Aortic Stenosis & Pregnancy

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Int J Cardiol. 2004 Mar;94(1):15-23.
Clinical and echocardiographic assessment of pregnant women with valvular heart diseases--maternal and fetal outcome.
Lesniak-Sobelga A, Tracz W, KostKiewicz M, Podolec P, Pasowicz M.
Department of Cardiovascular Diseases, Institute of Cardiology, Jagiellonian University, School of Medicine, Ul. Pradnicka 80, 31-202 Cracow, Poland.

The study aimed to compare the outcome of pregnancy in women with valvular heart diseases. MATERIAL: Two hundred and fifty-nine pregnant women with cardiac diseases, aged 18-42, were observed. Group I-158 patients with mitral valve disease: 30 patients with mitral stenosis; 44 patients with mitral regurgitation, 33 patients with combined mitral valve disease, 51 patients with mitral valve prolapse; Group II-54 patients with aortic valve disease: 32 patients with aortic stenosis, 22 with aortic regurgitation; Group III-47 patients after valve replacement (36 mechanical; 11 homograft valves). Medical history and physical examination, NYHA class assessment, ECG, and echocardiography were performed during consecutive trimesters of pregnancy and after delivery. RESULTS: Clinical deterioration was observed in 38 patients-in 25 women of Group I, 6 women of Group II, and 7 women of Group III. Newborns outcome : 250 healthy (10 prematures, 12 with intrauterine growth retardation), 6 aborted, 2 stillbirths, 1 neonatal death. Method of delivery : 200 vaginally, 53 cesarean sections. CONCLUSIONS: (1). Pregnants with critical mitral valve stenosis form a high-risk group of life-threatening complications. (2) In women with severe aortic stenosis, pregnancy could lead to sudden clinical status deterioration. (3) Cardiac complications can be expected in patients with left ventricular enlargement and its depressed function. (4) Key factors influencing successful course of pregnancy and labour in patients with prosthetic valves: adequate left ventricular function, properly functioning valves, and effective anticoagulation.

J Am Soc Echocardiogr. 1999 May;12(5):324-5.
Doppler echocardiography as a predictor of pregnancy outcome in the presence of aortic stenosis: A case report.
Wilansky S, Phan B, Adam K.
Department of Cardiology, Texas Heart Institute/St Luke's Episcopal Hospital, Houston 77030, USA.

Aortic stenosis in pregnancy can be a life-threatening condition, but fortunately it is rare. In the modern era, careful obstetric and cardiologic monitoring, particularly through echocardiography, have improved fetal and maternal outcomes. However, a test that could predict outcome has not been available for patients with aortic stenosis who seek prepregnancy counseling. We report a case in which exercise Doppler echocardiography was used to predict cardiac function and maximal gradients in a woman with a bicuspid aortic valve who wished to become pregnant.

J Obstet Gynecol Neonatal Nurs. 1997 Jan-Feb;26(1):67-77.
Aortic stenosis in pregnancy: a case report.
Comport KA, Seng JK.
Department of Maternal Fetal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.

This case report describes a pregnant patient with severe aortic stenosis. A multidisciplinary plan of care was developed for the antepartum, intrapartum, postpartum, and, ultimately, postoperative clinical course. Salient points reviewed include normal cardiovascular anatomy and physiology, hemodynamic and physiologic changes of pregnancy, bicuspid aortic valvular stenosis, and the patient's clinical data profile. Numerous psychosocial stresses and the need for specialized nursing added to the complexity of caring for this patient.

Pediatr Pol. 1996 Jun;71(6):505-10.
Prenatal echocardiography of aortic stenosis
Respondek M, Wilczynski J, Oszukowski P, Szaflik K, Kieszek S, Kaczmarek P, Borowski D, Czichos E.
Zespol ds. Wad Prenatalnych Centrum Zdrowia Matki Polki w Lodzi.

Between 1991-1995 five cases of fetal critical aortic stenosis were diagnosed by fetal echocardiography at the Polish Mother's Memorial hospital. The main cause for referral for fetal ECHO was fetal ascites detected during routine obstetrical ultrasound scan in four cases and positive family history in one case. Pregnant women had fetal echocardiography monitoring as in-patients. During the first examination, the mean aortic valve size was 3.9 mm, mean shortening fraction of LV was 15.8%, mean heart/chest area ratio was 0.51. In one case pharmacological treatment with digoxin (due to fetal congestive heart failure) and steroids (to stimulate fetal lung maturity) was introduced. Amniocentesis due to severe polyhydramnios and fetal ascites drainage were also performed in this case. The were 2 fetal demises at 26 and 28 weeks of pregnancy, 3 cesarean section due to fetal distress during the first period of labour. The pH of umbilical blood was > 7.2. The newborns died between days 2-4 of life. Conclusions: Aortic valve stenosis can be diagnosed prenatally. This type of fetal heart defect has a poor prognosis.

