1st April 2003
European Society of Cardiology
Summary, Abstract,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

To provide recommendations for the management of cardiovascular disease during pregnancy

TARGET POPULATION

Pregnant women with cardiovascular disease(s) and women with cardiovascular diseases who are considering pregnancy

INTERVENTIONS AND PRACTICES CONSIDERED

Congenital Heart Disease

Diagnostic Assessments/Evaluation

1. Electrocardiography
2. Risk assessment, based on New York Heart Association classification and underlying condition
3. Monitoring of oxygen saturation and systemic blood pressure
4. Foetal echocardiography
5. Foetal cardiac assessment

Treatment/Management

1. Termination of pregnancy
2. Restriction of physical activity
3. Supplemental oxygen
4. Low-molecular-weight heparin prophylaxis
5. Balloon valvotomy
6. Cardiopulmonary bypass
7. Genetic counseling preconception with genetic assessment
8. Surgical correction of coarctation of the aorta prior to pregnancy
9. Intraatrial repair for transposition of great arteries
10. Discontinuation of angiotensin-converting enzyme (ACE) inhibitors
11. Use of antiarrhythmic agents (e.g., quinidine, verapamil, beta blockers, amiodarone
12. Emergency DC cardioversion
13. Betamethasone administration for foetal lung maturation
14. Timing and mode of delivery (spontaneous delivery, induction of labor, caesarean section)

Marfan Syndrome and Other Inherited Conditions

Diagnostic Assessments/Evaluation

1. Regular echocardiography before, during, and after pregnancy
2. Genetic testing through chorionic villus biopsy, amniocentesis cell culture, or postnatal testing
3. Physical, echocardiographic, and ophthalmologic examination of newborns

Treatment/Management

1. Surgical repair of aortic dissection
2. Control of hypertension and arrhythmia
3. Beta blocker therapy
4. Counseling of high risk patients on alternatives to pregnancy

Acquired Valvular Disease

Diagnostic Assessments/Evaluation

1. Echocardiographic evaluation

Treatment/Management

1. Beta blockers in severe mitral stenosis
2. Vasodilators in regurgitant valve disease
3. Diuretics
4. Percutaneous mitral valvotomy
5. Open heart surgery
6. Use of vitamin K antagonists or other anticoagulant therapy (e.g., heparin, warfarin, low-molecular-weight heparin)
7. Planning of mode of delivery

Coronary Artery Disease

Diagnostic Assessments/Evaluation

1. Exercise testing

Treatment/Management

1. Beta blockers
2. Calcium antagonists
3. Percutaneous interventions
4. Coronary angiography with stenting
5. Genetic counseling

Peripartum or Dilated Cardiomyopathy

Diagnostic Assessments/Evaluation

1. Echocardiography

Treatment/Management

1. Therapy for heart failure
2. Counseling to avoid pregnancy
3. Termination of pregnancy
4. Hospitalization

Hypertrophic Cardiomyopathy

Diagnostic Assessments/Evaluation

1. Echocardiography
2. Electrocardiography, including ambulatory electrocardiography
3. Exercise testing

Treatment/Management

1. Genetic counseling
2. Beta blockers
3. Diuretics
4. Anticoagulation in the presence of atrial fibrillation
5. Amiodarone
6. DC reversion
7. Normal delivery

Infective Endocarditis

Treatment/Management

1. Antibiotic prophylaxis, with monitoring of gentamicin levels (if used)
2. Surgery

Arrhythmias

Treatment/Management

1. Vagal stimulation
2. Intravenous adenosine
3. Radiofrequency ablation for atrioventricular (AV) ablation
4. Antiarrhythmic drugs including, verapamil, sotalol, amiodarone, and beta-1 selective beta blockers
5. Monitoring of antiarrhythmic blood levels
6. Internal cardioverter defibrillator
7. Pacemaker implantation

Hypertensive Disorders

Diagnostic Assessments/Evaluation

1. Blood pressure monitoring
2. Evaluation of proteinuria

Treatment/Management

1. Antihypertensive drugs, including methyldopa; beta blockers (e.g., atenolol, labetalol, metoprolol, pindolol, oxprenolol); calcium channel blockers (e.g., nifedipine); clonidine, diuretics); hydralazine. (Note: ACE inhibitors are contraindicated in 2nd and 3rd trimesters)
2. Magnesium sulfate for severe preeclampsia and eclampsia
3. Steroids for foetal lung maturation
4. Close maternal and foetal surveillance
5. Antioxidants

MAJOR OUTCOMES CONSIDERED

• Pregnancy outcome
• Maternal mortality and morbidity
• Foetal mortality and morbidity
• Risk from complications such as pulmonary embolism, arrhythmias and stroke