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Managing Specific Cardiac Conditions During Pregnancy, Labor, and Delivery

Aortic Dissection For the expectant mother, there is an increased risk of aortic dissection because of the histologic and hemodynamic changes that occur during pregnancy. Histologic changes in the aortic wall include fragmentation of the reticulum fibers, diminished mucopolysaccharides, and loss of corrugation of the elastic fibers. Hemodynamic changes include increased stroke volume and blood volume. In patients with Marfan syndrome, who are predisposed to aortic…

Obstetric Events That Affect Cardiac Patients

Pregnancy dramatically increases the demands on a woman’s heart. Both stroke volume and cardiac output increase significantly in response to a number of factors, including increased oxygen demands by the growing fetus, the enlarging breasts, and the enlarging uterus; increased work by the mother because of weight gain; and the placental bed acting like an arteriovenous fistula. This chapter reviews the events that affect (or that…

Cardiac Conditions That May Affect Pregnancy

The pathologic changes that occur in women with cardiac disease may have major implications during pregnancy and delivery. This chapter discusses, in general terms, the potential complications that may occur related to cardiovascular pathology and suggests some management strategies. Between 1990 and 2013, the maternal mortality rate in the United States increased 136%, rising from a rate of 12 maternal deaths per 100,000 live births to…

Prepregnancy Counseling

Pregnant women with heart disease have an increased risk of both maternal and fetal complications. Given that an estimated 1 million women in the United States have underlying congenital heart disease, the likelihood that a health care provider will care for such a patient is increasing. Certain conditions, such as pulmonary hypertension or prior peripartum cardiomyopathy, carry such high risk that they may contraindicate a pregnancy.…

The Cardiac Physical Examination in Pregnancy

The many physiologic changes that occur in pregnancy are reflected in the cardiac physical examination. In this chapter, we note changes the practitioner should expect and the timing of those changes, with respect to respiratory rate and pattern, chest wall, lung sounds, pulse, blood pressure, jugular venous pressure, apical impulse, heart sounds, murmurs, and extremities. Respiratory Rate and Pattern Although minute ventilation increases in pregnancy, the…

Physiologic Adaptations to Pregnancy

For women with cardiac disease, the physiologic changes associated with pregnancy can impact the health of the mother and baby and affect the course of gestation and delivery. Many of these normal changes are driven by hormonal alterations initiated by the placenta (such as rising levels of estrogen and progesterone, which increase continuously during pregnancy), and they help optimize fetal growth, protect the mother from delivery…

Postpartum weight management and future pregnancy planning

Obesity and its associated metabolic transformations could constitute a significant burden in the postpartum period with its potential complications and outcomes. This chapter will highlight the effects of obesity beyond the immediate postpartum period and the best evidence to manage obesity as well as future fertility planning. 44.1 Complications of obesity Obesity is associated with Increased risk of overall mortality Lifetime impact of disability and morbidity…

Immediate postnatal care in obese women

Postnatal care is preeminently about the provision of a supportive environment in which a woman, her baby, and the wider family can begin their new life together. Maternal overweight and obesity (body mass index >25 kg/m 2 ) is an important modifiable risk factor in women of reproductive age. The rise in prevalence of obesity is seen in both high-income countries and low–middle-income countries. It is…

Sepsis in obese pregnant women (concise version)

42.1 Introduction The terms “overweight” and “obesity” are defined by the World Health Organisation (WHO) as an abnormal or excessive fat accumulation that presents a risk to health. Obesity is further classified into three categories: Class 1 (BMI 30.0–34.9 kg/m 2 ), Class 2 (BMI 35–39.9 kg/m 2 ) and Class 3 or morbid obesity (BMI >40.0 kg/m 2 ). Animal, epidemiological and limited human studies…

Assisted vaginal delivery in obese women

41.1 Introduction Although the duration of the second stage of labour is not affected by obesity, and the intrauterine pressure generated by the Valsalva manoeuvre is similar to normal-weight women, maternal obesity is a known risk factor for operative vaginal delivery, which is up to two times more frequent in class III obesity. The overall success rate of assisted vaginal delivery has been reported to be…

Intrapartum care for obese women

40.1 Introduction The prevalence of obesity in high-resource countries is rising in all age groups. It is estimated that over a third of women in the reproductive age are obese. Obesity is both a metabolic and an inflammatory disorder. Obesity is defined as a body mass index (BMI) of 30 or above, and the following classification is used in this chapter: o class I: BMI 30.0–34.9.…

Induction of labour in obese pregnancies

Induction of labour (IOL) involves artificially stimulating the onset of labour through chemical and/or mechanical methods, with the aim of achieving a vaginal delivery, prior to the onset of spontaneous labour. Approximately 33.0% of deliveries in the United Kingdom (UK) in 2019–20 were induced, whereas data from the Centres for Disease Control and Prevention demonstrated that 29.4% of deliveries in the United States (US) in 2019…

Venous thromboembolism in obese mother

38.1 Introduction Venous thromboembolism (VTE) is the leading cause of direct maternal deaths in the United Kingdom. Obesity is a significant contributory factor for VTE in pregnancy and the risk increases by fourfold when compared with women of normal BMI. Recent evidence has shown obesity as an important contributory factor for inappropriate dosage of low-molecular-weight heparin for thromboprophylaxis or VTE treatment as the dosage is mainly…

Obesity and preeclampsia

37.1 Introduction Pregnant women who are obese are at risk of a multiplicity of pregnancy-related complications, in particular preeclampsia and gestational diabetes. It has been suggested that similar to gestational diabetes and development of type 2 diabetes, gestational hypertension and preeclampsia are revealing those with a tendency to develop cardiovascular disease. Obesity is known to predispose to cardiovascular disease (CVD) out with pregnancy, therefore it is…

Short- and long-term effects of gestational diabetes and foetal outcomes

Gestational diabetes (GDM) affects around 3.5% of pregnancies in the United Kingdom and has a higher prevalence in obese pregnant women. Maternal hyperglycaemia increases risk of adverse pregnancy outcomes and GDM is associated with adverse outcomes for women and their offspring both in the short and long term. 36.1 Maternal diabetes and insulin resistance Pregnancy is a state of increasing insulin resistance (up to 40%–50%), with…

Management of obese pregnant women with pre-diabetes and type 1 and 2 diabetes mellitus

34.1 Background Diabetes is the most common metabolic complication of pregnancy and is independently associated with adverse pregnancy outcomes. Some of these adverse outcomes are in common with those occurring in women with obesity alone (e.g. caesarean delivery), while others are unique to diabetes (e.g. ketoacidosis). Pregestational diabetes (including type 1 and type 2 diabetes) affects approximately 1% pregnancies and is associated with a two to…

Screening for gestational diabetes mellitus

It has been estimated that diabetes affects an estimated 415 million people globally and is projected to increase to 642 million by 2040. There is also an equally high burden of prediabetes, approximately 318 million people and likely to increase to 481 million by 2040. These findings are accompanied by high levels of overweight and obese adults. The WHO data show that more than half of…

Challenges of third trimester scanning in obese women

32.1 Introduction Obesity has been recognised as an important public health problem, and worldwide the prevalence of obese pregnant women continues to rise. In the United States, approximately 61%–64.5% of the total population is classified as either overweight or obese; in the United Kingdom, 33% of women are overweight and 23% are obese, giving a total of 56% of women over the recommended BMI. Recent reports…