Advances in medicine have led to women with congenital heart disease to live longer and reach childbearing age. There are many specific recommendations based on the type of cardiac disease that a woman has. It is important that women with cardiac disease have a primary doctor and a cardiac specialist. Ideally, these women should have preconception counseling to learn the risks associated with pregnancy and develop a plan of care for pregnancy and delivery. The World Health Organization (WHO) categorizes patients into 4 pregnancy risk classes (I-IV), depending on their specific condition. Category I has no increased risk of maternal mortality and a slight increase in maternal morbidity. Category II and III may have small increases in maternal mortality or moderate increases in morbidity. Category IV patients may have an extremely high risk for maternal mortality or severe morbidity so much that pregnancy is not advised.
During the first trimester, the woman should have baseline labs and cardiac tests. Medications should be altered as needed. A coordinated plan for labor, delivery, and postpartum care should be developed by the end of the second trimester and reviewed with a multidisciplinary team, including labor and delivery staff and anesthesia, in the event of a spontaneous or indicated preterm delivery. In the third trimester, normal symptoms of pregnancy may worsen but require close monitoring.5
The American Heart Association (AHA) makes recommendations for specific cardiac conditions such as arrhythmia, mechanical heart valves, heart failure, pulmonary arterial hypertension, aortic stenosis, and left ventricular outflow tract obstruction. Women with stable cardiac disease can usually try to have a vaginal delivery at 39 weeks of gestation, with cesarean delivery done as needed for obstetric complications. Some patients with high-risk cardiac conditions may not be able to tolerate the fluctuations in cardiac output or Valsalva efforts that occur during vaginal delivery. For many of these patients, regional anesthesia during labor may provide sufficient pain relief to render a vaginal delivery feasible. Some of these women may require operative vaginal assistance during the 2nd stage of labor and some women will need to have a cesarean section.1 Women with arrhythmias may require cardiac monitoring during labor so it is essential to make sure that the labor and delivery unit can accommodate this. It is also important to have a plan to manage anticoagulation medications. The most important part of caring for a woman with cardiac disease is to have a plan for these women when they come to the hospital to deliver. The anesthesiologists should know about this woman and have a plan ready. Most of these women will benefit from an epidural, whether in labor or cesarean section). The high-risk women should deliver at a tertiary care center that accommodates their needs.
In the event that cardiac arrest occurs, although rare, resuscitation is similar to a non-pregnant person, except that early intubation is recommended due to increased oxygen needs and the woman’s uterus should be displaced. Prompt delivery is also recommended.1