Though all women are strongly encouraged to seek prenatal medical care as soon as they become pregnant, it is especially important for women with  heart-related conditions. These women are  urged to consult a physician and other qualified healthcare professionals prior to becoming pregnant to discuss possible complications. Heart-related conditions that may be of concern to mothers-to-be  include:  

Even a normal pregnancy places extraordinary demands on the heart. For example, cardiac output, or the amount of blood pumped by the heart, may increase 30 to 50 percent during the latter stages of a pregnancy. During labor and delivery, it may increase by 80 percent. Similarly, the maternal heart rate increases by 15 to 20 beats per minute. As a result of these changes, existing heart disease may be aggravated or new heart conditions may develop.

There is also the possibility that the fetus is at increased risk for heart complications. For example, some heart defects appear to run in families. A baby born to a parent (male or female) who has a heart condition has an increased chance of having congenital heart disease. It has also been shown that a family history of early heart disease on the mother’s side increases the risk for delivering a low birthweight baby.

Women with heart disease are strongly encouraged to work closely with their physicians before and during their pregnancy. Before pregnancy, all heart patients should obtain a full check-up, which includes a medical history, physical examination, echocardiogram and electrocardiogram. These tests will measure the function of the heart and establish and important baseline for the physician to use during the pregnancy. During the pregnancy, the expectant mother should be monitored by her physicians and closely follow all instructions. Medications may be altered, lifestyle changes may be recommended and fetal monitoring (e.g., ultrasound) may be increased. Issues to consider for the patient and child by the physicians include:

• Abnormal heart rhythms (arrhythmias)
  
  
• Problem with the pumping chambers of the heart (ventricles)
  
  
• The need for maintenance with medication, including antibiotics and anticoagulants

Some heart-related conditions carry greater dangers for the mother and/or the child. Expectant mothers are encouraged to work with their physicians to determine which approach (e.g., medication or bed rest) is the most appropriate. Studies show that good prenatal care, which includes close physician participation throughout the pregnancy, increases the chances of a healthy mother and baby.

Pregnancy causes wide-ranging and profound changes in the expectant mother’s cardiovascular and circulatory system. For example, during the later stages of pregnancy, cardiac output increases between 30 and 50 percent. During labor, the mother’s cardiac output increases up to 80 percent. This increase is connected to the greater volume of blood circulating in the mother’s body and her increased heart rate, which is typically increased by 15 to 20 beats per minute. Despite the increased blood volume and cardiac output, however, blood pressure typically falls during a healthy pregnancy.

In women with existing heart disease, pregnancy carries extra risks. Their heart disease may become worse, or they may have to stop taking medications to control their disease. For example, statin medications, which are used to lower cholesterol, and ACE inhibitors, which are used to treat heart failure and hypertension, are not recommended during pregnancy. In years past, rheumatic heart disease was the most common cardiac complication among pregnant women. However, because of improved medical techniques that enable more infants to survive to childbearing age, congenital heart disease is now the leading cardiac complication among pregnant women. Also, because more women are postponing childbirth until they are in their 30s or 40s, it is more common to see expectant mothers with high blood pressure, diabetes and elevated cholesterol levels.

Any cardiac condition is a cause for concern, and heart patients who wish to become pregnant, or who are pregnant, are strongly encouraged to consult with their physician. The standard check-up for pregnant heart patients includes a medical history, physical examination, echocardiogram and electrocardiogram. These tests provide the physician with a complete picture of how the expectant mother’s heart and circulatory system are responding to the pregnancy.

If there is concern, bed-rest may be ordered. Studies have shown that the stress placed upon the heart depends in part on the expectant mother’s posture. Lying down can decrease the cardiac output by up to 30 percent. Conversely, however, some heart disease patients are at increased risk for blood clots during their pregnancy. Blood clots are a leading cause of maternal death among all women, but women who have certain inherited conditions, or who have artificial heart valves, are at especially elevated risk. In this case, the physician may recommend standing or sitting in certain positions and staying active to encourage adequate blood flow through the legs, where blood clots normally form.

