Management of pregnancy in women with congenital heart disease

Management of pregnancy in women with congenital heart diseaseThe number of women with congenital heart disease reaching childbearing age is increasing, and this group now represents the majority of women with heart disease during pregnancy.This increase raises certain issues which have already been addressed in editorials in this journal, 1 2 relating to risk factors and the diYculties arising from pregnant women with severe congenital heart disease. Simple defectsAtrial and ventricular septal defects, and arterial duct, when operated on early in infancy, do not require any special treatment.Asymptomatic left-to-right shunts and moderate pulmonary stenosis are also usually well tolerated.These women should be able to give birth in non-specialist centres.The only concern is prevention of endocarditis in case of residual shunts or valvar regurgitation.Atrial septal defect is the most common congenital heart disease in adults, and in the absence of pulmonary hypertension induces barely any complications.3 Contraindications Eisenmenger reaction, major or significant aortic dilatation in Marfan syndrome, severe aortic stenosis, deep cyanosis, and heart failure put the patient at high risk of maternal death, even where there is close follow up .Eisenmenger reaction carries up to 50% mortality.1 Recent inquiries in the UK 4 report maternal death in the range of 2-11/ 100 000 from 1994-96.The main cardiac causes of death are pulmonary hypertension or dissecting aneurysm.Recommendations for Eisenmenger patients include avoidance of vasodilatation, maintenance of preload, and use of prophylactic heparin. 1 Marfan disease with aortic dilatation should contraindicate pregnancy when the ascending aorta is more than 40 mm as there is an increasing risk of aortic dissection.5 Even if the aorta is smaller, pregnancy should be followed up closely with monthly echocardiograms.