Women with congenital heart disease are at increased risk of complications during pregnancy due to the hemodynamic changes that occur. The risks depend on the type of heart defect and whether it involves cyanosis or pulmonary hypertension. While advances in treatment have improved survival, pregnancy remains risky especially for those with Eisenmenger syndrome or cyanotic heart disease with low oxygen saturation. Close monitoring during pregnancy is important to reduce maternal and fetal risks such as heart failure, arrhythmias, thromboembolism, preterm birth and growth restriction of the baby.

1. Risk of pregnancy in women with
congenital heart disease
Ng Soo Khai
Med IV

2.  Number of women with congenital heart
disease reaching childbearing age is
growing owing to advances in medical and
surgical treatment
 Despite these advances, congenital heart
disease remains an important cause of
maternal mortality and morbidity during
pregnancy
 2nd leading cause of maternal mortality
(second to suicide)

3. CHD
Acyanotic
 ASD
 VSD
 PDA
Cyanotic
 Tetralogy of Fallot
 Tricuspid atresia
 Transposition of great vessel
 Persistent truncus arteriosus
 Others

4. Adaptations in pregnancy
 Imposes strain on heart and
circulation leading to cardiorespiratory
adaptations
 Rise in intravascular volume resulting
in raise cardiac output by 50% during
the 1st and 2nd trimester
 Reduction in systemic vascular
resistance with fall in blood pressure
 Results in deterioration in women with
CHD

5.  Hypercoagulable state – increase in
Vit K dependent clotting factors and
reduction in protein S
 Increased in thromboembolic risk from
uterus compression on IVC resulting
in lower extremity venous stasis

6. Risks to mother
Cardiac complications
 Symptomatic arrhythmia
 Congestive heart failure
 Cardiovascular event
 Endocarditis
Obstetrical complications
 Thromboembolic complications
 Pre-eclampsia
 Postpartum hemorrhage

7.  Arrhythmia - mostly supraventricular
origin. Higher risk in
TGA, AVSD, Fontan repair
 Heart failure - mostly in cyanotic heart
disease, Eisenmenger syndrome, and
PAVSD
 Cardiovascular events such as
MI, stroke are seen mostly in those
with Eisenmenger
 Endocarditis – during labor and
delivery. Simple ASD appear to be a
greater risk.

8.  Thromboembolic complications –
substantially higher than normal
population
A study of 688 pregnant women with CHD,
incidence of thromboembolic events:
- 2% in CHD compare to
- 0.05-0.10% in normal pregnancy
 Preeclampsia - cluster in patients with
aortic coarctation, PS, PAVSD, and
TGA.

9. Risks to fetus
 Spontaneous abortion
 Premature birth
 Intrauterine growth restriction (IUGR)
 Fetal & perinatal mortality
 Congenital heart disease

10.  Premature birth – rate of 16%, higher
than generally population 10%
 Fetal and perinatal mortality - ~4% in
CHD compare to <1% in normal. As
high as 27% in Eisenmenger
 Recurrence of CHD - risk is higher
- 5.7% if mother had CHD
- 2.2% if the father had CHD

11.  Predictors for maternal and fetal
complications :
- Pulmonary hypertension
- Maternal cyanosis
- Preconception history of adverse
cardiac events eg MI, arrhythmia, TIA
- Left heart obstruction (mitral valve
area <2cm, aortic valve <1.5cm)

12.  New data shows no increase risk in
maternal mortality in women with CHD
uncomplicated by Eisenmenger’s
syndrome.
 Only mothers with Eisenmenger’s
syndrome have substantial mortality
during pregnancy of 10-30%

13. Pulmonary Hypertension
 most serious risk especially Eisenmenger
syndrome
Eisenmenger syndrome
 reversal of shunt in the setting of initial left-to-
right shunt due to development of pulmonary
hypertension
 drop in systemic resistance that accompanied
pregnancy amplify the shunt reversal
 body cannot compensate such short term
changes
 severe and potentially fatal hypoxemia during
pregnancy or postpartum period

14.  poorly tolerate the hemodynamic
changes associated with pregnancy
and susceptible to complications like
preeclampsia and postpartum
hemorrhage
 50% - preterm delivery and fetal
growth retardation
 Only 15-25% progress to full term
 Pregnancy is contraindicated in
women with Eisenmenger syndrome

15. Cyanosis
 Arterial oxygen saturation before pregnancy –
important predictor
Data from 104 pregnancies in 74 women with
CHD:
- 90% with cyanotic CHD
- 19% with acyanotic CHD had significant
postpartum complications
 Arterial O2 saturation below 80% increases the
risks
 No evidence that high sat O2 administration
benefits the mother

16.  Mother with cyanotic CHD without
pulmonary hypertension, maternal risk
is low but fetal risk is high.
96 pregnancies of cyanotic CHD:
 43% live birth, 37% of which were
premature
 Mean weight of full term infants –
2.5kg compare to normal 3.5kg

17.  One recent study reported a 12%
likelihood of a livebirth when the
arterial oxygen saturation at rest was
< 85%;
 Livebirth rate improved to 63% when
the oxygen saturation was > 85%.

19.  Review of most retrospective reports from
1985-2006 that described the outcomes of
2491 pregnancies in women with CHD:
- Cardiac complications in 11%
- 5% - heart failure
- 4.5% - arrhythmias
- 15% miscarriage
- 5% chose to terminate pregnancy
- 16% premature birth
- 4% small for gestational age
- 2.3% perinatal mortality
- 1.7% fetal mortality

20. THE END
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