Acute Cardiovascular Complications in Pregnancy

Assenza GE, Dimopoulos K, Budts W, et al.
Management of Acute Cardiovascular Complications in Pregnancy. Eur Heart J 2021;Aug 18:[Epub ahead of print].

The following are key points to remember from this state-of-the-art review on management of acute cardiovascular complications in pregnancy:

  1. 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 fetal complications.
  2. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and fetal health. Cardiovascular pathology is the leading cause of nonobstetric morbidity and mortality during pregnancy in developed countries.
  3. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence.
  4. For women with pre-existing cardiac conditions, preconception counseling, 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.
  5. However, many women do not receive prepregnancy counseling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including heart failure, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events.
  6. All women with suspected heart failure should be referred to an expert center with an established multidisciplinary pregnancy and heart disease team, with a surgical and mechanical circulatory/transplant program as back-up.
  7. The management of acute coronary syndromes (ACS) in pregnancy is similar to the general population. Fetal monitoring and a multidisciplinary approach are essential. The indications for acute revascularization are similar to nonpregnant patients with ACS.
  8. Caesarean delivery does not generally afford protection to pregnant women with cardiovascular disease and is usually associated with increased risk of infection and bleeding; however, it may offer benefits with respect to timing, care coordination, and the management of the anticoagulation regimen. Caesarean delivery is recommended for the fully anticoagulated woman who presents in labor, primarily due to concerns of fetal bleeding during vaginal delivery.
  9. Women with high-risk aortopathies and aortic dilatation, symptomatic heart failure (e.g., severe left/systemic ventricular dysfunction), symptomatic aortic stenosis, refractory arrhythmias with hemodynamic instability, or pulmonary arterial hypertension may benefit from the faster delivery offered by caesarean section, but many of these women can also deliver safely via vaginal birth in the proper setting.
  10. Finally, care of individuals with cardiovascular complications during pregnancy should be provided in centers with an established multidisciplinary pregnancy and heart disease team. General cardiologists and emergency physicians encountering such patients in an emergency or acute setting should seek prompt advice and support from tertiary referral centers to initiate appropriate treatment and transfer the patient when safe.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Anticoagulation Management and ACS, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Pulmonary Hypertension

Keywords: Acute Coronary Syndrome, Anticoagulants, Aortic Valve Stenosis, Arrhythmias, Cardiac, Cesarean Section, Counseling, Delivery, Obstetric, Dilatation, Fetal Monitoring, Heart Defects, Congenital, Heart Failure, Hemodynamics, Hypertension, Pulmonary, Pregnancy, Pregnancy, High-Risk, Pregnant Women, Primary Prevention, Risk, Thrombosis, Ventricular Dysfunction, Left, Women

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