Chapter
Copper intrauterine contraceptive devices
Medical termination of pregnancy
Surgical termination of pregnancy
Specific diseases for which effective contraception is critical
Pulmonary arterial hypertension
Section 2 Antenatal Care: General Considerations
3 Cardiovascular changes in normal pregnancy
Practical practice points
Hemodynamic changes during pregnancy
Peripheral vasodilatation
Cardiac anatomical change
Cardiac functional change
4 Antenatal care of women with cardiac disease: An obstetric perspective
Practical practice points
Hemodynamic changes in normal pregnancy
Recognition of the cardiac condition
Where should the woman be managed?
The underlying cardiac lesion
Trivial and low-risk cardiac lesions
Moderate- and severe-risk cardiac lesions
NYHA classification of cardiac function
Additional associated risk factors
What should the woman be told?
The multidisciplinary team and antenatal care
The fetus and fetal surveillance
Frequency of visits and admission to hospital
5 Antenatal care of women with cardiac disease: A cardiac perspective
Practical practice points
The spectrum of maternal heart disease
Organization of antenatal care
Recommendations for organization of antenatal care
The University College London Hospital experience
Current limitations and solutions
6 Cardiac monitoring during pregnancy
Practical practice points
Initial assessment of the patient
Organizing care and monitoring
Ventricular size and function
Valvar abnormalities and function
Estimation of cardiac pressures; in particular, pulmonary pressure
Cardiovascular magnetic resonance imaging
X-ray or nuclear imaging based procedures
7 Cardiac drugs in pregnancy
Practical practice points
Pharmacokinetics in pregnancy
Potential adverse effects of drugs
Adverse incident reporting
Angiotensin-converting enzyme inhibitors
Angiotensin II inhibitors
Nonpharmacological treatment of arrhythmia: Electrical cardioversion
Pulmonary hypertension in pregnancy
Beta-adrenergic receptor blockers
Drugs commonly used in pregnancy: Effects on women with cardiac disease
8 Surgical and catheter intervention during pregnancy in women with heart disease
Practical practice points
Fetal and maternal risks of cardiopulmonary bypass
Key points regarding cardiopulmonary bypass in pregnancy
Radiation and contrast agent risks to fetus and mother
Key points regarding radiation risk for cardiac interventional procedures during pregnancy
Mitral or aortic regurgitation
Miscellaneous interventions
Section 3 Antenatal Care: Fetal Considerations
9 Antenatal diagnosis of congenital heart disease
Practical practice points
The effect of prenatal diagnosis on outcome
Screening of the fetal heart in local obstetric units
Fetal cardiology in a tertiary center
Indication for referral to fetal cardiology
Maternal/paternal or family history of CHD
Exposure to teratogenic drugs
Suspected abnormality at screening
Raised nuchal translucency at first-trimester screening
Performing the fetal echocardiogram
Fetal medicine assessment
Progression of disease in pregnancy
Ongoing assessment: Fetal well-being
Timing and site of delivery
Fetal transcatheter intervention
New challenges and future direction
Early detection of congenital heart disease
Advances in imaging techniques
10 Fetal care and surveillance in women with congenital heart disease
Practical practice points
Severe left ventricular outflow tract obstruction
Cyanotic vs acyanotic heart disease
Uterine artery Doppler screening
Fetal arterial blood flow redistribution
Women needing heart surgery in pregnancy
Effects of anesthetic drugs on the fetus
Fetal monitoring during surgery
Section 4 Antenatal Care: Specific Maternal Conditions
11 Management of women with prosthetic heart valves during pregnancy
Practical practice points
Mechanical prosthetic heart valves
Low-molecular-weight heparin
12 Management of aortopathies, including Marfan syndrome and coarctation, in pregnancy
Practical practice points
Overview of the clinical problem
Normal aortic function during pregnancy
Aortopathies and related conditions
Nonaortopathy complications of Marfan syndrome
Pregnancy as a risk factor for aortic disease
Other autosomal dominant aortopathies
Monitoring during pregnancy
Treatment of aortic dissection or “near dissection” during pregnancy
Patients with repaired coarctation
Bicuspid aortic valve disease
Ehlers–Danlos type IV syndrome: Vascular
13 Management of mitral and aortic stenosis in pregnancy
Practical practice points
Mitral and aortic stenosis
Rheumatic mitral stenosis: Background and pathophysiology
Risk factors for a poor outcome in mitral stenosis
Congenital mitral stenosis
Aortic stenosis: Introduction and pathophysiology
Prepregnancy assessment of isolated aortic stenosis
Cardiopulmonary bypass surgery during pregnancy
Labor and delivery in aortic stenosis
14 Management of right heart lesions in pregnancy
Practical practice points
Preconception evaluation and counseling
