Cardiac disease of pregnancy encompasses a broad arena of pathologies. Many cardiac diseases during pregnancy are under investigation, and many others which are still not understood require further inquiry. Some of these diseases may be exacerbations of pre-existing conditions that the pregnant woman may already have, or they may develop a new disease process that presents because of the complex hormonal changes and physiology of pregnancy. Pre-existing conditions which can predispose the pregnant woman to cardiovascular disease include hypertension, diabetes mellitus, and congenital heart disease. Regardless, cardiac disease of pregnancy is a significant cause of or morbidity and mortality and has been cited to be present between 1-4% of all pregnancies. Although there is a significant risk involved with such pregnancies, one can successfully treat the majority of these incidents if early detection and careful follow-up are a part of routine care.
The etiology of cardiovascular diseases of pregnancy is variable and dependent on the pathology involved. The following summarizes some common cardiovascular diseases of pregnancy and their hypothesized etiologies:
The frequency of cardiac disease in women has not been clearly established. It is also unknown if there is an increased frequency of individuals in developed vs. under-developed countries. Based on the best data, estimates are that at least 0.2% of pregnancies have complications with cardiac disease. This frequency has been reported to be as high as 4%. If one includes hypertensive disease in this value, this number would be even higher, given that hypertensive disorders have been approximated to occur in up to 8% of pregnancies.
The underlying physiology of pregnancy and the changes that occur are often a core aspect in promoting some of these disease processes of the heart. Speculations are that women may undergo these physiological changes as early as 5 weeks into their pregnancy. It is essential to understand these changes and adaptation can vary among individuals. The belief is that many of these changes are the result of attachment of the placenta to uterine walls, which induces the release of hormones and subsequent changes to maternal physiology. These changes are often hemodynamic, and are counter-regulatory and still maintain the basic vascular principles of maintaining the new mean arterial pressure of pregnancy.
A combination of the above physiological and hormonal changes are hypothesized as contributing to certain decompensated states of pregnancy such as cardiomyopathy, congenital heart diseases, and valvular disease.
It is, however, without doubt, that specific structural changes occur to the maternal heart, and such changes can cause dysfunction in some of these pre-existing diseases. Because of the increase in the volume of pregnancy, a common effect is an enlargement of both atria and both ventricles by the end of pregnancy. Left ventricular mass increases by up to 50% by the third trimester and eccentric hypertrophy is also noted with increases in septal thickness. Some degree of cardiac remodeling exists to the maternal heart, as many of the changes that occur to the maternal heart are often seen to be reversed 6 to 8 months postpartum. For disease processes such as peripartum cardiomyopathy, it is easy to see why such dramatic changes would contribute to exacerbation of disease processes. However, no specific studies have concluded the exact reason these females are much more vulnerable to this disease process than others. Therefore, theories such as concurrent myocarditis, an autoimmune phenomenon, or familial linkage are potential explanations towards resultant peripartum cardiomyopathy. In mouse models, misregulation of VEGF and angiogenesis have been theorized to have a vital role in this disease process.
Regarding pre-existing valvular disorders such as mitral stenosis, mitral regurgitation, aortic stenosis, and others, the chamber and valvular enlargement along with a potential volume overloaded state can contribute to morbidity and mortality. All of these conditions can contribute to the fluid overloaded state, and place patients at risk for respiratory compromise, and poorly perfused states.
An accurate history is essential towards diagnosing the various conditions heart conditions of pregnancy. Certain features which would lead to a consideration of cardiac disease would include:
Physical exam findings would include:
Many of these findings can also be present in normal pregnancy; thus it is a challenge for the clinician to identify which of these processes are physiologic and which are pathologic. Combination of history and physical elements is critical to further delineate between these two.
Evaluation of cardiac disease in pregnant females will often require advanced workup. Initial basic workup with labs such as CBC, CMP, and urinalysis can give necessary clues to underlying processes that may be occurring. Elevated white blood cell count can help test for inflammatory conditions of the heart such as myocarditis or myocardial infarction. Routine serum creatinine measurement can help the provider test if the patient has had periods of hypo-perfusion in recent history. Liver enzymes could help identify congestive hepatopathy as they would in non-pregnant individuals. Urinalysis could reveal protein to help identify a state of pre-eclampsia. Labs such as brain natriuretic peptide (BNP) may have utility as some note to double during pregnancy. Still, those who have overt peripartum cardiomyopathy have been found to have higher levels of BNP than those who do not.
