Pregnancy and Echocardiography

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Presbitero P, Rabajoli F, Somerville J. Pregnancy in patients with congenital heart disease.
Schweizerische Medizinische Wochenschrift. Journal Suisse de Medecine 1995 Feb 18;125(7):311-5

Pregnancy and delivery in women with congenital heart disease remain inadvisable for patients at high risk due to the following congenital diseases: (1.) Severe left ventricular outflow tract obstruction (increase of pressure gradient); (2.) Eisenmenger syndrome (increase of right to left shunt with worsening of cyanosis and fetal growth retardation); (3.) Marfan syndrome with enlarged aortic root (risk of aortic dissection). In women suffering from cyanotic congenital heart disease the main risk is fetal complications. These are correlated to oxygen saturation and to the type of maternal disease, particularly if a palliative shunt operation has never been performed. Women with left to right shunt, right outflow tract obstruction or previous correction of the disease can go through pregnancy with low risk of mortality. The complications (mainly heart failure and arrhythmias) can be well managed with medical treatment, and the fetal outcome is similar to that in the general population.

Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus.
Circulation 1994 Jun;89(6):2673-6

In a series of 416 women with congenital heart disease seen in the Royal Brompton National Heart and Lung Hospital, London, and the Hospital Giovanni Bosco, Torino, Italy, there were 822 pregnancies. The outcomes of 96 pregnancies in 44 patients with cyanotic congenital heart disease were studied. Patients with the Eisenmenger reaction were excluded. Patients were divided arbitrarily into groups according to the type of maternal congenital cardiac anomaly, and factors influencing maternal and fetal outcome were evaluated. The incidence of maternal cardiovascular complications was high (32%), with one death from endocarditis 2 months after delivery. Forty-one (43%) of 96 pregnancies resulted in a live birth; 15 (37%) were premature. Mean weight of full-term infants was 2575 g. Univariate analysis suggested that maternal disease, Ability Index, hemoglobin, and arterial oxygen saturation before the pregnancy were factors that discriminated between successful and unsuccessful fetal outcome, with hemoglobin and arterial oxygen saturation being the most important predictors. Women with cyanotic congenital heart disease can go through pregnancy with a low risk to themselves, with frequent treatable complications, but there is a high incidence of miscarriage, premature births, and low birth weights. An incidence of congenital heart disease in the fetus of 4.9% (2 of 41 live births) is higher than that found in the normal population.

Rabajoli F, Aruta E, Presbitero P, Todros T. Risks of contraception and pregnancy in patients with congenital cardiopathies. Retrospective study on 108 patients.
Giornale Italiano di Cardiologia 1992 Oct;22(10):1133-7

108 women with congenital heart disease in child-bearing age (16-38 years, mean age 28) were followed up for a period of ten years. Possible complications of contraceptive methods, and incidence of full-term pregnancies, spontaneous abortions and cardiovascular complications during pregnancy and delivery, were considered. Half of these patients had a cyanotic congenital heart disease, 23 had left-to-right shunt mainly at atrial level, 18 had right and 14 left ventricular outflow tract obstruction. 60 women had previous surgical procedures for their congenital heart disease. 83% of the patients were in NYHA functional class I-II. No complications were found during oral contraceptive regimen during intrauterine device insertion with antibiotic prophylaxis, except for the development of pulmonary hypertension in one patient with an atrial septal defect. 146 pregnancies occurred, but only 89 were full-term. There was a high number of interrupted pregnancies, rarely for medical reasons. The incidence of spontaneous abortion was similar to that of normal population (18% versus 10-15%). Maternal cardiovascular complications were found in the 22% of the full-term pregnancies, but were well controlled by medical treatment. In conclusion, good family planning and pregnancies are possible in most young females with congenital heart disease. In the absence of cyanosis and pulmonary hypertension, oral contraception does not carry any particular risk. With appropriate medical care intrauterine devices may be an alternative in high risk patients. In the presence of a good cardiac function, a normal full-term pregnancy with an healty baby is the rule. A cesarean section is seldom needed.

J La State Med Soc 1998 Feb;150(2):97-102
Pregnancy and pre-existing heart disease.
Danzell JD.
Department of Medicine, LSU School of Medicine in Shreveport, La., USA.

Heart disease is encountered in nearly 1% of pregnancies, and the incidence is increasing. This is likely due to advances in cardiac management over the past 25 years, particularly advances in cardiac surgery and drugs, which have allowed more women with congenital and other abnormalities not only to survive to reach the age of child-bearing but also to carry a pregnancy to term successfully. Cardiac diseases of particular importance include stenotic valvular lesions, cyanotic disorders, and lesions accompanied by pulmonary hypertension. These abnormalities are associated with increased fetal and maternal morbidity and mortality, and therefore require very close monitoring during pregnancy. The physician also should be familiar with the more common cardiac disorders seen in pregnancy, be familiar with cardiovascular drugs and their potential effects on the pregnant patient and fetus, and be aware of cardiac disorders which are relative and absolute contraindications to pregnancy due to high rates of maternal mortality.

