Andersons pediatric cardiology 2133
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DiagnosticandTherapeuticInterventions
DuringPregnancy
Diagnostictestingforawomancontemplatingpregnancyshouldoptimallybe
completedbeforeconception.Thisallowscomprehensiveassessmentwithout
concernabouttheimpactofthetestingprocedureonthepregnancyandalso
allowstheapplicationofsurgicalortherapeuticinterventionspriortopregnancy
whenindicated.Thisisnotalwayspossible.Ifadequatecurrentinformation
aboutcardiacstatusisnotavailableforawomanwhoisalreadypregnant,
neededinvestigationsshouldbecompletedexpeditiously.Echocardiographyis
safeduringpregnancy.Exercisestresstestingisprobablysafe,although
guidelinesonhowtointerpretandapplytheresultsofstresstestingdoneduring
pregnancydonotexist.Cardiacmagneticresonanceimagingavoidsionizing
radiationandoftenproducesinformationofhighdiagnosticquality;thereforeit
shouldbeconsidered.Fetalriskshavenotbeenfullycharacterizedbutarelikely
low.Riskmaybelessenedbyavoidingfirst-trimesterstudiesifpossible,by
minimizingtimeinthecoil,andbyusinglowermagneticenergy.Gadolinium
contrastisnotknowntobesafeandshouldbeavoided.Ionizingradiation,as
generatedinx-rayandnuclearstudies,exposesthefetustotheriskof
teratogenesisandtoanincreasedriskofcancer.Nonethelessthemajorityoftests
thatmightbecontemplatedexposethefetustoradiationdoseswellbelow50
mGy,andnocongenitalabnormalitieshavebeenreportedwithexposurebelow
thisthreshold.Shieldingshouldbeused,althoughmostfetalirradiationis
receivedthroughscatterandthusisnotpreventedbyshielding.Theincremental
lifetimeriskofcancercanbecalculatedbutisexceedinglysmall.Forthese
reasons,necessaryx-rayandnuclearproceduresshouldnotbewithheldsolely
becauseofpregnancyifeffectivealternativetechniquesareunavailable.
Cardiopulmonarybypassduringpregnancyiscontemplatedonlyinurgent
situations.Thematernalmortalityisnohigherthanforsimilaremergency
proceduresinthenonpregnantpatient.Fetalmortalityishighandhasbeen
reportedintherangeofone-fifth.75Outcomesmaybeimprovedbyapplying
normothermictechniquesinvolvingpulsatilebypassathighratesofflowandby
administeringtocolyticspreemptively.Interventionaloroff-pumpprocedures
shouldbeconsideredinsteadiffeasible.Deliveryofthefetuspriorto
cardiopulmonarybypassmaybepreferableinlatepregnancy.
AnnotatedReferences
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PartIIofthisseriesdescribestheapproachtothe
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