consistent approach: optimizing preload, optimizing afterload, and monitoring for the development of arrhythmia and pulmonary edema. This chapter addresses the majority of cardiac conditions that can complicate pregnancy and highlights the specific considerations for each.

Cardiopulmonary bypass (CPB) is infrequently utilized in pregnant patients and reserved for those with acute presentations requiring surgical intervention. Given the associated elevated risk to the mother and fetus, pertinent considerations are essential for the conduct of CPB. Timing of cardiac surgery with CPB, gestational age, and severity of cardiovascular disease play important roles in maternal and fetal outcomes. CPB after fetal delivery in those at advanced gestational age or premature delivery with cesarean section in those at early gestational age minimizes maternal and fetal risk. Greater detail on general considerations for CPB and those specific to common cardiac diseases in pregnancy is described in this chapter.

The number of women of childbearing age with cardiovascular disease (CVD) is growing because of increased survival of children with congenital heart disease. More women are also becoming pregnant at an older age, which is associated with increased rates of comorbidities including hypertension, diabetes, and acquired CVD. Over the past decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counselling, antenatal and postpartum cardiac surveillance, and labor and delivery planning. Prepregnancy counselling in a COP should be offered to women with suspected CVD who are of childbearing age. In women who present while pregnant, counselling should be performed in a COP as early as possible in pregnancy. The purpose of counselling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor, and delivery. This Clinical Practice Update highlights the COP approach to prepregnancy counselling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight “red flags” that should trigger a more timely assessment in a COP. We also describe the approach to some of the cardiac emergencies that the care provider might encounter in a pregnant woman.

Le nombre de femmes en âge de procréer atteintes d’une maladie cardiovasculaire (MCV) augmente en raison du meilleur taux de survie des enfants atteints d’une cardiopathie congénitale. De plus, davantage de femmes sont enceintes à un âge plus avancé, ce qui est associé à des taux accrus de comorbidités comme l’hypertension, le diabète et la MCV acquise. Au cours de la dernière décennie, le domaine de la cardiologie obstétrique a fait des progrès considérables avec l’apparition de programmes de cardio-obstétrique (PCO) multidisciplinaires visant à répondre au fardeau croissant des MCV chez les femmes enceintes. Avec l’arrivée des PCO officiels, les issues de grossesse des femmes atteintes d’une maladie cardiaque se sont améliorées. Les PCO offrent des consultations préconception, une surveillance cardiaque prénatale et post-partum, ainsi qu’une planification de l’accouchement. Les consultations prégrossesse dans un PCO devraient être offertes aux femmes chez qui l’on soupçonne une MCV et qui sont en âge de procréer. Pour les femmes qui consultent alors qu’elles sont déjà enceintes, les consultations devraient se tenir dans un PCO le plus tôt possible dans la grossesse. L’objectif des consultations est de réduire les risques liés à la grossesse à la fois pour la mère et le fœtus lorsque possible. Cela se fait par une stratification du risque maternel et fœtal précise, l’optimisation des lésions cardiaques, l’examen de l’innocuité des médicaments pris durant la grossesse, et l’élaboration d’un plan détaillé pour la grossesse, le travail et l’accouchement. Cette mise à jour de la pratique clinique souligne l’approche des PCO à l’égard des consultations prégrossesse, de la stratification du risque et de la prise en charge des maladies cardiaques fréquemment observées durant la grossesse. Nous mettons en évidence les signaux d’alarme qui nécessitent une évaluation plus rapide dans un PCO. Nous décrivons aussi l’approche à privilégier à l’égard de certaines urgences cardiaques que les prestataires de soins pourraient voir chez les femmes enceintes.

Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.

Les cardiopathies rhumatismales demeurent une cause majeure de mortalité et de morbidité chez les femmes enceintes dans les pays à revenu faible ou intermédiaire. Outre les défis cliniques, ces pays doivent composer avec des infrastructures et des ressources déficientes en matière de détection précoce, et de nombreuses femmes se présentent aux services médicaux pour la première fois lorsqu’elles affichent des signes de détérioration clinique en cours de grossesse. La possibilité d’un counseling et d’une planification prégrossesses peut donc être perdue. Idéalement, toutes les femmes devraient être vues avant la grossesse et stratifiées en fonction du risque que présentent leur état clinique et leur pathologie. Le rôle de l’équipe cardio-obstétrique s’est imposé au cours de la dernière décennie dans l’optique d’une transition sans heurt vers et depuis les degrés de soins appropriés pendant la grossesse. Les sténoses symptomatiques sévères des valves mitrale et aortique posent le plus grand risque pour la mère et le fœtus. En cas de sténose mitrale, les bêtabloquants sont la pierre angulaire du traitement, et seul un petit nombre de patientes doivent subir une valvuloplastie percutanée. En présence de lésions régurgitantes, le traitement de l’insuffisance cardiaque repose principalement sur la prise de diurétiques en monothérapie. L’accouchement se fait habituellement par voie basse; la césarienne est pratiquée lorsqu’elle est indiquée sur le plan obstétrique ou en présence d’une sténose sévère et d’un état clinique péjoratif. Le post-partum comporte aussi un risque élevé d’événements indésirables maternels, les plus fréquents étant l’insuffisance cardiaque et les arythmies. Le présent article décrit une démarche multidisciplinaire pratique fondée sur des données probantes qui convient à la prise en charge des cardiopathies rhumatismales pendant la grossesse.