A pathophysiology driven case based approach to managing pregnancy complicated by cardiac disease: Redefining the obstetrician’s role

Background: Cardiovascular disease (CVD) is a leading and potentially preventable cause of maternal morbidity and mortality. Management is complicated by the profound physiological adaptations of pregnancy, including increases in plasma volume, heart rate, stroke volume and cardiac output. Understanding the interaction between these physiological changes and the underlying cardiac condition enables obstetricians to anticipate clinical deterioration, individualize management and facilitate multidisciplinary care.Case presentation: This approach is illustrated by the case of a 27-year-old woman with Eisenmenger syndrome (modified World Health Organization class IV) who became pregnant despite medical advice and declined termination. Cardiovascular optimization, thromboprophylaxis, infection prevention, fetal surveillance, management of pre-eclampsia, management of fetal growth restriction, preterm caesarean delivery, intensive postpartum care and definitive contraception are the cornerstones of management. Conclusion: Management of CVD in pregnancy should be based on the pathophysiology of the underlying cardiac lesion and the cardiovascular demands imposed by pregnancy, labour and the puerperium. The obstetrician has a central role in integrating specialist recommendations into a coordinated plan that ensures maternal and fetal wellbeing.