30th June 2023

Cardiovascular disease

Cardiovascular disease is the leading indirect cause of maternal death in the UK. The physiological changes of pregnancy can have a significant impact on pre-existing conditions, as well as resulting in new-onset symptoms.

The reduction in colloid osmotic pressure significantly increases the risk of pulmonary oedema in the presence of increased preload or increased capillary permeability due to conditions like pre-eclampsia.

Hypertension

The first line option in pregnancy is labetalol; women with chronic hypertension should be changed from ACE inhibitors and ARBs prior to conception. Thiazide and thiazide-like diuretics should also be avoided. Women on other antihypertensive treatments should be advised that there is no evidence of an increased risk of congenital malformation.

Target BP should be <135/85 if medicated. Treatment should be started if BP >140/90.

Chronic hypertension carries an increased risk of pre-eclampsia and growth restriction, so women should be advised to take aspirin 150mg until 36/40 and have growth scans from 28/40.

Ischaemic heart disease

Risk factors for ischaemic heart disease in pregnancy include increased parity as well as the usual risk factors. The risk is highest in the third trimester and peripartum. Atherosclerotic lesions are still the most common cause however the incidence of coronary artery dissection is increased compared to the non-pregnant population. The left anteriorly descending (LAD) is the most common site of dissection, followed by the right coronary artery (RCA) and the circumflex artery.

In most situations, the management of acute coronary syndrome is the same as non-pregnancy; pregnancy and recent delivery by caesarean are not contraindications for primary percutaneous coronary intervention or thrombolysis. Clopidogrel is normally used as an alternative to newer antiplatelet agents.

Adult congenital heart disease

More women are choosing to become pregnant after a diagnosis of congenital cardiac disease. The majority of women will have had successful surgery in childhood and have no long-term sequelae from their treatment. Baseline function assessments, including an echo, are helpful in risk stratification.

The presence of pulmonary hypertension is a significant risk factor for severe morbidity and mortality regardless of underlying aetiology.