COMMENTARY

Pregnancy in Women With Congenital Heart Disease

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

Disclosures

February 03, 2014

Editorial Collaboration

Medscape &

In This Article

When to Manage, When to Refer

Dr. Pereira: Patients should have a comprehensive evaluation before contemplating pregnancy, and they need to be guided very carefully through the process. When a general cardiologist encounters such a patient who is contemplating pregnancy, when should that cardiologist consider referring her to a specialized program that deals with adult congenital heart disease?

Dr. Warnes: For simple lesions, such as a repaired ductus arteriosus, a very small ventricular septal defect with no valvular consequences, or a repaired atrial septal defect, those simple lesions can be handled by a general cardiologist as long as he or she is comfortable with managing these women through pregnancy. Mild pulmonary stenosis is another example.

For other congenital heart lesions that the cardiologist is not aware of, if the cardiologist is not familiar with management of the lesion during pregnancy (valvular stenosis or cardiomyopathy, for example), or if there is any doubt at all, the patient should be referred to a special center. This is a difficult time, and there is potential for maternal and fetal mortality. In accordance with both the American College of Cardiology guidelines and the more recently published European guidelines,[2] patients with any other lesions should be seen first.

Dr. Pereira: If the cardiologist takes it upon himself or herself to manage these patients, can you briefly touch upon the cardiac drugs that are absolutely contraindicated in pregnancy and perhaps should be discontinued? Most drugs don't fall into a safe category, but some are absolutely contraindicated.

Dr. Warnes: The drugs that are most problematic are angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Statins are also contraindicated during pregnancy. Fortunately, most of the other cardiac drugs can be used. We have to weigh the risks and the benefits for the mother, We also have concerns about Coumadin® (warfarin), and that requires a special discussion, particularly in the context of patients with mechanical prosthetic valves.

Dr. Pereira: Can you expand on that? How do you manage pregnant patients with mechanical prosthetic valves?

Dr. Warnes: This needs to be individualized, and patients should undergo a complete assessment. Is the valve working normally? What is the patient's cardiac function? The decision will follow as to how to manage the patient's anticoagulation through pregnancy.

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