Women with previous myocardial infarction need counseling about future pregnancy. Although there is limited evidence on the recurrence risk of acute coro- nary syndrome during pregnancy in this subgroup, the maternal mortality seems to be low.[ 32 ] Impaired left ventricular function is one of the main determinants of maternal and neonatal outcome. No reviews are avail- able that indicate a cut-off value for a left ventricular
ejection fraction below which pregnancy is contraindi- cated in this group of patients. An echocardiographic ejection fraction >40% with an appropriate rise in blood pressure during exercise may suggest a good pregnancy outcome although complications can still occur. If the ejection fraction is <30% with increased left ventricular dimensions, then pregnancy should be strongly discouraged .[ 11 ]
Pregnant women with heart disease, and their close relatives, should receive general advice before conception. Recommendations should include smok- ing cessation and limiting alcohol intake, and advice regarding medication. Th e use of any medication in pregnancy and during lactation requires consideration of the safety and tolerability for the fetus: discontinu- ation of potentially harmful medication or a switch to a “safer” drug should be discussed before conception.
When ACE inhibitors and/or angiotensin II inhibitors are being used, stopping this medication and perform- ing an echocardiography and stress test aft er 3 months is advised before conception. Th e results can inform further discussions about the wisdom of going ahead with pregnancy. Th e physiological maternal changes during pregnancy may lead to altered pharmaco- dynamics; thus, dose adjustment may be necessary for some drugs (e.g. digoxin) .
Women should be advised during pregnancy to restrict salt and fl uid intake and to weigh themselves reg- ularly. In the event of sudden unexpected weight gain, the woman should be aware that fl uid retention due to heart failure or preeclampsia might be developing. Serial echocardiographic evaluation should be performed.
Particular attention should be paid to the recogni- tion of ventricular arrhythmias during pregnancy and the peripartum. Most antiarrhythmic drugs can be pre- scribed safely in pregnancy; nevertheless, every eff ort should be made to diagnose a treatable cause before conception and initiation of antiarrhythmic therapy.
Antiarrhythmic drugs typically cross the placenta;
thus, their potential fetotoxicity should be taken into consideration, particularly during the fi rst trimester of pregnancy .[ 32 , 33 ]
References
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Heart Disease and Pregnancy, 2nd edn. ed. Philip J. Steer and Michael A. Gatzoulis. Published by Cambridge University Press.
© Cambridge University Press 2016.
Antenatal Care: Specifi c Maternal Conditions
Section 4 Chapter
Practical practice points
1. Timely restoration of sinus rhythm is strongly advisable in pregnant women with tachyarrhythmias and underlying heart disease.
2. Most therapies such as catheter ablation and antiarrhythmic drugs are relatively safe in pregnancy; amiodarone should be avoided in breastfeeding women because it is secreted at high levels in breast milk.
3. Direct current cardioversion is safe, although attention should be paid to airway management because of the risk of aspiration/regurgitation of gastric contents; care should also be taken to avoid the supine position because of its accompanying risk of aortocaval compression. Fetal monitoring is advisable because rare cases of fetal bradycardia have been reported aft er direct current
cardioversion .