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Give birth no later than 40 weeks, recommends ESC to women with heart disease

Give birth no later than 40 weeks, recommends ESC to women with heart disease

Pregnant women with heart disease are recommended to give birth at no later than 40 weeks gestation, according to the 2018 European Society of Cardiology (ESC) Guidelines for the management of cardiovascular diseases during pregnancy.

The guidelines are published in the European Heart Journal. 

“Beyond 40 weeks, pregnancy has no added benefit for the baby and may even have negative effects,” said Professor Jolien Roos-Hesselink, Co-Chairperson of the Guidelines Task Force and Cardiologist, Erasmus Medical Centre Rotterdam, the Netherlands. “Pregnancy is a risky period for women with heart disease because it puts additional stress on the heart, so the guidelines advise inducing labor or a cesarean section at 40 weeks.”

Hear disease is the main reason for the death of women during pregnancy in western countries.  pregnant women with heart disease have a 100-fold greater risk of death or heart failure as compared to healthy pregnant women. However, they should be aware that they have a higher risk of obstetric complications including premature labor, pre-eclampsia, and post-partum bleeding. An estimated 18-30% of offspring have complications and up to 4% of neonates die.

Heart disease in pregnancy is increasing as more women with congenital heart disease reach adulthood due to improved treatment and as the age at first pregnancy rises, accompanied by the higher rates of ischaemic heart disease in older, compared to younger, women. Cardiovascular risk factors including hypertension, diabetes and overweight are also on the rise in pregnancy as older women become pregnant and women now acquire risk factors at a younger age.

Other Recommendations:

  • IVF often uses high doses of hormones, which increase the risk of thrombosis and heart failure, so women with heart disease need a cardiologist’s confirmation that the chosen method is safe.
  • Since carrying more than one baby puts more stress on the heart, women with heart disease undergoing IVF are strongly advised to transfer a single embryo.
  • Girls with congenital heart disease need contraception advice to avoid an unplanned pregnancy.
  • Some contraception methods are contraindicated in patients with certain types of heart disease.
  • In the case of an emergency, drugs that are not recommended by the pharmaceutical industry during pregnancy and breastfeeding should not be withheld from the mother. The potential risk of a drug and the possible benefit of the therapy must be weighed against each other.
  • All women with congenital or other possible genetic heart diseases should be offered fetal echocardiography in weeks 19–22 of pregnancy.
  • Vaginal delivery is the first choice for the majority of patients.
  • In women with a moderate or high risk of complications during pregnancy (mWHO II–III, III, and IV), pre-pregnancy counseling and management during pregnancy and around delivery should be performed in an expert center by a multidisciplinary team: the pregnancy heart team.
  • A delivery plan should be made between 20–30 weeks of pregnancy detailing induction, management of labor, delivery, and post-partum surveillance.
  • Induction of labor should be considered at 40 weeks of gestation in all women with cardiac disease.
  • Indications for a cesarean section are:
    • pre-term labor in patients on oral anticoagulants (OACs)
    • aggressive aortic pathology
    • acute intractable heart failure
    • severe forms of pulmonary hypertension (including Eisenmenger’s syndrome)
  • Pregnancy termination should be discussed if there is a high risk of maternal morbidity or mortality, and/or of fetal abnormality.
  • Pregnancy is not recommended in patients with certain types of heart disease – for example, pulmonary arterial hypertension severely dilated aorta, or severely reduced ability of the heart to pump blood.
  • When drug companies have no data on whether a drug is safe during pregnancy and breastfeeding they tend to say it is not recommended. It may be appropriate to give a drug to a severely ill woman if there are no harmful side effects noted in the databases listed in the guidelines.”
  • Pregnancy, and consequently fertility treatment, is contraindicated in women with mWHO class IV.
  • Thrombolytics to treat thrombo-embolism should only be used in patients with severe hypotension or shock.
  • Methyldopa, labetalol, and calcium antagonists are recommended for the treatment of hypertension in pregnancy.
  • Women with a mechanical valve prosthesis are at high risk of maternal morbidity (especially valve thrombosis and bleeding) and even mortality and should be managed by a pregnancy heart team in expert centers.

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Source: With inputs from European Heart Journal

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