Semin Perinatol 2000 Feb;24(1):11-4
Hemodynamic changes in pregnancy.
Thornburg KL, Jacobson SL, Giraud GD, Morton MJ.
Department of Physiology & Pharmacology, Informatics & Outcomes Research School of Medicine, Oregon Health Sciences University, Portland 97201, USA.

The basic mechanisms that underlie alterations in the physiology of pregnancy are virtually unknown. Basal oxygen consumption increases by some 50 mL/min in pregnant women at term. Blood volume increases gradually over gestation as does red cell mass. Cardiac output increases by some 50% by mid-third trimester. Stroke volume and heart rate increase over the course of pregnancy with heart rate increasing gradually until term. The heart of the pregnant woman remodels dramatically in the first few weeks of pregnancy; end diastolic volume increases. Stroke volume is augmented by the increase in end diastolic volume and maintenance of ejection fraction through a possible increase in contractile force. Systolic and diastolic blood pressures drop during normal pregnancy. There is evidence of blood vessel remodeling in all vessels. Venous compliance and venous blood volume are increased. Renal plasma flow increases by some 70% in pregnancy with glomerular filtration rate increasing by 50% by unknown mechanisms. The complex hormonal environment is changing throughout pregnancy. In summary, under the influence of circulating chemical mediators blood flow is redistributed to the uterus, breast, and kidney.

Obstet Gynecol 1997 Jun;89(6):957-62
Changes in hemodynamics, ventricular remodeling, and ventricular contractility during normal pregnancy: a longitudinal study.
Gilson GJ, Samaan S, Crawford MH, Qualls CR, Curet LB.
Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, USA.

OBJECTIVE: To investigate the hemodynamic changes occurring in normal pregnancy and to see if these changes were associated with an increase in myocardial contractility. METHODS: In a longitudinal study, primigravidas were studied with echocardiography in early (15 +/- 1.8 weeks), mid (26 +/- 1.2 weeks), and late (36 +/- 1.0 weeks) gestation, as well as at 6 weeks postpartum. Cardiac dimensions were measured with two-dimensional and M-mode echocardiography and hemodynamic indices were calculated. All measurements were made with subjects in the left lateral decubitus position. Statistical analysis was performed with repeated measures analysis of variance. RESULTS: Seventy-six women with normal pregnancy outcomes completed all four studies. From the baseline study to late gestation, an increase in cardiac output of 27% (from [mean +/- standard error] 4.2 +/- 0.1 to 5.8 +/- 0.2 L/min, P = .001), and a decrease in total peripheral resistance of 33% (from 1356 +/- 69 to 941 +/- 37 dynes/second cm-5, P = .001) occurred. Over this same time period, left ventricular function, while demonstrating a small and non-significant increase in velocity of circumferential fiber shortening (from 1.25 +/- 0.02 to 1.27 +/- 0.02 cm/second), revealed a 12% decrease in wall stress (from 36.3 +/- 1.0 to 31.9 +/- 1.0 g/cm2, P = .001) and a 13% decrease in the load-independent wall stress to velocity of circumferential fiber shortening ratio (from 30.0 +/- 1.2 to 26.1 +/- 1.0, P = .01), implying enhanced intrinsic myocardial contractility. CONCLUSION: Normal pregnancy is characterized by enhanced myocardial performance.

Full text: Circulation 1997 May 20;95(10):2407-15
Serial assessment of the cardiovascular system in normal pregnancy. Role of arterial compliance and pulsatile arterial load.
Poppas A, Shroff SG, Korcarz CE, Hibbard JU, Berger DS, Lindheimer MD, Lang RM.
Department of Medicine, University of Chicago Medical Center, IL 60637, USA.
BACKGROUND: Temporal changes in systemic arterial compliance and wave propagation properties (pulsatile arterial load) and their role in ventricular-systemic arterial coupling during gestation have not been explored. Noninvasive methods combined with recently developed mathematical modeling techniques were used to characterize vascular and left ventricular (LV) mechanical adaptations during normal gestation. METHODS AND RESULTS: Fourteen healthy women were studied at each trimester of pregnancy and again postpartum. Experimental measurements included instantaneous aortic pressure (subclavian pulse tracings) and flow (aortic Doppler velocities) and echocardiographic imaging of the LV. A small increase in LV muscle mass and end-diastolic chamber dimension occurred by late gestation, with no significant alterations in myocardial contractility. Cardiac output increased and the steady component of arterial load (total vascular resistance) decreased during pregnancy. Several changes in pulsatile arterial load were noted: Global arterial compliance increased (approximately 30%) during the first trimester and remained elevated thereafter. The magnitude of peripheral wave reflections at the aorta was reduced. The mathematical model-based analysis revealed that peripheral wave reflections at the aorta were delayed and that both conduit and peripheral vessels contributed to the increased arterial compliance. Finally, coordinated changes in the pulsatile arterial load and LV properties were responsible for maintaining the efficiency of LV-to-arterial system energy transfer. CONCLUSIONS: The rapid time course of compliance changes and the involvement of both conduit and peripheral vessels are consistent with reduced vascular tone as being the main underlying mechanism. The pulsatile arterial load alterations during normal pregnancy are adaptive in that they help to accommodate the increased intravascular volume while maintaining the efficiency of ventricular-arterial coupling and diastolic perfusion pressure.

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