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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