Andersons pediatric cardiology 2126
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ImpactofPregnancyonCommon
CardiacDiagnosticTests
Thesurfaceelectrocardiogrammayshowasinustachycardia.Becauseofthe
changeinpositionoftheheart,theelectrocardiogrammayshowashiftinthe
frontalplaneaxisorinversionoftheTwavesintheinferiorleads.Thechest
radiographmayshowamorehorizontalcardiacshadowbecauseofelevationof
thediaphragmandanenlargedcardiacsilhouette.Thepulmonaryvascular
markingsmaybecomemoreprominentduetoincreasedbloodflow,simulating
thevascularityproducedbyasystemic-to-pulmonaryshunt.
Echocardiographically,theincreaseinbloodvolumemanifestsasmildincreases
inthedimensionsoftheatriaandventricles.Theleftventricularmassincreases.
Innormalpregnancies,theleftventricularsystolicfunctionispreserved.The
increasedcardiacoutputisassociatedwithanincreaseinvelocityofflowacross
allcardiacvalves.Mitralregurgitationmayeitherimproveorworsen,depending
ontherelativeimpactofthefallinsystemicvascularresistanceversusthe
changeingeometryofthemitralvalvarapparatusassociatedwithincreasing
chambersize.
PreconceptionCounselingand
Contraception
Allwomenwithcongenitalheartdiseaseshouldhaveage-appropriatecounseling
regardingcontraceptionandpotentialpregnancybeginninginadolescence.The
responsibilityofprovidingsuchcounselingoftenfallstothespecialistin
congenitalcardiacdiseasecaringforthewomanatthetimeandhisorherteam,
asthepatientwilloftennothaveaccesstoothersqualifiedtooffer
knowledgeableadvice.Table80.1listsissuesthatshouldbeaddressedduring
preconceptioncounseling.
Table80.1
ApproachtoPreconceptionCounselingforWomenWithHeartDisease
Component
Contraception
selection
Maternalcardiacrisk
Description
Reviewsafetyandreliabilityofcontraceptionoptions
Cardiacriskstratificationbyanexpertinpregnancyandheartdisease
Determineifcardiacinterventionsarerequiredpriortopregnancy
Discusscardiacrisksofpregnancy
Reviewmedicationsanddiscontinueormodifyasappropriate
Discusslong-termprognosis
Maternalobstetricrisk Discussmaternalobstetricrisks
Fetalandneonatalrisk
Discussfetalandneonatalrisks
Discussriskoftransmissionofcongenitalheartdiseasetooffspring
Geneticsreferralwhenappropriate
Pregnancyplanning
Discussgeneralpregnancycareplanningincludingantenatalfollow-upanddelivery
location
Commonly,informationregardingdiagnosis,previousprocedures,and
prognosisarenotknowntopatientsoraremisunderstoodbythem.Clarification
ofdiagnosisandfunctionalcapacityarefundamentaltoeffectivepreconception
counseling.Thespecialistincongenitalcardiacdiseaseiswellsuitedtothistask
andalsotoensuringthatthisinformationisprovidedtoothercaregivers
involvedinthemanagementofthepregnancyandunderstoodbythem.
Discussionoflong-termprognosisofthemothermaybestraightforwardorvery
complexandsensitive,dependingontheunderlyingcardiaclesion,thetypesof
surgicalinterventions,theresiduallesions,andcomorbidmedicalconditions.
Becausematernalcardiacstatuscanchangeovertime,womenwithcongenitally
malformedheartsshouldbeadvisedtoensureregularfollow-upand,in
particular,toobtainacontemporaneousupdatedassessmentpriortofinalizinga
decisiontopursuepregnancy.Wediscussmaternalandfetalrisksassociated
withpregnancyinthelatersectionsofthischapter.
Whenpregnancyisactivelyconsideredorwhenthewomanpresentsina
gravidcondition,theassessmentmustincorporateadviceabouttheproperlevel
ofobstetricandmultidisciplinarycareduringpregnancy.Mostwomenwith
congenitalheartdiseasewillbenefitfromaninitialcardiacandhigh-risk
obstetric(maternalfetalmedicine)consultation.Thosewithminorlesionsand
theircaregiversandfamiliescanbereassuredregardingthelowriskofadverse
eventsandtheappropriatenessofstandardobstetriccare.Womenathigherrisk
canbereferredappropriatelytohigh-riskobstetricunitsinordertohaveaccess
tospecialistswithexperienceinmanagingcomplexcardiacdiseasethroughout
pregnancy.
Forwomenwhodonotwishtobecomepregnant,thesafetyandefficacyof
varioustypesofcontraceptionmustbeconsidered.Recommendationsregarding
properuseofcontraceptiveshavebeenextrapolatedfromstudiesinwomen
withoutcardiacdiseaseandarebasedonexpertopinion.1,2Barriermethodsdo
notposeahealthrisktothemotherbutareassociatedwithhighratesoffailure.
Uptoone-thirdofwomenusingbarriertechniquesalonewillhavean
unintendedpregnancywithinthefirstyearofuse.Barriermethodsalone,
therefore,shouldnotberecommendedaseffectivecontraceptivechoicesto
womeninwhomthereisasignificantmaternalriskofpregnancy,although
condomsmaybeusedinconjunctionwithothermethods.Combinedestrogen
andprogestinoralcontraceptiveshavegoodefficacy,buttheestrogen
componentisassociatedwithanincreasedriskofthrombosis,whichconstrains
theiruseinwomenwithcyanoticcardiacdisease,Fontancirculation,significant
systemicventriculardysfunction,sustainedarrhythmias,mechanicalvalves,
and/orpriorthromboembolicevents.Theriskofstrokeinassociationwith
combinedoralcontraceptivesisfurtherincreasedifawomanhasahistoryof
hypertension,diabetes,obesity,smoking,ormigraineheadaches.Estrogensand
progestinscaninterferewiththemetabolismofwarfarin,andinternational
normalizedratiosneedtobemonitoredmorecloselyinwomenusingthese
formsofcontraception.Progestin-onlyoralcontraceptivesaresafeinwomen
withheartdiseasebutareassociatedwithhigherratesoffailurecomparedwith
combinedoralcontraceptivesandshouldnotbeusedinwomenwithcardiac
diseasewhofacesubstantialriskofpregnancy.Insertionofanintrauterine
deviceisoftenasafeandreliableoptionforwomenwithheartdisease.Insome
