AHA Statement on Managing Pregnant Women With CVD

The American Heart Association (AHA) outlined several considerations for the management of pregnant women with cardiovascular disease (CVD) or CVD-related conditions in a statement published in Circulation.

Prepregnancy Counseling

Women of childbearing age with CVD should receive counseling on the risks to themselves and their baby associated with their disease. Pregnant women with CVD should be managed by a specialized cardio-obstetrics team with experience treating high-risk women with CVD during pregnancy. Shared decision-making and planning of anticipated or potential events should occur between the patient and the cardio-obstetrics team.

CVD medications should be reviewed for safety prior to conception. Medications with known teratogenicity should be replaced with other effective options with a safer profile.

The modified World Health Organization (WHO) classification, which is the only prospectively validated risk assessment tool for estimating individual maternal CV risk in women with CVD should be used in patients who plan on getting pregnant. Although several CV conditions are considered by the WHO to represent contraindications to pregnancy, women with these conditions may still consider pregnancy. The cardio-obstetrics team should collaborate with the mother in an effort to mitigate maternal CV and fetal risks in these cases.

Management of Medical Conditions During Pregnancy

Hypertension is a common CV-related disorder of pregnancy. Hypertensive disorders of pregnancy are preeclampsia/eclampsia, gestational hypertension, chronic hypertension, and chronic hypertension with superimposed preeclampsia. The American College of Obstetricians and Gynecologists (ACOG) and AHA jointly recommend multidisciplinary management for pregnant women with hypertension. Multidisciplinary management should include treatments targeting lifestyle and behavior, diet, smoking cessation, and appropriate drug therapy. The fullPIERS model can be used to stratify maternal risk and identify predictors of adverse maternal outcomes in women with preeclampsia or hypertension developed after hospital admission.

Women with a history of valvular heart disease, which is typically congenital, should undergo preconception valvular repair and preconception evaluation by a cardio-obstetrics team. Mitral stenosis, which is associated with increased maternal and fetal morbidity and mortality, should also be assessed in women with a history of valvular heart disease. Risks for morbidity and mortality during pregnancy increase with the severity of stenosis. Valvular regurgitant lesions have a lower risk profile and are less likely to cause complications during pregnancy.

Mechanical prosthetic heart valves can also increase the risk for fetal and maternal morbidity and mortality. Clinicians should discuss these risks with a patient if she asks about pregnancy prior to conception. For women with mechanical prosthetic heart valves who are already pregnant, the management options are controversial. It was recommended in the 2014 AHA/American College of Cardiology guideline for the treatment of patients with valvular heart disease and in the 2018 European Society guidelines for the treatment of CVD during pregnancy that warfarin be continued in pregnant women with mechanical prosthetic heart valves if therapeutic anticoagulation is maintained at ≤5 mg/day.

Arrhythmias are becoming more common in pregnancy, possibly due the increasing numbers of women pursuing pregnancy at later ages. Pharmacologic treatment is generally not recommended for palpitations caused by atrial and ventricular ectopy and sinus tachycardia. A cardio-obstetrics team should be consulted for more complex arrhythmias. Titration of antiarrhythmic therapy or electrophysiology studies and radiofrequency ablation may be considered in these patients.

Ischemic heart diseases, which are rare but may be fatal in pregnant women should be managed with a multidisciplinary approach, as the risk for acute myocardial infarction is much higher in pregnant women. Timely coronary reperfusion by percutaneous coronary intervention, fetal radiation protection with lead shielding, and conservative management are recommended for different forms of ischemic heart disease.

Approaches to Labor and Delivery

Spontaneous labor and vaginal birth are preferred approaches for women with heart disease. Cesarean delivery, while sometimes necessary, may increase the risk for thrombotic complications and excess blood loss, and should be reserved for the most decompensated women with CVD who require a fast delivery or those who are fully anticoagulated with vitamin K antagonists in an effort to protect the fetus from being exposed to hemorrhagic complications.

For women with CVD or CV-related conditions, induction of labor may be favored over Cesarean delivery, particularly in cases where labor fails to progress. Induction agents are generally safe in women with CVD, with a mechanical cervical ripening agent preferred over pharmacologic agents which have vasoactive properties.

The ACOG advises against elective labor induction before 39 weeks of gestation, due to the associated risk for poor neonatal outcomes. ACOG does not offer delivery timing recommendations for women with WHO class 4 maternal cardiac conditions, and the AHA recommends that such decisions be made by the high-risk cardio-obstetric team on a case-by-case basis.

Follow-Up Recommendations

The AHA recommends discussing and offering contraception to a woman after delivery and prior to hospital discharge, especially if contraception plans were not made during the antepartum period. In the immediate postpartum period, women may use long-acting reversible contraceptives. Contraception should be carefully considered in women with thrombogenic conditions, rheumatologic conditions, and women who are at risk for bleeding. The AHA recommends clinicians refer to the Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use to determine a contraceptives plan in the context of an underlying CV condition.

Reference

Mehta L, Warnes CA, Bradley E, et al. American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Cardiovascular considerations in caring for pregnant patients: A scientific statement from the American Heart Association [published online May 4, 2020]. Circulation. doi:10.1161/CIR.0000000000000772