Heart conditions and pregnancy

There are many types of heart disorders with varying causes and levels of severity as well as treatment options. However, special treatment considerations arise when a woman who has heart disease is also pregnant -- a situation that occurs in about 1 percent of all pregnancies in the United States. In such cases, the treatment approach is tailored to individual circumstances and takes into account pregnancy-related changes affecting your heart and circulatory system, as well as the type and severity of heart disorder.


Causes/associated factors
Pregnancy places added stress on your body and all of its organs, including your heart and circulatory system. For example, during pregnancy the volume of blood circulating through your body increases by 40 to 50 percent, partly to nourish the growing placenta (a structure in the womb that develops during pregnancy to nourish the fetus and help it discard waste). This increase occurs steadily from early pregnancy through the middle of the third trimester.
In addition, the amount of blood your heart pumps each minute (cardiac output) increases by 30 to 50 percent, and your heart rate also increases. All of these changes cause your heart to work harder. And, of course, labor and delivery place additional stress on your heart.

As early as the fifth or sixth week of pregnancy, your circulatory system may begin changing to meet the demands of pregnancy. About two to five weeks after delivery, your circulation returns to normal. With appropriate care, most women who have heart disease but are not considered high risk can have a successful pregnancy. The nature and severity of your heart disease, as well as the presence of complications, will determine your risk during pregnancy.

If you have a congenital (present at birth) heart problem, the baby has a 4 to 5 percent chance of developing one also. Women with heart disease have a higher risk of stillbirth, miscarriage and premature delivery, as well as low birth weight babies. However, more frequent prenatal care and extensive monitoring can help ensure a safe, successful pregnancy. For example, you may need a cardiologist or perinatologist to partner with your obstetrician to provide the best treatment and bring your baby to term. Your doctor may also recommend delivering your baby at a medical center that specializes in cardiac care, manages high-risk pregnancies and offers a neonatal intensive care unit.


Signs/symptoms
Throughout your pregnancy, your doctor will monitor your vital signs, heart function and any pregnancy-related changes that may affect your heart and circulatory system. Although certain symptoms are common during pregnancy, always contact your doctor if you have any concerns about your symptoms or changes in your health. Symptoms that need medical attention include:
breathlessness or difficulty breathing
increased swelling
rapid weight gain
heart palpitations, rapid heart rate or irregular pulse
feeling lightheaded or passing out
chest pain
cough
unusual fatigue, weakness or impaired activity level

Diagnosis
To evaluate your heart function, your doctor may do tests such as an echocardiogram (using sound waves to study the heart) or electrocardiogram (a recording of the electrical activity of the heart). Exercise stress testing may also be needed. The doctor will use ultrasound (using sound waves to create images of internal body parts) to gauge the growth and well-being of your baby. After the 17th to 18th week of pregnancy, an ultrasound exam of the fetal heart may be done if there is concern about the possibility of a congenital heart defect.
If you need a chest X-ray at any time during the pregnancy, your abdominal area should be shielded with a lead apron to protect the baby. Be sure to remind the X-ray technician and any other health care providers you see that you're pregnant.


Treatment
To ease the stress of pregnancy on your heart, your doctor may make the following suggestions:
Reduce anxiety. Keep up-to-date on your progress and learn what to expect throughout your pregnancy, labor, delivery and postpartum recovery to help reduce your stress. For example, being reassured that pain relief will be available during labor and delivery may help reduce your stress.

Get plenty of rest and eliminate strenuous exercise or activity. Your doctor will determine the amount of exercise and activity that's right for you based on the nature and severity of your heart disease. Some women need bed rest.

Prevent infections. Avoid people who have respiratory infections, including colds and other contagious diseases. Immediately report any signs of infection to your doctor.

Avoid heat and humidity. To avoid dilating your blood vessels and diverting blood from your uterus, don't take long, hot showers or tub baths. A cool, dry environment helps reduce stress on your heart.

Eat healthfully and avoid excessive weight gain.

Prevent abnormal heart rhythms (arrhythmia) whenever possible by following your doctor's specific instructions. Arrhythmia can put extra strain on your heart.

Prevent blood clots. Poor circulation can cause swelling in your lower legs and increase the risk of blood clots forming and traveling to other parts of your body. To reduce this risk, it's essential to care for your legs meticulously and start walking as soon as possible after delivery. Support stockings may be recommended. Pantyhose are preferable to knee-high hose or thigh-high stockings because they won't roll down and further restrict your circulation.

Take medications carefully. Because medications prescribed for heart disease can cross the placenta and reach the baby, your doctor will choose those that are safest for you and the baby. Do not take any medications, including over-the-counter drugs or nutritional supplements, without consulting your doctor.
The method and timing of your delivery, as well as the type of anesthesia used if you opt for medication, will depend on your medical condition. Of course, you'll be monitored closely during labor and delivery. Discuss any questions or concerns you may have with your doctor.


Considerations
If you're considering breastfeeding your baby, discuss it with your doctor before delivery. Breastfeeding has not been found to put additional stress on the heart and, once you establish a routine, it may actually help you relax. However, your doctor must carefully choose cardiac medications if you're breastfeeding because many of these drugs can pass into your breast milk. Some may even harm the baby. Your baby may need close follow-up by his or her doctor. If you must take medications that could potentially harm your baby, your doctor will recommend feeding your baby with formula.

Complications
Congestive heart failure is the most common serious complication during pregnancy for women who have heart disease. This occurs due to the increased blood volume during pregnancy. Although rare during pregnancy, heart attacks can be very serious, especially if they occur late in the pregnancy or during the postpartum period. Risk factors include coronary artery disease, previous oral contraceptive use, smoking and cocaine abuse.

Prevention
If you have a congenital heart defect, any type of heart disease, a heart murmur, an artificial heart valve, a history of rheumatic fever, high blood pressure or other cardiovascular conditions, discuss your plans to get pregnant with your doctor in advance. Again, certain medications commonly used to treat heart conditions are not used during pregnancy. Therefore, changes to your medication may need to be made before you become pregnant. Your doctor may also recommend being vaccinated against viruses that cause pneumonia and the flu.
Certain heart conditions carry a high risk of maternal and/or fetal death during pregnancy, including significant pulmonary hypertension, severe mitral valve stenosis, Marfan's syndrome, Eisenmenger's syndrome, severe uncorrected aortic valve stenosis and coarctation of the aorta, and unrepaired cyanotic heart defects. If it's an option, your doctor may recommend corrective surgery before becoming pregnant. If the risk of a serious complication is too great, you may be advised to avoid pregnancy completely.