Pregnancy in Women With Congenital Heart Disease

Naveen L. Pereira, MD; Carole A. Warnes, MD


February 03, 2014

Editorial Collaboration

Medscape &

In This Article

Cardiac Hemodynamics in Pregnancy

Dr. Pereira: Could you tell us more specifically from your practice what kinds of adult congenital heart diseases you encounter, and when patients with heart disease are pregnant, what typical cardiac lesions do they have (for example, prosthetic valves)?

Dr. Warnes: In our practice, which is a big tertiary care congenital heart disease program, we see women with the most complex heart diseases wanting to become pregnant. The good news is that most women with proper care can have a pregnancy. That is an important thing to underscore. However, we see the whole spectrum, from women who have small atrial septal defects or ventricular septal defects to those with the most complex disease, such as repaired tetralogy of Fallot or single ventricle after a Fontan procedure. Prosthetic valves must be managed properly.

Most of these women want to have a baby. They want to have a normal family, and it underscores the importance of a proper, detailed prepregnancy evaluation.

Dr. Pereira: Could you briefly summarize the important physiologic changes that occur in pregnancy that can exacerbate underlying heart disease or result in heart disease?

Dr. Warnes: The most important thing to consider is the volume load of pregnancy, which begins to rise in the first trimester and then peaks around the middle of the second trimester to about 50% above baseline. Whatever cardiac disease is present, that ventricle has to withstand that volume load, which is very significant.

A fall in afterload also accompanies pregnancy. Blood pressure tends to drop, and the heart rate increases along with cardiac output. Those hemodynamic changes help in understanding which lesions are better tolerated during pregnancy. With the fall in afterload, for example, any stenotic lesion, such as aortic stenosis, will not be as well tolerated because the gradient will increase.

Conversely, a regurgitant lesion, such as mitral regurgitation, despite the increase in volume load, will be offset somewhat by the afterload reduction. In general, regurgitant lesions are better tolerated than stenotic ones.


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