Practice Pregnancy Plus

Valvular heart disease

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39365.655833.AE (Published 15 November 2007) Cite this as: BMJ 2007;335:1042
  1. E Gelson, clinical research fellow1,
  2. M Gatzoulis, professor of cardiology2,
  3. M Johnson, reader in obstetrics and obstetric medicine1
  1. 1Academic Department of Obstetrics and Gynaecology, Imperial College London, London SW10 9NH
  2. 2Adult Congenital Heart Centre, National Heart and Lung Institute, Royal Brompton Hospital, London SW3 6NP
  1. Correspondence to: E Gelsonegelson{at}imperial.ac.uk

    Valvular disease may be unmasked in pregnancy when physiological changes increase demands on the heart. Women with valvular heart disease require close follow-up during pregnancy, delivery, and postpartum

    Valvular heart disease in pregnancy is rare, but it significantly increases maternal and fetal risk. Despite an overall decline in the incidence of rheumatic heart disease in Europe and North America,1 worldwide rheumatic mitral stenosis is the most common valvular lesion in pregnancy.w1 With changing patterns of immigration, rheumatic heart disease may well become a serious problem in the United Kingdom. Advances in cardiac medication and surgery mean that more women with congenital valvular disease survive into adulthood and reproductive maturity.

    Valvular heart disease may present for the first time in pregnancy as the increasing demands on the heart lead to decompensation and cardiac failure. However, the diagnosis is not always easy as the symptoms of pregnancy (tiredness, shortness of breath, and palpitations) can mask those of deteriorating disease. Moreover, in the United Kingdom, a decline in rheumatic fever means that valvular heart disease is now rare, and doctors—particularly general practitioners and obstetricians, to whom these patients present—are less aware of and less familiar with the condition. The scenario box highlights the complexities of the management of valvular heart disease in pregnancy.

    Does pregnancy affect valvular heart disease?

    Changes that occur in pregnancy pose a substantial demand on cardiac function in women with valvular disease. By eight weeks' gestation, systemic vascular resistance falls by 30-70% of its preconception value, initiating a 30-50% increase in cardiac output, an increase of 10-20 beats/min in heart rate, and a 30-50% increase in blood volume. Systemic vascular resistance falls by 30-70% of its preconception value. Labour, particularly the second stage, is associated with a further increase in cardiac output. Pain induces a sympathetic response causing an increase in heart rate. …

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