During delivery, many physicians will allow the expectant mother to go into labor naturally and attempt a vaginal delivery. Studies have shown that vaginal deliveries pose less risk to heart patients than Caesarean deliveries. If, however, the mother is at an elevated risk level, then the physician may recommend inducing labor under controlled circumstances. Overall, a pregnant woman’s risk level from heart disease depends on the nature of the disease. Maternal cardiac conditions that carry the lowest overall risk to the mother and fetus include:

Cardiac conditions that carry moderate risk to the mother and fetus include:

• Narrowing of the aortic valve (aortic stenosis), which may require surgical repair before pregnancy is recommended
  
  
• Narrowing of the mitral valve (mitral stenosis)
  
  
• History of heart attack
  
  
• Marfan syndrome (with a normal aorta)
  
  
• Tetralogy of Fallot (a type of heart defect)
  
  
• Coronary artery disease, which is relatively rare among childbearing women but may result in heart attack
  
  
• Various arrhythmias, which may range from harmless to very dangerous

High-risk conditions include:

• Eisenmenger syndrome (50 percent of these women do not survive pregnancy)
  
  
• Severe forms of cardiomyopathy, especially affecting the left ventricle
  
  
• Peripartum cardiomyopathy (a gestational heart-related condition)
  
  
• Pulmonary hypertension (high blood pressure in the vessels of the lungs)
  
  
• Artificial heart valves that require anticoagulation
  
  
• Heart failure

Various studies have sought to discover the link between cardiovascular disease and any number of birth issues, from birth weight (the lower the birth weight, the higher the chance for heart disease later in life, according to some studies) to breast-feeding (breast-fed babies have a lower risk of heart disease and of impaired insulin function). While the correlations are not always clear, these studies do prove that good prenatal care, which includes close physician participation throughout the pregnancy, increases the chance of having a healthy baby.

Conditions that affect the cardiovascular system and the developing fetus, as well as the pregnant mother, include:

Some conditions may prevent a healthy delivery. Severe forms of cardiomyopathy and pulmonary hypertension, as well as conditions that involve a right-to-left shunt (e.g., Tetralogy of Fallot), all affect the flow and oxygenation of blood. These heart conditions can significantly affect fetal growth and development. Women with any of these conditions should learn about the associated risks of their condition(s) before becoming pregnant.

For all pregnant women, especially those whose pregnancies are considered high-risk, healthy habits and precautions are encouraged. These include:

Women are also encouraged to speak with a cardiologist about which of the four New York Heart Association (NYHA) classifications would best characterize their pregnancy. Women in Class I and Class II are less likely to experience serious complications than women in Class III or Class IV.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to pregnant heart patients:

1. How can I tell if I have a heart condition that could affect my pregnancy?
   
   
2. What diagnostic tests can evaluate my heart condition?
   
   
3. Could my current heart problem interfere with my pregnancy in any way?
   
    
4. What is the best way to monitor my heart condition throughout my pregnancy?
   
   
5. Will I need to be followed by any specialists during my pregnancy?
   
   
6. Are there any lifestyle changes I can make to increase the chances that my heart problem will not interfere with my pregnancy? Do I need to quit smoking?
   
   
7. Could I develop a heart problem as a result of my pregnancy? If so, how will it be detected?
   
   
8. If my pregnancy does cause me to develop a heart condition, will this condition go away after I give birth? How soon?
   
   
9. Am I at higher risk for heart problems based on my family or medical history?
   
   
10. Is there any way to tell if my heart problem is adversely affecting my unborn child?
    
    
11. Will my heart condition affect the delivery of my child in any way? Do you recommend a vaginal birth or a Caesarian section?
    
    
12. Are there any activities I should avoid during my pregnancy?
    
    
13. What are the chances my child will inherit the same heart condition?