Labor and delivery and the postpartum period
Congenital right heart lesions
Ebstein anomaly of the tricuspid valve
Congenitally corrected transposition of the great arteries
Transposition of the great arteries
Univentricular hearts after Fontan-type operations
Pulmonary atresia with VSD and MAPCA
15 Management of pulmonary hypertension in pregnancy
Practical practice points
Making the diagnosis of PH
Epidemiology and treatment of PH
The challenges of managing a pregnant patient with PH
Cardiovascular adaptations during pregnancy, labor, and the postpartum period
Management of PH in pregnancy in the pre-PAH treatment era
Management of PH in pregnancy in the PAH treatment era
Management of PH in pregnancy: A pragmatic approach
Initiation of targeted pulmonary vascular therapy and anticoagulation
Assessment and follow-up during pregnancy
Monitoring the mother at delivery and in the early postpartum period
Mode of delivery and anesthetic management
16 Management of cardiomyopathies in pregnancy
Practical practice points
Peripartum cardiomyopathy
Breastfeeding and bromocriptine
Recurrence and risks in future pregnancies
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
Left ventricular noncompaction
17 Management of ischemic heart disease in pregnancy
Practical practice points
Treatment of acute coronary syndrome
Previous myocardial infarction
18 Management of maternal cardiac arrhythmias in pregnancy
Practical practice points
Arrhythmias without underlying cardiac disease
Incidence of arrhythmias during pregnancy
Arrhythmia in women with heart disease during pregnancy
Mechanism of arrhythmia in women with heart disease during pregnancy
CHD and various arrhythmias
Arrhythmia management during pregnancy
Supraventricular tachycardia
Atrioventricular nodal reentry tachycardia and atrioventricular reciprocating tachycardia
Sinus nodal reentry tachycardia and intra-atrial reentrant tachycardia
Direct current cardioversion
Implantable cardioverter defibrillator
Electrophysiological study and catheter ablation
Second or third degree atrioventricular block
Intraventricular conduction block
Considerations with specific antiarrhythmic drugs
Arrhythmia during pregnancy in specific categories of CHD
Effect of arrhythmia on the mother and fetus
Counseling of pregnancy and fetal cardiac screening in women with arrhythmias
Contraception in women with arrhythmias
Maternal surveillance during pregnancy
Anesthetic management of women with arrhythmias during delivery
Multidisciplinary team approach during pregnancy and delivery
Postpartum management of women with arrhythmias
19 Management of maternal endocarditis in pregnancy
Practical practice points
Definition of endocarditis
Pathogenesis of endocarditis
Endocarditis in pregnancy
Protocol for prevention, diagnosis, and treatment of endocarditis in pregnancy
20 Management of women with heart and lung transplantation in pregnancy
Practical practice points
Pregnancy after heart and lung transplantation: Specific risks
Hemodynamic changes during pregnancy
Heart transplant physiology
Systemic hypertension and diabetes
Fertility, preconception counseling, and contraception
Surveillance during pregnancy
Section 5 Intrapartum Care
21 Pregnancy and cardiac disease: Peripartum aspects
Practical practice points
Significance of cardiac disease in the peripartum period
Anesthesia in the peripartum period
Regional anesthesia/analgesia
Advantages of general anesthesia
Disadvantages of general anesthesia
Basic noninvasive monitoring
Noninvasive cardiac output monitoring
Training and resuscitation
Equipment and environment
Section 6 Postpartum Care
22 Management of the puerperium in women with heart disease
Practical practice points
Physiological changes occurring in the puerperium in healthy women
Circulating volume changes
The effects of drugs and fluids
Risks during the puerperium for women with heart disease
Alteration in cardiac shunting of blood
Timing of maternal deaths during the puerperium
Morbidity in the puerperium associated with specific cardiac conditions
Repaired tetralogy of Fallot
Valvular and aortic disease
Management of the woman with significant cardiac disease during the puerperium
Planning ahead with multidisciplinary input
Multidisciplinary care during the puerperium
Cardiovascular monitoring
Thromboprophylaxis and anticoagulation
Pharmacological management of specific cardiac problems
Pain relief, oxygen, and posture
23 Impact of pregnancy on long-term outcomes in women with heart disease
Practical practice points
Specific lesions with more long-term data
The systemic right ventricle
Dilated and peripartum cardiomyopathy
24 Long-term outcome of pregnancy with heart disease
Practical practice points
Peripartum cardiomyopathy
Connective tissue disorders and aortopathies
Appendix A: New York Heart Association classification of cardiovascular disease
Appendix B: Antenatal care pathway
Heart Disease and Pregnancy
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