Pregnancy from the Heart – Heart Problems during Pregnancy

Until several decades ago, women who suffered from even mild heart problems or diseases were counseled to abstain from pregnancy due to the risk that the pregnancy could possibly exacerbate their conditions, and even lead to death. In 1950s and 1960s, for example, women suffering from mitrial valve stenosis attributed to juvenile arthritis (a common defect of the left atrioventricular valve) and women with mild to moderate disorder were prohibited from becoming pregnant. If they did become pregnant, they were forced to abort.

"This is only one example when heart problems, some of which were common, were used as a reason to prevent women from experiencing pregnancy," explained Dr. Avraham Shotan, Director of the Cardiology Department at Hillel Yaffe Medical Center, who has spent many years advising women on heart and pregnancy issues. "Today, relying on the knowledge that has been gained, pregnancy and childbirth can be safe in most cases, relying on monitoring and drug therapy that does not endanger the mother or unborn child. At the same time, since knowledge in this field is lacking, some doctors are still naturally inclined to adopt a conservative approach with these women by presenting a high level of risk to women and their husbands prior to pregnancy, and occasionally recommending termination of pregnancy for women with heart conditions, even if the condition is stable and the level of risk is not high."

Who might suffer from heart problems during pregnancy?
The large majority of women who are referred to cardiologists during pregnancy are healthy. Even healthy women, during a normal pregnancy, might develop complaints typical of heart patients, such as strong heart beats, tachycardia, shortness of breath, fatigue or findings in physical examinations of heart murmurs or mild edema in the legs. These, as previously mentioned, are complaints and findings frequently observed in pregnancy in a healthy pregnant woman, and they generally disappear after birth. In a normal pregnancy, blood volume and plasma in the woman's body increases between 30%-50%, and in a pregnancy with twins, it is even higher. The pregnant woman, even if healthy, copes with significant load that causes her complaints.

"These complaints should be addressed, and these women should be monitored during pregnancy to make sure that the condition hasn't progressed or deteriorated enough to trigger a "real" cardiac disease."

For example: tachycardia is experienced by 60% of the healthy population and in 90% of those involved in sports. During pregnancy, tachycardia increases. In most cases, women do not even notice it, but occasionally the sensation is unpleasant and even frightening. When dealing with a healthy heart, no treatment is necessary, other than when the complaint is that the feeling is intolerable. Even then, treatment only involves alleviation of symptoms.

Despite the aforementioned, there are significant heart problems that must be addressed and even treated during pregnancy. About 1% of pregnant women suffer from preexisting heart disease or a disease that develops during pregnancy. Toxemia, hypertension, heart failure and the like may occur during pregnancy and remain even after childbirth. Hypertension, particularly when it develops into pre-eclampsia or toxemia, is condition that threatens the life of the mother and unborn child. The condition must be treated immediately upon diagnosis. Serious cases may require hospitalization.

Although most cases of arrhythmia do not require treatment, on occasion there are significant complaints that require treatment and even a visit to the ER or hospitalization.

Heart failure attributed to pregnancy primarily occurs towards the end of pregnancy or during the first months after childbirth. It is a relatively rare occurrence that is diagnosed in 1 of every 3,000 pregnant women. In most cases, the heart failure passes within days or several months as heart function recovers. In some cases, however, the heart remains damaged, and its function deteriorates to the point at which a heart transplant is required and, on rare occasions, results in death. "Unfortunately," explained Dr. Shotan, "We do not currently have tools to predict which women might contract this disease, with the possible exception of a multiple pregnancy, in which the incidence is higher, but still rare."

How is pregnancy in women who suffer from chronic heart disease handled?
Women of childbearing age who suffer from various heart conditions fall into several main categories, based on the heart disease. Heart disease comes in varying degrees of severity such as hypertension, heart valve disease, coronary disease, congenial heart defect, arrhythmia or cardiomyopathy. Since these women frequently need regular drug therapy, in addition to the increased risk posed by pregnancy, the unborn child faces increased risk of the effect of the drug the woman is taking.

In this respect, Dr. Shotan emphasizes the importance of prenatal counseling before any decision made by the woman or couple. What is the risk of progression of the disease? Can drug therapy continue during pregnancy? Some drugs cannot be taken during pregnancy. Is there an alternative treatment?

"My approach is to allow the pregnancy, even under complicated heart conditions. Prenatal counseling allows for suitable preparation that will help the woman experience a safe pregnancy and prevent harm to the unborn child and mother."

During the counseling stage, the risk to the mother and fetus is considered, as is the question of whether the pregnancy endangers the life of the mother. We also examine whether the mother requires additional treatment. For example, a patient with stable moderate valve disease might experience a progression of the disease due to the added load of pregnancy, resulting in heart failure. Here it is important to consider whether the valve problem can possibly be corrected before the woman becomes pregnant.

Additional aspects reviewed include possible anemia, iron deficiency, need for surgery during pregnancy, caesarean section option and more. All of these factors are considered by OB/GYN specialists, anesthesiologists, cardiologists, etc. – on needed, and are decisively important in the entire process.

During the pregnancy monitoring, which generally speaking is not much different than the monitoring of a healthy pregnant mother, attention should be paid to when symptoms increase beyond normal range and when drug treatment, surgical intervention or, on rare occasions, even termination of pregnancy, might become necessary. Medical monitoring includes a physical examination and echocardiograph monitoring to determine whether the heart disease has progressed.    

During the delivery itself, close monitoring and pain management for the woman's disease is required. For example: if the decision is made to perform a C-section on the woman rather than a vaginal delivery, the anesthesiologist must adjust treatment in surgical anesthesia to the mother's basic disease. From a cardiological perspective, the decision as to whether the mother will undergo surgery using existing monitoring devices or whether a special catheter is inserted into the heart to accurately measure the pulses during surgery and birth.

Dr. Shotan said, "Although significant improvements in knowledge and treatment of heart disease have been made over the past several decades in terms of pregnancy and birth, there are conditions which, unfortunately, preclude some women with heart disease from becoming pregnant in order to prevent endangering their health. At the same time, the trend is definitely to allow most women suffering from heart problems to experience pregnancy and childbirth, while emphasizing the risks involved.