The following are key points to remember from an American Heart Association Scientific Statement about cardiovascular considerations in caring for pregnant patients:

1. Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States and has gradually increased over time. Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of CVD during pregnancy.
2. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Furthermore, advancing maternal age and pre-existing comorbid conditions have contributed to the increased rates of maternal mortality.
3. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with pre-existent cardiac conditions or history of pre-eclampsia. Early and specialized multidisciplinary care in the antepartum, peripartum, and postpartum time frames is essential to improve cardiovascular outcomes and to reduce maternal mortality up to the first year postpartum. A general understanding of CVD during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians.
4. For severe hypertension during pregnancy, treatment with intravenous labetalol or intravenous hydralazine is typically recommended. Less severe hypertension can be managed with labetalol, nifedipine, and methyldopa, which are commonly used as first-line antihypertensive medications. Regarding hyperlipidemia, statins are contraindicated during pregnancy, and all women who are on any lipid-lowering agents should review with their physician the safety of treatment during pregnancy and whether to discontinue treatment during pregnancy.
5. Treatment of heart failure during pregnancy is directed at controlling volume status (e.g., diuretics), afterload reduction (e.g., nitrates, hydralazine), rhythm control (e.g., beta-blockers, digoxin), and anticoagulation if necessary.
6. For stroke prevention in patients with valvular heart disease or high stroke risk during pregnancy, vitamin K antagonists can be used after the first trimester, whereas low-molecular-weight heparin (LMWH) should be accompanied by periodic evaluation of anti–factor Xa. Regardless of pathogenesis and prior treatment, women with a history of valvular heart disease should undergo preconception evaluation by the cardio-obstetrics team. Safety and potential risks should be discussed before pregnancy, including in those with mechanical prosthetic valves or moderate to severe native regurgitant or left-sided stenotic valvular lesions and those with associated ventricular dysfunction or pulmonary hypertension.
7. Intravenous unfractionated heparin (UFH) is recommended for acute pulmonary embolism and for deep vein thrombosis with large clot burden, for hemodynamic instability, and when surgery or delivery is anticipated. In stable patients, LMWH is preferred over UFH.
8. Intravenous thrombolysis in acute ischemic stroke of the pregnant patient is still considered a relative contraindication in the absence of disabling deficits; however, retrospective studies have found it to be safe.
9. Contemporary approaches to labor and delivery favor spontaneous labor and vaginal birth for the majority of women with heart disease in pregnancy. Current guidelines recommend elective induction of labor for pregnant women with cardiac disease between 39 and 40 weeks of gestation in patients who do not have spontaneous onset of labor or clinical indications for preterm delivery.
10. Finally, the peripartum/postpartum visit offers an excellent time to discuss the possibility of future pregnancy, contraception, follow-up needs, and the likelihood of late cardiovascular risk.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Homozygous Familial Hypercholesterolemia, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Hypertension

Keywords: Anticoagulants, Antihypertensive Agents, Arrhythmias, Cardiac, Heart Failure, Heart Valve Diseases, Heparin, Heparin, Low-Molecular-Weight, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hyperlipidemias, Hypertension, Maternal Mortality, Myocardial Infarction, Obstetrics, Pregnancy, Primary Prevention, Stroke, Thromboembolism, Vascular Diseases

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