An electrocardiogram may be done and reveal various findings as well similar to those who have cardiovascular disease outside of pregnancy. Normal heart changes in pregnancy will cause rotation of heart to the left and a resultant mild left axis deviation. As previously mentioned, dilation of all chambers of the heart occur in pregnancy, and thus this predisposes these individuals to develop dysrhythmias. Some of the most common dysrhythmias seen in pregnancy include atrial premature beats, supraventricular tachycardias, and ventricular premature beats. Ventricular tachyarrhythmias may also form but are much rarer. If an individual is undergoing ischemic changes, one would expect to find ECG changes consistent with an ischemic burden, including ST-elevations or depressions, T-wave inversion, or formation of Q-waves. Non-specific changes to ST segment or T-waves present in up to 14% of pregnancies.
An echocardiogram is essential towards evaluating those undergoing cardiac insults of pregnancy. Physiologic findings may reveal chamber enlargement, physiologic aortic, mitral, and tricuspid regurgitation, and valvular dilatation. Clinical manifestations of these processes along with the degree of echocardiographic findings will require evaluation by a clinician to evaluate their significance. No strict cutoff for each of these has been deemed “normal” or “abnormal” in pregnancy. Findings of cardiomyopathy may reveal exaggerated septal thickening, end-diastolic posterior wall thickening, and resultant eccentric hypertrophy. Echocardiography can diagnose peripartum cardiomyopathy if ejection fraction reveals to be less than 45% and/or M-mode shortening below 30%, and end-diastolic dimension is greater than 2.7cm/m2. Localized wall motion abnormalities may present in myocardial ischemia or infarction. Pericardial effusion may also be evident in pregnancy, and in small amounts can be physiologic, however, if the patient is exhibiting signs of hypotension, JVD, or pulsus paradoxus, then evaluation of tamponade should be undertaken with echocardiography.
There are no recommended empiric regimens towards preventing cardiac disease in pregnancy. Those who have a prior history of cardiac disease should merit increased vigilance, and these individuals should continue their prior regimen. If such regimens contain teratogenic drugs, a qualified provider should substitute these medications. Treatment modalities for cardiac disease of pregnancy vary based upon the disease process occurring and required an individualized approach. The following discusses some common cardiac disorders and their appropriate recommended treatment regimens:
Cardiac diseases of pregnancy need evaluation as new processes or exacerbations of previous disease processes. With any cardiac disease process detected in pregnancy, the pre-existing pathology must be ruled out. Such include prior dilated cardiomyopathy, restrictive cardiomyopathy, hypertensive obstructive cardiomyopathy, ischemic heart disease, or previous valvular disorders.
The World Health Organization has established a modified classification of maternal cardiovascular risk. This is used as a tool to evaluate risk status for pregnant females with various cardiovascular conditions. The classifications are as follows
Although heart disease in pregnancy is a high-risk state, successful outcomes are possible, and even common, in patients that have regular follow up. Some conditions of pregnancy carry more morbidity and mortality than others, however.
Complications related to cardiac disease in pregnancy include:
Consultations should include:
Patients should be made aware of their cardiac conditions from the outset and allowed to be engaged in decision making throughout the process. It is of utmost importance to highlight the risks involved to the patient and the fetus. From the conception of pregnancy, mothers should receive counsel regarding risk factors attributed to cardiac disease of pregnancy. These risk factors include drug use, alcohol abuse, hypertension, diabetes mellitus, pre-existing heart disease, myocarditis, and familial heart disease of pregnancy.
Each pregnancy requires a team of professionals working together to provide coordinated and effective care. This level of cohesion is even more necessary in pregnant patients with cardiac disease. Physicians play an essential role in distinguishing normal versus abnormal pregnancy states; this can be difficult to decipher regarding cardiac disease because often, pregnant females might exhibit symptoms of cardiac disease in a healthy pregnancy. Nurses have a vital role in the healthcare setting for pregnant patients with cardiac disease. With the admission of these patients to the hospital, their nurses must be cognizant of the complex dynamics of pregnancy and especially when interventions may be necessary. Early recognition of disease states is essential to prevent worse outcomes for these patients. Pharmacists also have a unique role in the care of pregnant females with cardiac disease. A vast number of drugs and medications routinely used at other times may be detrimental to pregnant women and/or their unborn children. Pharmacists have the unique role of being aware of these medications and interactions and recommending adjustments when they may be needed. Lynch et al. highlighted the critical role of communication between physicians and pharmacists for the best outcomes of pregnancy. The interdisciplinary team is an essential part of the healthcare system, and the need for balanced coordination of care only expands in managing the pregnant patient through a safe pregnancy for the mother and child.