Pre Existing Heart Disease and Pregnancy
Women who were born with congenital heart conditions or who have been diagnosed with heart disease later in life are often under the care of cardiologists for ongoing monitoring of their hearts.
But what if a woman with pre-existing heart disease or a heart-related condition wants to get pregnant or becomes pregnant?
Below, Dr. Lissa M. Melvin addresses common questions women with heart conditions have about pregnancy, why planning before pregnancy is so important, and how specialized care can help keep the mother and baby healthy from pre-conception to birth.
Establishing Care Before Pregnancy
By Lissa M. Melvin, MD, Maternal Fetal Medicine Specialist
For women with heart-related conditions or heart disease, we recommend scheduling an appointment with a maternal-fetal medicine specialist before getting pregnant. Preconception counseling allows us to talk about the specific risks, management, and recommendations we have for a particular condition. For cardiac issues, we first want to assess a woman’s baseline function.
For example, is she having issues when she is resting? Does she get shortness of breath when she is engaged in her daily activities? This information can help us predict how she may handle pregnancy and whether or not we would recommend that she get pregnant in the first place.
We also ask that our patients see a cardiologist before they get pregnant, where they can have studies such as an EKG and echocardiogram (ultrasound of their heart) to get a better picture of how it is functioning. This will also help inform us about the woman’s baseline function so we can determine how she may handle a pregnancy.
Pregnancy puts a lot of demand on the cardiovascular system, because a woman’s blood volume increases substantially during pregnancy, especially during the end of pregnancy. Because of this, if you have a heart condition and your valves don’t work properly or your heart doesn’t squeeze well, that extra stress from the increased blood volume can put you at an increased risk of serious complications and even death. In the U.S., cardiovascular-related complications have emerged as the number one cause of maternal mortality, so this is an important issue, and we strongly urge women who fall into this category to seek out this kind of specialized consultation prior to getting pregnant.
Some Heart Conditions Are Riskier Than Others During Pregnancy
Women who were born with congenital heart defects are at a lesser risk for complications during pregnancy if they have already undergone surgery to correct those issues. We still recommend that women in this category get evaluated by their cardiologists prior to getting pregnant, but because their surgeries addressed the issues, their hearts are often strong enough and working well enough to support the strain created during pregnancy. However, women who have not yet addressed their heart condition should be very careful not to become pregnant until they undergo surgery or they are cleared by their cardiologist.
In some cases, and for some conditions, we will recommend that a woman not get pregnant at all because the risk is too great for her heart and her own health. One condition that can be especially serious for a woman if she becomes pregnant is pulmonary hypertension. This is when there is high blood pressure in the arteries that lead to your lungs, and that can ultimately lead to heart failure.
Individuals with Marfan syndrome, which affects the body’s connective tissue and can lead to aneurysms in the aorta, are also very high-risk.
Serious heart disease can also develop over time because certain conditions can put ongoing stress on a person’s heart and put them at risk for conditions such as heart failure or heart attacks. This trend is increasing in the United States. Women who have the highest risk are those who have hypertension (high blood pressure), obese women, and older women (greater than 35 years old). Importantly, race and ethnicity are also key risk factors; black women have over a three times higher risk of dying due to cardiovascular disease-related pregnancy complications compared to other women. These and other factors are always important to address before and during a women’s pregnancy so that the mother and baby can have closer monitoring.
How Maternal-Fetal Medicine Specialists Help Manage Your Care
Maternal-Fetal Medicine specialists will work closely with a patient’s cardiologist and OB-GYN throughout a woman’s pregnancy if she has a pre-existing heart condition. This multidisciplinary approach optimizes the care pregnant patients receive. Each specialist plays a different role in ensuring women remain as healthy as possible throughout the course of their pregnancy. Depending on the condition, an anesthesiologist and genetic counselor may also be a part of this multidisciplinary team. Typically, women with pre-existing heart conditions will have more frequent ultrasounds and more frequent office visits, in which we will monitor vital signs and blood pressure and perform ultrasounds to make sure the baby is growing well. These patients will also see their cardiologists throughout their pregnancy. In addition, we sometimes perform fetal-echocardiograms, which gives a detailed look at a fetus’ heart to check for any heart defects.
There is also extra preparation for these patients ahead of delivery. Depending on the patient’s condition and disease state, we carefully make plans to have any specialist we may need on hand, which could include a cardiologist for monitoring the heart as well as the ICU and anesthesiology teams. The better you plan, the better the outcomes, which is why we are always looking to multidisciplinary management of our high-risk pregnant patients.
We also do our best to help women carry their babies full-term, but in some cases, we will deliver sooner if the mother’s health is at risk. For example, we may delivery early if a woman has pulmonary hypertension as she enters the third trimester. As the pregnancy progresses, it may become more difficult for her heart to maintain its healthy state and for her to get oxygen or get her baby oxygen. We also try to deliver vaginally whenever possible, because that is associated with a better recovery, less blood loss and less risk for postoperative complications like blood clots. If delivering vaginally, sometimes we use forceps or a vacuum to help deliver the baby so the mom will have to exert less effort to push (which can put strain on the heart). Having heart disease does not automatically mean you must have a C-section, but in certain cases, it might be safer for you or your baby.
Will My Baby be at Increased Risk for a Heart Condition if I Have One?
Because some congenital heart defects (a heart defect someone is born with) can be hereditary, there are instances in which a baby will have an increased risk for also having a heart defect. Genetic counselors can work closely with women to determine if their heart condition has a genetic component, and they can also provide insight about the likelihood that she may pass that gene onto any offspring. This is another reason we recommend women with pre-existing heart conditions seek out counseling prior to becoming pregnant.
Gathering as much information as possible and being as informed as possible is the safest, healthiest route for both you and your baby. Although we see patients with unplanned pregnancies, women with heart conditions—especially those who have heart conditions that put them at extremely high risk of complications during pregnancy—should avoid becoming pregnant until they are cleared by a specialist. Unfortunately, some women’s conditions make it unsafe for pregnancy and can put both the mother’s and the baby’s lives in danger.
Our multidisciplinary teams work with all of our patients to provide as much information as possible and to help guide each woman on her journey, with her health our top priority.