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Pregnancy After Heart Transplant

Just over three decades have passed since the first successful pregnancy in a heart transplant patient, and in the intervening years, several hundred additional cases have been reported. Looking ahead, it is likely that many more heart and heart–lung transplant patients will choose to conceive. Given this reality, we present an overview of pregnancy after heart transplant and discuss the need for prepregnancy counseling, the risks…

Nursing Considerations

Caring for pregnant women with heart disease is a complex undertaking for several reasons. First, neither nurses nor physicians have typically trained, or practiced, in both the obstetric and adult critical care settings. Second, the care of pregnant women always involves two patients, a seldom-experienced situation for nonobstetric nurses and physicians. Third, management of the critically ill obstetric patient requires care directed not only at the…

Assessment of Maternal Risk and Assessment of Fetal Risk

Assessing the risk posed by pregnancy, for both the mother and baby, is an essential component of caring for women with cardiac disease who are considering becoming pregnant as well as for those who are already pregnant. This chapter explores both maternal and fetal risk assessment. Maternal Risk Assessment Whenever possible, risk stratification should occur antenatally, and for women at high risk, who have a lesion…

The Maternal Cardiac Care Team and the Maternal Cardiac Care Facility

Need for Maternal Cardiac Care Programs A maternal cardiac care program requires the marshalling of significant resources, particularly in terms of personnel, space, and equipment. To justify these resources, we advise estimating the number of patients in need of such a program. An estimated 0.2% to 4.0% of pregnancies are complicated by cardiovascular disease. In our program, the prevalence of cardiac disease in pregnant women was…

Cardiac Arrest in Pregnancy

This chapter presents an overview of cardiac arrest in pregnancy and discusses the measures that can be taken to address it: advanced cardiac life support (ACLS), perimortem cesarean section (PMCS), and postarrest targeted temperature management. Overview: Cardiac Arrest in Pregnancy The Centers for Disease Control and Prevention reports the incidence of cardiac arrest in pregnancy at 17 in 100,000 live births. Other sources estimate the incidence…

Cardiac Testing During Pregnancy

Cardiac testing during pregnancy may include one of more of the following: cardiac magnetic resonance imaging (MRI) scan, chest radiography, computed tomography (CT), electrocardiography, graded exercise testing, Holter monitor or other wearable event recorders, implantable loop recorder, radionuclide investigations, stress echocardiography, dobutamine stress echocardiography, transesophageal echocardiography (TEE), and transthoracic echocardiography and Doppler. Each of these is described in this chapter, with an emphasis on its use,…

Anesthesia for Nonobstetric Procedures During Pregnancy

During pregnancy, women may present for nonobstetric surgical procedures, most commonly related to traumatic injury, appendicitis, or cholecystitis. Care must be taken to provide a safe anesthetic for both patients, with maternal stability directly correlating with fetal well-being. Although there are not robust data on which to base anesthetic management, there are numerous cohort studies that point to the safety of anesthesia for surgical interventions that…

Anesthesia for Cardiac Patients During Labor and Delivery

Pregnant women with preexisting cardiac disease provide a unique challenge to anesthesiologists in the peripartum period. Pregnancy-related death has been increasing over the past three decades, and cardiovascular disease is the number one cause of pregnancy-related death in the United States. Caring for this challenging patient population depends on an understanding of the cardiovascular changes associated with pregnancy, effective communication between all members of the care…

Cardiac Effects of Anesthetic Agents That May Be Used in Labor and Delivery

With the increasing number of women with cardiac disease presenting to labor and delivery, anesthesiologists must be equipped to manage their analgesia and anesthesia in the peripartum period. Therefore, it is important to consider the potential cardiovascular effects of the anesthetic agents encountered during the process of labor and delivery and how they may affect patients with cardiac disease. This chapter reviews the most common classes…

The Use of Cardiac Drugs During Pregnancy

In Chapter 12 , we presented an overview of pharmacology during pregnancy; in this chapter, we focus on drugs specifically used to treat cardiac conditions in expecting mothers. These conditions include acute coronary syndromes and postoperative care (after angioplasty, stenting, or coronary bypass surgery), angina, arrhythmias, heart failure, and hypertension. The chapter concludes with a list of drugs commonly used to treat cardiac disease with recommendations…

An Overview: Pharmacology During Pregnancy

Pregnancy affects almost every aspect of pharmacology, including volume of distribution, protein binding, absorption, and metabolism. Consequently, when giving drugs to pregnant patients, the maternal cardiac care team must consider these changes in the maternal handling of drugs as well as how the drug will affect the fetus—not only potential teratogenesis but also the pharmacologic effects on the baby. Volume of Distribution A major effect of…

Arrhythmias During Pregnancy

Arrhythmias of any type may occur during pregnancy. Patients who have a condition that predisposes them to develop arrhythmias may have their initial episodes during pregnancy, and patients who already have arrhythmias may have them continue during pregnancy. Some patients with supraventricular tachycardias (SVTs) have a reduction in the frequency of episodes while pregnant, and others have an increase. This chapter first provides an overview of…

Endocarditis in Pregnancy

Endocarditis usually occurs on previously damaged heart valves or is associated with shunt lesions or baffles. When seen on previously normal valves, endocarditis is most often on the right-sided valves and is associated with intravenous (IV) drug abuse. This chapter discusses the incidence and risk factors, diagnosis, and treatment of endocarditis in pregnancy. Incidence and Risk Factors Although endocarditis is rare in pregnancy (incidence of 0.03–0.14…

Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM), a disorder specific to pregnancy, is one of the most feared complications for pregnant women and their medical care teams. It carries such a heightened risk for recurrence and subsequent morbidity and mortality that it warrants counseling against future conception. However, relatively little is understood about its underlying pathophysiology, risk factors, and early warning signs. This chapter explores the incidence and risk factors,…