ESC: Guideline Issued to Treat CVD in Pregnancy
By Todd Neale, Senior Staff Writer,
Published: August 27, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.
Action Points
Explain that the European Society of Cardiology has released guidelines for the management of cardiovascular disease during pregnancy, although most of the recommendations are based on small studies, retrospective data, registries, expert consensus, or a combination.
Point out that the guidelines recommend pre-pregnancy risk assessment and counseling in all women with known or suspected congenital or acquired cardiovascular and aortic disease.
PARIS -- Despite a dearth of prospective, randomized data, the European Society of Cardiology has released guidelines for the management of cardiovascular disease during pregnancy.
Because of the lack of evidence, most of the recommendations are classified as level C, meaning that they are based on small studies, retrospective data, registries, expert consensus, or a combination.
They were crafted by the ESC's task force on the management of cardiovascular diseases during pregnancy -- chaired by Vera Regitz-Zagrosek, MD, of Charité Universitaetsmedizin Berlin -- and published online in the European Heart Journal before the start of the society's annual meeting here. The guidelines will be formally introduced later in the meeting.
Even though a small fraction of pregnancies in developed countries -- 0.2% to 4% -- are complicated by cardiovascular diseases, "knowledge of the risks associated with cardiovascular disease during pregnancy and their management are of pivotal importance for advising patients before pregnancy," the authors wrote.
They added that heart disease is the leading cause of maternal death during pregnancy.
Regitz-Zagrosek and colleagues noted that the guidelines come at a time when the risk of cardiovascular disease in pregnant women is growing as a result of increasing age at first pregnancy and higher rates of diabetes, hypertension, and obesity.
Also contributing are improvements in the treatment of congenital heart disease, which allows more women to reach reproductive age. In western countries, congenital heart disease accounts for 75% to 82% of cases of cardiovascular disease during pregnancy.
There are particular considerations surrounding the treatment of cardiovascular disease in pregnant women, according to the authors, because of the physiological changes that occur during gestation.
Pregnancy leads to increased blood volume and cardiac output; reductions in systemic vascular resistance and blood pressure; and a higher risk of thromboembolic events. In addition, some changes affect the absorption, excretion, and bioavailability of medications.
The guidelines detail screening for heart disease in pregnant women, assessing risk, and counseling.
Although there are multiple methods for assessing the risk of cardiovascular events in pregnant women, the authors recommended using the World Health Organization risk classification, which takes into account all known maternal cardiovascular risk factors, including underlying heart disease and comorbidities.
According to this system, as risk increases, so does the frequency of the recommended follow-up visits during pregnancy. The guidelines state, however, that women at the highest risk should be advised against pregnancy altogether. If pregnancy occurs, termination should be discussed, but if gestation continues, the woman should be followed monthly or bimonthly, the authors wrote.
Contraindications to pregnancy in this classification include:
Pulmonary arterial hypertension of any cause
Severe systemic ventricular dysfunction
Previous peripartum cardiomyopathy with any residual impairment of left ventricular function
Severe mitral stenosis
Severe symptomatic aortic stenosis
Marfan syndrome with the aorta dilated more than 45 mm
Aortic dilatation greater than 50 mm in aortic disease associated with bicuspid aortic valve
Native severe coarctation
The guidance includes both general recommendations and more specific advice for certain groups -- those with congenital heart disease, aortic disease, valvular heart disease, coronary artery disease and acute coronary syndromes, cardiomyopathies and heart failure, arrhythmias, hypertensive disorders, or venous thromboembolism.
The class I general recommendations (all level C evidence) are as follows:
Pre-pregnancy risk assessment and counseling is indicated in all women with known or suspected congenital or acquired cardiovascular and aortic disease.
Risk assessment should be performed in all women with cardiac diseases of childbearing age and after conception.
High-risk patients should be treated in specialized centers by a multidisciplinary team.
Genetic counseling should be offered to women with congenital heart disease or congenital arrhythmias, cardiomyopathies, aortic disease, or genetic malformations associated with cardiovascular disease.
Echocardiography should be performed in any pregnant patient with unexplained or new cardiovascular signs or symptoms.
Before cardiac surgery, a full course of corticosteroids should be administered to the mother whenever possible.
The same measures used in non-pregnant patients should be used in pregnant patients for the prevention of infective endocarditis.
Vaginal delivery is recommended as the first choice in most patients.
The single class III (level C) general recommendation advises against the use of prophylactic antibiotic therapy during delivery.
The guidelines conclude with a section on the use of cardiovascular drugs during pregnancy and breastfeeding, although there are no specific recommendations regarding treatment.
"In case of emergency, drugs that are not recommended by the pharmaceutical industry during pregnancy and breastfeeding should not be withheld from the mother," the authors wrote. "The potential risk of a drug and the possible benefit of the therapy must be weighed against each other."