Heart Failure in Pregnancy

Abstract

Cardiovascular mortality remains an important cause of maternal mortality other than the obstetric direct causes. Most cardiovascular deaths occur due to heart failure. Rheumatic heart diseases (RHD) account for more than two-thirds of heart diseases in pregnancy in low–middle income countries. Among RHD patients, 49% of patients with severe mitral stenosis, 31% with moderate mitral stenosis, and 23% with moderate to severe mitral regurgitation present with heart failure during pregnancy. In the U.K. registry, 25% of patients had heart failure due to cardiomyopathy. Congenital heart diseases such as atrial septal defect with severe pulmonary hypertension, significant atrioventricular valve regurgitation, peripartum, or dilated cardiomyopathy are less common causes of heart failure in pregnancy. Coronary artery diseases usually present as acute coronary syndromes during pregnancy, and heart failure as presentation is a rare occurrence. Preeclampsia and chronic hypertension can lead to increased vascular resistance, diastolic dysfunction, acute pulmonary edema, and acute heart failure. Two-thirds of heart diseases are diagnosed during the antepartum period itself. Preconception counseling, optimal medical therapy and avoidance of teratogens, and planning interventional or surgical therapies in patients with severe or moderate valvular diseases and congenital heart diseases will enable patients to enter the pregnancy well compensated. During pregnancy and postpartum, close surveillance and a multidisciplinary approach involving the obstetrician, cardiologist, physician, and anesthetist will lead to better maternal and fetal outcomes.