J Clin Anesth. 1993 Mar-Apr;5(2):154-7.
Comment in: J Clin Anesth. 1995 May;7(3):264-5.
Aortic stenosis, cesarean delivery, and epidural anesthesia.
Brian JE Jr, Seifen AB, Clark RB, Robertson DM, Quirk JG.
Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock.

A 23-year-old female was referred to the University of Arkansas for Medical Sciences at 32 weeks' gestation with a history of aortic stenosis following aortic valve replacement. Evaluation by echocardiography showed an approximately 90 mmHg transvalvular pressure gradient. Pregnancy progressed to 36 weeks' gestation without problem, at which time the patient underwent cesarean section with lumbar epidural anesthesia. Invasive hemodynamic monitors were used to assess cardiac performance and as a guide for anesthetic management. The impact of aortic stenosis on pregnancy is discussed, as are management aspects of lumbar epidural anesthesia in such patients.

Int J Cardiol. 1991 Jul;32(1):1-3.
Percutaneous balloon aortic valvuloplasty during pregnancy.
McIvor RA.
Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, U.K.

Severe aortic stenosis may potentiate sudden life threatening complications during pregnancy. We report a case of successful percutaneous balloon aortic valvuloplasty in a pregnant patient with severe symptomatic aortic stenosis due to congenital bicuspid aortic valve at 14 weeks' gestation. Use of percutaneous valvuloplasty allowed asymptomatic progression of the pregnancy to term and normal delivery of a healthy 2920 g infant.

Acta Obstet Gynecol Scand. 1990;69(7-8):651-3.
Aortic valve replacement during pregnancy. A case report and review of the literature.
Ben-Ami M, Battino S, Rosenfeld T, Marin G, Shalev E.
Department of Obstetrics and Gynecology, Central Emek Hospital, Afula, Israel.

Aortic stenosis (AS) is an uncommon complication during pregnancy, but when it occurs it results in significant maternal and fetal morbidity and mortality. We present a gravida with severe AS in which aortic valve replacement was performed in the 3rd trimester of her pregnancy. She had severe AS with mild aortic regurgitation and severe congestive heart failure. Fetal heart rate and uterine activity were monitored and recorded during the operation. The pregnancy was carried uneventfully to term and the patient was delivered of a healthy baby. The literature is reviewed and recommendations are made for the management of AS during pregnancy.

J Reprod Med. 1978 Apr;20(4):229-32.
Aortic stenosis and pregnancy.
Arias F, Pineda J.

Pregnancy in patients with aortic stenosis results in a maternal mortality rate of 17.4% and perinatal mortality rate of 31.6%. Medical treatment, valve replacement and termination of pregnancy are the main modes of therapy. The number of cases reported in the literature is small, and the indications for selecting one method of management over the others have not been established. A case is presented that illustrate some of the difficulties encountered in the management of these patients.

Maternal and fetal outcomes in pregnant women with congenital aortic stenosis.
C Silversides, M Sermer, J Colman, S Sorensen, J Smallhorn, D Farine, S Siu. University of Toronto, Toronto

Background: Pregnancy in women with congenital (Cong) aortic stenosis (AS) has been associated with high rates of maternal and fetal mortality. Pregnancy outcomes in a contemporary cohort of women with CongAS have not been well defined. This study examined the risks of cardiac (CV), neonatal (NE), and obstetric (OB) complications in pregnant women with CongAS receiving comprehensive antenatal care. Methods: We reviewed the ante-, peri- and postpartum course of consecutive pregnant women with CongAS receiving care at the Toronto General or Mount Sinai Hospitals from 1986 to 2000. Women who experienced miscarriage or underwent termination were excluded. The frequency of adverse CV (pulmonary edema, arrhythmia, stroke, or death), NE (premature birth, low birth weight, respiratory distress syndrome, intraventricular haemorrhage, fetal or neonatal death), and OB (pregnancy-induced hypertension or postpartum haemorrhage) events during the ante-, peri-, and postpartum period were recorded. Results: Sixty-five women with CongAS (29 6 years) underwent pregnancy during the study period; 59 women had bicuspid aortic valve (peak aortic gradient 44 28 mmHg); 22% of women had severe AS (aortic valve area <1.0 cm2 or a peak aortic valve gradient >50 mmHg). Moderate or severe aortic regurgitation was present in 26% of patients. Nineteen women also had associated coarctation. Pulmonary edema and/or cardiac arrhythmia occurred in 8% of pregnancies. NE and OB events complicated 14% and 5% of pregnancies respectively. Twenty-one percent of pregnancies were complicated by either an adverse CV, NE, or OB events. There were no maternal, fetal, or neonatal death. Three women experienced an antepartum deterioration in NYHA functional class by >2 compared to baseline. Conclusions: In this contemporary cohort, women with CongAS generally tolerated pregnancy well. Although maternal and fetal mortality was much lower than previously reported, pregnancy in women with CongAS was associated with a substantial rate of maternal or fetal morbidity.

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