COMMENTARY

Pregnancy in Women With Congenital Heart Disease

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

Disclosures

February 03, 2014

Editorial Collaboration

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In This Article

Peripartum Cardiomyopathy and Future Pregnancy

Dr. Pereira: Finally, could you say a few words about peripartum cardiomyopathy? Do you use bromocriptine in patients who have developed cardiomyopathy? Many of these patients recover left ventricular function spontaneously. There are no good prospective data on the issue. What do you do? How do you advise these patients? Many want to have a second pregnancy. How do you go about making that decision?

Dr. Warnes: This is always a difficult question. After the first episode of peripartum cardiomyopathy, 20%-40% of women will normalize their ventricular function. If their ejection fraction normalizes, they still have to recognize that there is a significant chance of developing peripartum cardiomyopathy with the second pregnancy. Although it varies by patient and perhaps the country they live in, the recurrence rate is at least 20%.

The problem is that if the ejection fraction declines again with a second pregnancy, it might stay down. Most available data show that the ejection fraction often declines by another 20%, and it may stay there. If a woman's ejection fraction didn't normalize after her first pregnancy (let's say it's 45%) and she becomes pregnant again, her mortality risk is higher. A small retrospective series found that that maternal mortality was as high as 19% in women whose ejection fraction did not normalize after their first episode of peripartum cardiomyopathy.

My usual advice is to avoid another pregnancy. If she has a healthy baby, and she survived what could have been a catastrophic situation with impaired ventricular function, ventricular tachycardia, and pulmonary edema, she should not risk it. Even if her ventricular function is normal, and the risk for mortality with a second pregnancy is very low, there is a significant risk for permanently impaired ventricular function. If she has a healthy baby, she might want to be around for 20 years at least to see that child grow up.

The bromocriptine story is fascinating. It prevents the prolactin toxicity that has been implicated in the development of this interesting condition, although it is not ready for prime time. There are some very interesting animal data and small studies, particularly from Karen Sliwa and her group.[6] We have concerns about the thrombotic implications with bromocriptine. We will have more data, though, within the next few years, and it may be that it comes more into routine clinical practice when we have more data. It is certainly very promising.

Dr. Pereira: You don't use it in your practice routinely?

Dr. Warnes: We have used it once or twice in recent cases, but not routinely.

Dr. Pereira: I could go on asking questions -- you are a fountain of knowledge. Thank you so much for these valuable and great insights. I learned a lot.

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