Management of the Parturient With Cardiovascular Disease

3Unfortunately, the cardiovascular changes of pregnancy may place additional stress on patients with underlying cardiac disease, increasing the risk of peripartum morbidity and mortality when compared with the general population, with the actual risk depending on the underlying cardiac disease process. 1,2 Taking the altered physiologic processes into account, women with congenital heart disease and those with a history of ischemic heart disease require special attention and a multidisciplinary cooperation for optimal outcome during vaginal delivery or cesarean section. The decision to perform regional or general anesthesia will ultimately depend on a thorough understanding of the cardiac condition and condition-specific hemodynamic goals. 2 In the United States between 1991 and 1999, 34% of maternal deaths that were attributable to medical conditions other than embolism, hemorrhage, and pregnancy-induced hypertension (the leading causes of death) were from cardiovascular problems. 4 During this same time frame the percentage of maternal deaths attributable to cardiomyopathy increased from 6% to 9%. 4 Seventy percent of maternal deaths from cardiomyopathy between 1991 and 1997 were from peripartum cardiomyopathy (PPCM), a form of dilated cardiomyopathy. 5 PPCM may present itself unexpectedly in the otherwise healthy parturient and may quickly become life-threatening, with exceedingly high rates of morbidity and mortality. Early recognition of the signs and symptoms of PPCM is critical, with rapid diagnosis and treatment crucial. Even in the best of circumstances maternal mortality is a very real concern in the presence of PPCM.