Pregnancy and cardiac interventions: What are the optimal management options?

Abstract

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Cardiac Surgery Under Cardiopulmonary Bypass in Pregnancy: Report of Four Cases

“…CPB has a greater impact on the fetus and the fetal mortality rate is high, ranging from 16 to 33 percent [9]. Therefore, the study of Chandni Patel et al recommended that cesarean section be performed prior to CPB-MVR to improve fetal outcome [9]. Concurrent cardiac surgery and cesarean section, like cases 3 and 4 in our report, should also consider the increased risk of postpartum bleeding as an important risk factor, which may cause pregnant women to lose their uterus.…”

“…CPB has a great influence on the fetus, the main influencing factors include the time of CPB heparinization, perfusion fluid temperature, perfusion flow and pressure, maternal temperature and so on. In the case that open heart operation is inevitable for pregnant women, anesthesia management, CPB management, intraoperative fetal monitoring, perioperative management are particularly important [9]. In the two cases reported in our report, with the cooperation of the surgeon, anesthesiologist and nurses in the operating room, the operation time was only about 4 hours, which greatly reduced the time of CPB and kept the perfusion fluid at room temperature of 35℃ to the greatest extent to reduce the adverse outcome of low temperature on the fetus.…”

“…The perfusion was performed with high flow, high pressure and high hematocrit, and the fetal heart rate was monitored by Doppler ultrasound during the whole operation. Fetal deaths most often occur during the cooling and rewarming phases of CPB [9]. Thus, the risk of fetal death can be greatly reduced by performing the operation at room temperature and controlling the temperature changes during the diversion.…”

Acute aortic dissection during pregnancy: Trials and tribulations

“…23 The jury on whether aortic root diameter changes during pregnancy is, as yet, undecided. 15 T A B L E 1 Summary of current evidence of aortopathies in pregnancy [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] BAV occurs in up to 2% of the population, rendering it the most common congenital cardiac malformation. 24 Investigating BAV may require other modalities than echocardiography, such as CT or MRI, due to the location of the dilatation (distal ascending aorta).…”

“…Murray et al looked at maternal morbidity in their study of 565 pregnancies. Their mortality rate of pregnancyrelated deaths was 5.3% (30). Arterial dissection or rupture occurred in 9.2%, including three fatal aortic ruptures, two during labor at term, and one postpartum.…”