Managing Heart Disease During Pregnancy
With a little planning and the right information, most women with heart conditions can have a safe and healthy pregnancy.
There's a misconception that women living with a heart condition should never get pregnant, but in fact heart disease can be safely managed during pregnancy, says Stephanie Martin, D.O., medical director for labor and delivery and the obstetric intensive care unit at the Texas Children's Pavilion for Women in Houston. "An evaluation is important to determine whether pregnancy is a good idea, but it's very rare that a patient's heart condition would make pregnancy too risky." In some cases, "the hormonal changes in pregnancy actually help a compromised heart work better," adds John Folk, M.D., associate professor of Obstetrics and Gynecology at SUNY Upstate Medical University in Syracuse, NY. Women with high-risk a heart condition should always get expert counseling before they conceive, as well as specialized prenatal care to help increase their odds of having a healthy pregnancy.
Your heart has to pump 40 percent more blood to all of your organs during pregnancy, which means it has to work that much harder than normal. Your blood vessels dilate to accommodate the increased blood flow, lowering your blood pressure, and your blood becomes more likely to clot, which is nature's way of protecting pregnant women from excessive bleeding during childbirth. "A normal heart can handle those changes just fine," Dr. Martin says. "But I tell my patients who have heart issues that pregnancy is like a nine-month treadmill stress test."
Plan ahead, if possible. Go to your ob-gyn, explain that you're thinking about becoming pregnant, and discuss any testing that you might need. Your doctor may advise that you meet with a maternal fetal medicine expert (someone who specializes in high-risk pregnancies) and/or a cardiologist, who will want to know how you function day-to-day with your heart condition. "The most important thing to do when evaluating a patient before or during pregnancy is assessing whether they are able to do their normal, daily activities," Dr. Folk says. "If you can do all the things you normally would do, including keeping up with exercise and being athletic, and you have that kind of high-functional status, there is a very high likelihood of doing well and having a nice delivery at term." If your daily activity is restricted, doctors can use several different rating systems to determine whether you're able to have a safe pregnancy.
Conditions that shouldn't stop you from getting pregnant
Many women with the following heart conditions can have a healthy pregnancy, even if doctors have advised them otherwise.
Heart Murmur: A heart murmur is an extra sound heard during a heartbeat, and it's very common. (In fact, some women develop one during pregnancy because of the increase in blood volume, Dr. Martin says.) If you have a murmur, talk to your doctor about whether you need to be evaluated further.
Arrythmias: Arrythmia is a technical word for an irregular heart rate. Some can worsen during pregnancy because your heart is working harder, or even develop for the first time, Dr. Martin says. Often, they require no treatment, but there are medications that can be safely used to treat an arrythmia during pregnancy, if necessary.
Mitral Valve Prolapse: This common condition occurs when the valve separating the upper and lower chambers of the heart does not close properly. "It can cause heart palpitations or it can be completely asymptomatic," Dr. Martin says. Rarely, it can cause an infection of the lining of the heart, abnormal heart rhythms, or, for severe mitral valve prolapse, congestive heart failure during pregnancy -- but these complications can be safety treated with medication during pregnancy.
High Blood Pressure: "As more and more women are delaying pregnancy until later in life, high blood pressure is one of the most common medical conditions managed in pregnancy," says Chad Klauser, M.D., perinatologist and clinical assistant professor at the Mount Sinai School of Medicine in New York City. The greatest risk for pregnant patients who have high blood pressure is developing preeclampsia, but many of these women have uneventful pregnancies or preeclampsia that can be managed until the baby reaches a safe gestational age for delivery. Women contemplating pregnancy should review their current medications with their obstetrician to ensure that the antihypertensive agent they are on is safe to use during pregnancy, Dr. Klauser adds.
Conditions that require careful consultation before conceiving:
Although these conditions may not be an impediment to pregnancy "they definitely require a consultation with a maternal fetal medicine expert and a cardiologist to determine if pregnancy is a good idea," Dr. Martin says.
Artificial Valves: "These can be a minor or major concern, depending on the kind of valve and where it is located," Dr. Martin says. Women with artificial valves are on blood-thinning medications, some of which are not recommended during pregnancy, but your doctor can help you switch to a safer medication.
Mitral Valve Stenosis: This rare condition occurs when the heart's mitral valve is narrowed and doesn't open properly; thus, blood flow is blocked from coming into your left ventricle, the main pumping chamber of your heart. A woman's pregnancy risk depends on how narrowed the valve is, her history with the condition, and what kind of treatment she's had in the past. "It is possible to have a safe pregnancy with proper care or with correction of a severe obstruction before conception," Dr. Martin confirms.
b>Cardiomyopathy: There are several types of this acquired condition (a woman is not born with it), which develops when the heart muscle is weakened for various reasons. There are also types of cardiomyopathy that can be genetic, but do not become clinically significant until teen years or young adulthood.
- Dilated Cardiomyopathy: A very rare kind of heart failure that usually results from an infection and causes the heart to expand like an overstretched water balloon.
- Peripartum Cardiomyopathy: Heart failure that develops during or within the first six months after pregnancy in 1 in 5,000 to 8,000 pregnant women. It can be managed during pregnancy with medications, but most women are advised not to get pregnant again.
- Restrictive Cardiomyopathy: A condition that can develop in people who have chronic high blood pressure or are obese. The heart muscle has been working so hard for so many years that, like any muscle you work out, it becomes bigger and thicker, which can put women at risk for heart failure, especially during labor.
Conditions that may mean pregnancy is not possible There are a few rare conditions that usually mean a woman should not attempt a pregnancy at all, Dr. Martin says. These include:
Marfan Syndrome: An inherited disease that causes people to be very tall, with incredibly long arms, and, often, an overbite. People with Marfan (some of whom may not know they have it), have a defect in their connective tissue that causes them to be hypermobile. The concern in some pregnant patients is that the aorta is weak and can rupture, which is fatal. Women who suspect they may have this syndrome should be evaluated and advised of risks.
Pulmonary hypertension caused by Eisenmenger Syndrome: A rare condition that can develop in women who are born with a hole in the heart that causes blood to flow backwards into the lungs, creating high blood pressure in the lungs over time. When the pressure becomes great enough, the heart is no longer able to pump blood into the lungs, which means a person cannot get adequate oxygen and can die. Because pregnancy lowers the blood pressure, it often brings that dangerous scenario on faster.
Severe aortic stenosis: In this condition, the aortic valve, which is responsible for blood flow to the body, is narrowed, making it difficult for blood to pass through. Very quickly, blood can back up in the heart and lungs leading to heart failure. The good news is that can be fixed through surgery, but women who have aortic stenosis need to be evaluated before pregnancy to see if surgery can repair the problem and make pregnancy possible.
History of a heart attack "In most cases, we advise against pregnancy, because pregnancy loss rates and maternal complication rates are very, very high in someone who has had a heart attack," Dr. Martin says.