Recommendations for the Management of High-Risk Cardiac Delivery

Figures

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  Central Illustration. Key Considerations for Intrapartum and Immediate Postpartum Management of Pregnant Patients With High-Risk Cardiovascular Disease Prior to labor and delivery, mode of delivery, timing of induction, and location of intrapartum and postpartum care should be discussed. Anesthetic and antithrombotic therapy strategies should also be determined prior to labor and delivery. During labor and delivery, use of invasive monitoring, cardiac devices, and mechanical circulatory support are guided by the patient’s cardiac risk profile and clinical hemodynamic status. Postpartum management should focus on optimization of fluid status, breastfeeding, and establishment of a postpartum contraception plan. Multidisciplinary cardio-obstetrics teams and electronic health record/hospital algorithms, protocols, and toolkits are critical for the optimal management of these high-risk individuals.

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  Figure 1. Hemodynamic Changes of Labor, Delivery, and Immediate Postpartum Period Changes in cardiac output, heart rate, mean arterial pressure, and systemic vascular resistance that occur during labor/delivery (by stage of labor) and the first 72 hours postpartum are displayed. Stage 2 of labor is characterized by repeated Valsalva maneuvers. Phase I of the Valsalva maneuver corresponds to an increase in thoracic pressure due to strain, resulting in transient increase in blood pressure. In phase 2, maintenance of the Valsalva maneuver leads to decrease venous return, decrease in blood pressure, and reflex tachycardia. With release of the Valsalva in Phase 3, there is a brief drop in blood pressure with normalization of intrathoracic pressure. Finally, phase 4 is characterized by restoration of LV preload, increase in blood pressure, and decrease in heart rate. MAP = mean arterial pressure; SVR = systemic vascular resistance; VTE = venous thromboembolism.