Management of Gravidocardiac Disease in Pregnancy

Risk Assessment and Diagnosis

The European Society of Cardiology recommends that all women with cardiac diseases should undergo risk assessment before conception and immediately after pregnancy is confirmed 2
Echocardiography should be performed in any pregnant patient with unexplained or new cardiovascular signs or symptoms, as recommended by the European Society of Cardiology 2
MRI without gadolinium should be considered if echocardiography is insufficient for diagnosis, according to the European Society of Cardiology 2, 3
Chest radiography with fetal shielding may be considered when other methods fail to clarify the cause of dyspnea, as suggested by the European Society of Cardiology 2, 3
Cardiac catheterization may be considered with strict indications and proper shielding of the fetus, as recommended by the European Society of Cardiology 2, 3

Pulmonary hypertension carries a high maternal mortality risk (17-33% in recent studies), according to the European Society of Cardiology 2
Severe left-sided obstructions (mitral stenosis, aortic stenosis) can cause problems even when asymptomatic before pregnancy, as noted by the European Society of Cardiology 1
Dilated poorly functioning left ventricles and fragile aortas (as in Marfan syndrome) are dangerous conditions during pregnancy, according to the European Society of Cardiology 1
Women in NYHA functional class III or IV have significantly higher risk, as reported by the European Society of Cardiology 1
Peripartum cardiomyopathy (PPCM) requires special attention with a reported mortality rate of 6-27.6%, according to the European Society of Cardiology 4

High-risk patients should be monitored by a multidisciplinary team including cardiologists, obstetricians, and anesthesiologists, as recommended by the European Society of Cardiology 2
Medication management must consider both maternal and fetal effects: ACE inhibitors, ARBs, and renin inhibitors are contraindicated during pregnancy, while beta-blockers and low-dose aspirin are considered relatively safe, according to the European Society of Cardiology 5
Regular assessment of maternal cardiac status and fetal well-being throughout pregnancy is essential, as noted by the European Journal of Heart Failure 4
Continuous invasive hemodynamic monitoring may be necessary for women with severe cardiac disease, as recommended by the European Journal of Heart Failure 4

Vaginal delivery is recommended as first choice in most patients with cardiac disease, according to the European Society of Cardiology 2, 7
Spontaneous onset of labor is appropriate for women with normal cardiac function, as suggested by the European Society of Cardiology 7
For induced labor with favorable Bishop score, oxytocin and artificial rupture of membranes are indicated, as recommended by the European Society of Cardiology 7
Epidural analgesia is preferred during labor as it stabilizes cardiac output, according to the European Journal of Heart Failure 4
Caesarean delivery should be considered for patients with specific high-risk conditions, such as dilatation of ascending aorta >45 mm, severe aortic stenosis, or Eisenmenger syndrome, as recommended by the European Society of Cardiology 2

Continuous monitoring of maternal vital signs and fetal heart rate is essential, as noted by the European Journal of Heart Failure 4
Positioning in lateral decubitus or sitting-up position as needed for cardiac status, as suggested by the European Journal of Heart Failure 4
Avoid fluid overload during intravenous infusions, as recommended by the European Journal of Heart Failure 4
For the third stage, a single dose of intramuscular oxytocin is recommended; ergometrine is contraindicated, according to the European Journal of Heart Failure 4

Close monitoring for at least 24-48 hours after delivery due to significant hemodynamic changes, as noted by the European Journal of Heart Failure 4
Auto-transfusion of blood from the lower limbs and contracted uterus may significantly increase preload, as reported by the European Journal of Heart Failure 4
A single IV dose of furosemide is commonly given after delivery to manage increased preload, according to the European Journal of Heart Failure 4
Anticoagulants should be restarted in consultation with the obstetrician and anesthesiologist when post-partum bleeding has stopped, as recommended by the European Journal of Heart Failure 4
For patients with PPCM, breastfeeding may not be advised due to potential negative effects of prolactin subfragments, as noted by the European Journal of Heart Failure 4

For acute coronary syndrome during pregnancy, primary PCI is preferred over thrombolysis, as recommended by the European Society of Cardiology 5
Bare metal stents are preferred over drug-eluting stents during pregnancy, according to the European Society of Cardiology 5