Management of Acute Cardiovascular Complications in Pregnancy

Gabriele Egidy Assenza; Konstantinos Dimopoulos; Werner Budts; Andrea Donti; Katherine E. Economy; Gaetano Domenico Gargiulo; Michael Gatzoulis; Michael Job Landzberg; Anne Marie Valente; Jolien Roos-Hesselink

Disclosures

Eur Heart J. 2021;42(41):4224-4240.

Abstract and Introduction

Abstract

The growing population of women with heart disease of reproductive age has been associated with an increasing number of high-risk pregnancies. Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and thromboembolic events, and the management of mechanical heart valves during pregnancy. Cardiovascular pathology is the leading cause of non-obstetric morbidity and mortality during pregnancy in developed countries. For women with pre-existing cardiac conditions, preconception counselling and structured follow-up during pregnancy are important measures for reducing the risk of acute cardiovascular complications during gestation and at the time of delivery. However, many women do not receive pre-pregnancy counselling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including HF, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events. This review provides a summary of recommendations on the management of acute cardiovascular complication during pregnancy, based on available literature and expert opinion. This article covers the diagnosis, risk stratification, and therapy and is organized according to the clinical presentation and the type of complication, providing a reference for the practicing cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research.

Graphical Abstract

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Multidisciplinary and expert team ('pregnancy heart team') should be ideally involved early in the care of a pregnant woman presenting with an acute cardiovascular complication during gestation. Proposed staged approach to expedite risk stratification, diagnosis and management is summarised in the graphical abstract.

Introduction

The number of pregnancies and deliveries in women with cardiovascular conditions has been growing for several decades, largely due to the increasing population of adults surviving with congenital heart disease (CHD) and the rising average age of pregnant women in developed countries.^[1–3] Cardiovascular diseases are the most common cause of non-obstetric death during pregnancy,^[4] whereas cardiac patients requiring emergency hospitalization during pregnancy (high dependency of intensive care, 6.4/1000 pregnancies) have a significant mortality of 5%.^[5,6] There is limited evidence to guide the management of pregnant women with cardiovascular disease, with most data deriving from retrospective series or large international registries; therefore, expert opinion remains important in formulating clinical recommendations.^[4,7]

Cardiovascular complications during pregnancy often occur outside tertiary referral centres and pose significant challenges to practitioners in cardiac and emergency medicine.^[7] Our paper is aimed at practitioners who may encounter such patients in emergency, non-tertiary settings, and discusses the diagnosis and management of acute cardiovascular complications during pregnancy, based on expert opinion and best evidence (Graphical abstract).^[4,7,8]

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Table 1. Modified World Health Organization classification of heart disease during pregnancy
	mWHO I	mWHO II	mWHO II–III	mWHO III	mWHO IV
Diagnosis	Small or mild Pulmonary stenosis Patent ductus arteriosus Mitral valve prolapse Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage) Atrial or ventricular ectopic beats, isolated	Unoperated atrial or ventricular septal defect Repaired tetralogy of Fallot Most arrhythmias (supraventricular arrhythmias) Turner syndrome without aortic dilatation	Mild left ventricular impairment (EF > 45%) Hypertrophic cardiomyopathy Native or tissue valve disease not considered WHO I or IV (mild mitral stenosis, moderate aortic stenosis) Marfan or other HTAD syndrome without aortic dilatation Aorta <45 mm in bicuspid aortic valve pathology Repaired coarctation Atrioventricular septal defect	Moderate left ventricular impairment (EF 30–45%) Previous peripartum cardiomyopathy without any residual left ventricular impairment Mechanical valve Systemic right ventricle with good or mildly decreased ventricular function Fontan circulation. If otherwise the patient is well and the cardiac condition uncomplicated Unrepaired cyanotic heart disease Other complex heart disease Moderate mitral stenosis Severe asymptomatic aortic stenosis Moderate aortic dilatation (40–45 mm in Marfan syndrome or other HTAD; 45–50 mm in bicuspid aortic valve, Turner syndrome ASI 20–25 mm/m², tetralogy of Fallot <50 mm) Ventricular tachycardia	Pulmonary arterial hypertension Severe systemic ventricular dysfunction (EF <30% or NYHA Class III–IV) Previous peripartum cardiomyopathy with any residual left ventricular impairment Severe mitral stenosis Severe symptomatic aortic stenosis Systemic right ventricle with moderate or severely decreased ventricular function Severe aortic dilatation (>45 mm in Marfan syndrome or other HTAD, >50 mm in bicuspid aortic valve, Turner syndrome ASI >25 mm/m², tetralogy of Fallot >50 mm) Vascular Ehlers–Danlos Severe (re)coarctation Fontan with any complication
Risk	No detectable increased risk of maternal mortality and no/mild increased risk in morbidity	Small increased risk of maternal mortality or moderate increase in morbidity	Intermediate increased risk of maternal mortality or moderate to severe increase in morbidity	Significantly increased risk of maternal mortality or severe morbidity	Extremely high risk of maternal mortality or severe morbidity
Maternal cardiac event rate (%)	2.5–5	5.7–10.5	10–19	19–27	40–100
Counselling: Pregnancy advisable	Yes	Yes	Yes	Yes: expert counselling required	No: pregnancy contraindicated: if pregnancy occurs, termination should be discussed
Care during pregnancy	Local hospital	Local hospital	Referral hospital	Expert centre for pregnancy and cardiac disease	Expert centre for pregnancy and cardiac disease
Minimal follow-up visits during pregnancy	Once or twice	Once per trimester	Bimonthly	Monthly or bimonthly	Monthly
Location of delivery	Local hospital	Local hospital	Referral hospital	Expert centre for pregnancy and cardiac disease	Expert centre for pregnancy and cardiac disease

From Regitz-Zagrosek et al. ⁴
ASI, aortic size index; EF, ejection fraction; HTAD, heritable thoracic aortic disease; mWHO, modified World Health Organization; NYHA, New York Heart Association; WHO, World Health Organization.

Table 2. Suggested thromboprophylaxis doses for antenatal and postnatal low molecular weight heparin
Weight	Enoxaparin	Dalteparin	Tinzaparin
<50 kg	2000 IU/day	2500 IU/day	3500 IU/day
50–90 kg	4000 IU/day	5000 IU/day	4500 IU/day
91–130 kg	6000 IU/day^a	7500 IU/day	7000 IU/day^a
131–170 kg	8000 IU/day^a	10 000 IU/day	9000 IU/day^a
>170 kg	60 IU/kg/day^a	75 IU/kg/day	75 IU/kg/day^a
High prophylactic dose 50–90 kg	4000 IU b.i.d.	5000 IU b.i.d.	4500 IU/day

From the Royal College of Obstetricians and Gynaecologists, Green-top Guideline 37a (https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf).
^aMay be given in two divided doses.

Table 3. Anticoagulation in mechanical valves and target international normalized ratio for mechanical prostheses
Thrombogenicity of the prosthesis	Number of patient-related risk factors (mitral or tricuspid valve replacement, previous thromboembolism, atrial fibrillation, mitral stenosis any degree, or LVEF <35%)
Thrombogenicity of the prosthesis	None	≥1
Low (Carbomedics, Medtronic Hall, ATS, Medtronic Open-Pivot, St Jude Medical, On-X, Sorin Bicarbon)	2.5	3.0
Medium (other bileaflet valve with insufficient data)	3.0	3.5
High [Lillehei-Kaster, Omniscience, Starr-Edwards (ball and cage), Bjork-Shiley, other tilting disc valves, any pulmonary valve prosthesis]	3.5	4.0