Pregnancy and heart disease: what Internists should know

Abstract

Cardiac disease can rarely complicate pregnancy (e.g., only 1 to 4% of pregnancies in the United States), but it still remains a major cause of non-obstetric maternal morbidity and mortality. 1 During pregnancy, a woman can suffer from heart failure because of a pre-existing heart disease or a new onset cardiopathy pregnancy correlated. Approximately 2% of pregnancies involve cardiac disease, and in the current era, most maternal disease is due to congenital heart disease (CHD).2 Currently cardiac surgery improvement of the last 50 years has permitted an increased number of survivors. Instead, in the past, rheumatic heart disease was the leading cause of heart failure in pregnancy.3,4 Further, with increasing maternal age, other etiologies of heart disease should not be ignored and, particularly, ischemic and hypertensive heart disease should be considered in an over forty pregnant women. 5 Physiology of normal pregnancyImportant hemodynamic changes appear during pregnancy and are responsible for heart failure in pregnant women with pre-existing heart disease. These changes begin early in pregnancy, generally during the first eight weeks, reach their peak during the late second trimester, and then remain relatively constant until delivery. 6 The plasma volume and red cell mass are the first major cardiocirculatory modification, actually they expand in the 8 th week and peak around 30 th week, with a net plasma volume gain of 1000-1600 mL, corresponding to 30-50% above baseline.7 A greater increase in intravascular volume compared to red cell mass results in the dilutional anemia of pregnancy. This aspect generally results at 30-34 weeks when plasma volume peaks in relation to red cell mass and is associated with sodium and water retention. Actually 1000 mEq of sodium and 6 liters of water are retained and distributed among amniotic fluid, fetus and intra and extracellular spaces.8 Further cardiac output increases to satisfy increase fetal and maternal metabolic needs. It can be estimated 30-50% above baseline levels during the entire pregnancy, but half of this change occurs by 8 th week. This relevant change is a consequence of blood volume augmentation, afterload reduction and maternal heart rate rise.9 Systemic Pregnancy and heart disease: what Internists should know ABSTRACTPregnant women with heart disease are increasing due to medical and surgical progress and, nowadays, congenital heart disease is the most frequent heart disease affecting these women. Pregnancy represents a considerable effort for an altered heart with negative consequences for life quality, disease progression and mortality. Risk differs a lot among patients and depends not only on the type of heart disease. Clinician should stratify risk and offer patients a correct pre-counselling and accurate follow-up. At the same time Clinician should be able to diagnose rapidly heart failure as some cardiopathies, such as peripartum cardiomyopathy, are related to pregnancy and produce symptoms that can be confused with normal pregnancy progression...