What you need to know about pregnancy for women with heart conditions

When it comes to planning for a baby, there are several considerations you’ll need to make. One of the most important factors to consider, however, is your health. Unfortunately, it’s also something that can be easily overlooked. Putting your health first – following a balanced diet, exercising regularly, taking daily vitamins and getting a medical checkup – is the best thing you can do for your baby (and yourself) before you get pregnant.

Pregnancy Complications for Women with Heart Conditions

This is especially true for a woman with a pre-existing heart condition (congenital or acquired). During pregnancy, your body makes more blood for your growing baby. As your body adjusts, your heart enlarges, pumping faster and harder, placing additional strain on your heart and circulatory system. So, for an expectant mom with any type of heart condition, the strain and risks to her heart are that much greater.

According to a May 2019 report from the American Congress of Obstetrics and Gynecology (ACOG), maternal heart disease has emerged as a major threat to safe motherhood and women’s long-term cardiovascular health. In the U.S., disease and dysfunction of the heart and vascular system (also known as cardiovascular disease) is now the leading cause of death in pregnant women and women in the postpartum period, accounting for 4.23 deaths per 100,000 live births. The most recent data indicates that cardiovascular diseases constitute 26.5 percent of U.S. pregnancy-related deaths.
 
You may be wondering what’s behind these startling statistics. There are a few contributing factors. First, more women are having babies later in life. There are also increasing rates of obesity, hypertension, and diabetes in the general population, including pregnant women. Unfortunately, these are all major cardiovascular risk factors that are complicating the journey to motherhood for many women.
 
If you have a pre-existing heart condition or heart disease, you’re not alone. Approximately one out of every 150 adults have a congenital heart condition, while more than 30 million Americans have acquired heart disease. The good news is most women with a heart condition or disease can still go on to have healthy pregnancies and deliveries; however, the key is understanding the risks associated with the heart condition and managing it accordingly.
 
That’s why a pre-pregnancy checkup with your OB/GYN a few months before you begin trying to get pregnant is crucial. You and your doctor will discuss any tests or vaccines you’ll need; prenatal vitamins; any medicines you’re currently taking; and how to manage any pre-existing health conditions. You may also be referred to a maternal fetal medicine (MFM) specialist, who handles high-risk pregnancies including those with heart conditions.

Types of Maternal Heart Conditions and Associated Risks

Not all heart conditions cause problems during pregnancy – the risks vary. For example, some conditions carry a greater risk of causing miscarriage, a premature birth or a low-birth-weight baby. So, how do you know your risk level?

According to the World Health Organization, there are four risk categories for maternal heart conditions (congenital and acquired heart disease). If you have any of the following heart conditions, your cardiologist and/or OB/GYN will discuss the associated risks and how to best manage your condition prior to and throughout your pregnancy:

• Class I (very low risk) – Mild pulmonary stenosis; patient ductus arteriosus; or mitral valve prolapse – all of which can cause heart murmurs or shortness of breath; repaired simple lesions such as a hole in the heart; atrial or ventricular ectopic beats
• Class II (low to moderate risk) – Unoperated atrial or ventricular septal defect; repaired tetralogy of Fallot; most arrhythmias (irregular heartbeat)
• Class III (high risk) – Mechanical valve; systemic right ventricle; Fontan circulation; cyanotic heart disease (unrepaired); other complex congenital heart disease; Marfan syndrome with aortic dilatation 40-45 mm
• Class IV (extremely high risk) – Pulmonary arterial hypertension; severe systemic ventricular dysfunction; cardiomyopathy; severe symptomatic mitral or aortic stenosis; Marfan syndrome with aorta dilated >45 mm; aortic dilation >50 mm in aortic disease associated with bicuspid aortic valve; native severe Coarctation

For example, if you have an unrepaired heart defect, your doctor might want to do additional testing and treatment before you get pregnant. This may even include surgically repairing any defects to better protect your heart for future pregnancies. Or, if you’re taking medications for your heart condition, your doctor will need to evaluate all of them to see which are safe to continue during pregnancy. Depending on the risks to the baby, you may need to try a different medication that’s deemed pregnancy-safe or lower risk.
 
Although it’s rare, there are specific heart conditions where pregnancy is not recommended, because the risks are just too great for both mom and baby. These conditions include severe pulmonary hypertension, which is high blood pressure that affects the arteries in the lungs and the right side of the heart; Marfan syndrome with a severely enlarged aorta; severe aortic stenosis; Eisenmenger’s syndrome; and congestive heart failure.

Special Monitoring during Pregnancy and Labor/Delivery

The amount of monitoring you’ll need throughout your pregnancy will depend on your heart condition. If you’re in the low-risk category (class I or II), you may only need to see your cardiologist once or twice during your pregnancy. However, if your condition is classified as class III or IV, you’ll need to see your cardiologist more frequently – perhaps once or twice per month.

As far as monitoring, you may undergo an echocardiogram (echo) and an electrocardiogram (EKG) to ensure your heart is functioning well. Your baby will undergo routine ultrasounds while in utero and possibly a fetal EKG to check for any signs of heart problems. Some congenital heart diseases are genetic, so it’s possible that your baby may develop the same condition. However, the sooner a congenital heart defect is detected, the better, allowing parents and doctors valuable time to prepare a plan.

You can also expect additional monitoring during your labor and delivery, tracking both you and your baby’s heart rates and rhythms for any signs of distress. Instead of lying flat on your back, you may be asked to lie on your side and draw one of your knees toward your chest. Your doctor may also suggest getting an epidural to reduce labor pains, which can create more strain on the heart.
 
For vaginal deliveries, you may be advised to receive support with forceps or a vacuum extractor, limiting the need to push. In other cases, a C-section may be recommended. Following delivery, you and your baby will continue to be monitored closely to be sure you’re recovering accordingly and to watch for any signs of distress.

Beware of the Warning Signs

Certain heart conditions can cause noticeable symptoms during your pregnancy, such as:

• Difficulty breathing
• Shortness of breath with physical activity or when at rest
• Heart palpitations, rapid heart rate or irregular pulse
• Chest pain
• A bloody cough or coughing at night (not due to a cold)

If you experience any of these symptoms or simply feel that something is off, call your OB/GYN or MFM immediately. If you can’t reach your provider, call 911 or go to the emergency room.

The bottom line is many women with pre-existing heart conditions are able to enjoy safe, healthy pregnancies and deliveries. The key is taking certain precautions as recommended by your OB/GYN, MFM and/or cardiologist both before and during the pregnancy to ensure the health and wellbeing of mom and baby. For more information, learn about high-risk pregnancy services at SSM Health St Mary’s Hospital – St. Louis or find a provider near you.