Peripartum Echocardiographic Assessment of Women with Cardiovascular Diseases

Abstract

In the western world, the risk of cardiovascular diseases (CVDs) in pregnancy has increased due to increasing age at first pregnancy frequently associated with an increasing prevalence of cardiovascular risk factors, especially diabetes, hypertension, and obesity. Additionally, an increasing number of women with congenital heart disease reach childbearing age. In western countries, maternal heart disease is the major cause of maternal death during pregnancy, and peripartum intensive care unit admissions are increasing in frequency. Knowledge of the risks associated with CVDs during pregnancy and their management in pregnant women is of pivotal importance for advising patients before pregnancy. Several risk scores have been developed to risk-stratify women with heart disease desiring pregnancy. The risk estimation needs to be re-evaluated during each prepregnancy visit, because the risk of complications may change over time. The last ESC guidelines for the management of cardiovascular diseases during pregnancy enforce WHO classification of maternal risk and introduce the “pregnancy heart team” a multidisciplinary team that includes cardiologists, anesthesiologists, and obstetricians with expertise in caring for women with heart disease for achieving optimal outcomes.

The use of Doppler cardiac output measurement techniques has greatly increased our understanding of the magnitude and timing of cardiac changes during pregnancy. It is important to develop uniformity in echocardiographic methodology, gestational age, ethnicity, prepregnancy body mass index, and equipment and data collection when evaluating serial changes in echo Doppler parameters during each trimester of pregnancy.

Transthoracic echocardiography is the preferred imaging method in pregnancy. Echocardiography provides information about disease etiology, accurate and noninvasive assessment of severity, and means of monitoring progression. Transesophageal echocardiography is relatively safe; however, the risk of vomiting/aspiration and sudden increases in intra-abdominal pressure should be considered, and fetal monitoring performed. Doppler and qualitative color Doppler are useful to clarify the pathophysiology of the hemodynamic consequences of structural valve defects during pregnancy with respect to the transient nature of gradients resulting from variable loading overload of pregnancy.

Congenital heart disease (CHD) is the most common birth defect, and just under 1% of newborns have congenital heart disease. Advances in diagnostic, medical, and surgical management options have improved the long-term survival of patients with CHD. Thus, most women born with CHD will reach reproductive age. While many women with CHD tolerate the hemodynamic changes of pregnancy, others may face significant immediate or late risks of pregnancy including volume overload, arrhythmias, progressive cardiac dysfunction, thrombosis, and death. Fortunately, most of these complications could be managed.

The risks associated with pregnancy in women with congenital heart disease depend on the underlying heart defect as well as on additional factors such as ventricular function, functional class, and cyanosis. The risk of pregnancy includes adverse maternal and fetal outcomes.

The issues surrounding this growing selected population of women will increase in importance in the future as more women with greater age than in the past and with other comorbidities will became pregnant. An echocardiogram taken before the pregnancy is useful in establishing the baseline status and may be repeated safely throughout pregnancy.

Patients with complex cardiac diseases should be informed about maternal and fetal risks related to pregnancy and managed and delivered at a regional or tertiary center where a multidisciplinary team with knowledge and experience in cardiac diseases is available.