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Pregnancy can mask heart disease

OB/GYN News, July 1, 2002 by Kathryn DeMott

HILTON HEAD, S.C. -- The signs and symptoms of a normal pregnancy can mask the presence of cardiac disease, Dr. Carole Warnes cautioned at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Especially in high-risk patients with a known congenital heart condition, the onset of a cough or asthma-like symptoms during pregnancy may actually be an indication of an underlying heart problem growing worse, said Dr. Warnes, a cardiologist at the Mayo Clinic.

She managed such a patient who was near death at 32 weeks' gestation when she was flown to the Rochester, Minn., medical center for emergent care due to severe aortic stenosis.

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Such presentations aren't rare at the clinic, noted Dr. Kirk Ramin, chair of the division of maternal-fetal medicine at the center.

"I've seen too many patients [with valve problems] treated with inhaled steroids and antibiotics," he said.

And it's not just obstetricians who fail to be proactive enough in managing and counseling patients about heart problems in pregnancy. "It's cardiologists, too," Dr. Warnes said.

The patient with aortic stenosis whom Dr. Warnes saw at Mayo was 30 years old and had a history of a heart murmur since childhood, but that condition was never adequately evaluated in the context of her pregnancy. As a result, her physicians misdiagnosed her symptoms of cough and dyspnea as bronchitis instead of recognizing them as pulmonary edema. She was treated with antibiotics.

In the 48 hours before admission at Mayo, she was profoundly dyspneic, arriving in extremis with orthopnea. Her pulse was 120 beats per minute. She was in sinus rhythm with a low-volume pulse. Her blood pressure was 85/60 mm Hg, and she was sitting bolt upright, short of breath, and struggling to speak. A harsh systolic murmur was heard in the aortic area with a third heart sound.

Consistent with the clinical exam, her echocardiogram showed severe aortic stenosis with heavy calcification and a valve area approximately 0.7 [cm.sup.2]. Her peak gradient was 95 mm Hg, and her mean gradient was 50 mm Hg.

She also had aortic regurgitation, and her left ventricle ejection fraction was estimated to be around 36%.

Just 3 weeks earlier, a woman who had been closely followed by cardiologists in a prior pregnancy for aortic stenosis arrived at Mayo at 14 weeks' gestation with a valve area of 0.3 [cm.sup.2], severe dyspnea, a mean gradient of 150 mm Hg, and carrying twins.

After her first pregnancy she had been told that she should probably have a valvo-plasty when she was around 40 years old. No one ever acknowledged that she might get pregnant again or counseled her about subsequent pregnancies.

The good news is that fetuses that make it to about 30 weeks' gestation have a pretty good chance of having favorable outcomes if they are delivered early. By 24-26 weeks' gestation, the fetus is viable. And if it makes it to 30 weeks "we're happy" In fact, once a fetus makes it to 32 weeks' gestation, "our long-term follow-up at 5 years is no different than term infants," Dr. Ramin explained.

Ideally the baby can be delivered before the mother undergoes a cardiac intervention. But that's not always possible, he acknowledged.

In the situation of the case patient, the mother's status was so severe, she probably wouldn't have survived an induction of anesthesia, let alone the blood loss associated with caesarean section delivery. She ended up successfully undergoing an aortic valve replacement before delivery with an obstetric team standing by to deliver the baby by C-section immediately afterward.

Alternatively, sometimes the chest can be opened just before delivery and the cardiac procedure can occur after delivery. In the absence of any data, experts are conflicted about which procedure should occur first.

How should you advise a patient with aortic stenosis seeking prepregnancy counseling?

Patient with mild to moderate stenosis "can usually get through a pregnancy provided that they are managed properly." But it's critical that they have a thorough prepregnancy evaluation, Dr. Warnes said.

And even if they have moderate aortic stenosis "when we see them to evaluate them before pregnancy usually they'll be OK if they're asymptomatic." Yet since many of these patients tend to avoid the very activities that would create symptoms, an exercise stress test is invaluable for sorting out who truly is asymptomatic, she said.

"If they can do more than 90% of their predicted functional aerobic capacity" without ECG wave changes or angina and their ventricular function is good, "usually we can get them through a pregnancy as long as they're compliant," Dr. Warnes said.

In a patient with more severe stenosis, pregnancy should ideally be delayed until the patient has a valvoplasty or valve replacement.

Management is more complicated in the patient who is already pregnant and has new-onset angina or dyspnea, tachycardia, ECG wave changes, or pulmonary edema, or if her left ventricular function or aortic velocity starts to decline.

Health Care Industry

Pregnancy can mask heart disease

OB/GYN News, July 1, 2002 by Kathryn DeMott

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