Congenital Heart Disease: Is Pregnancy Risky for You?

New guidelines for complex congenital heart disease (CHD)

If you have congenital heart disease (CHD) and always wanted to have a baby but were afraid of the risk, there’s good news.

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A new statement from the American Heart Association says that most women with complex CHD can have a successful pregnancy and normal vaginal delivery. Experts say it’s important to work with both a maternal-fetal medicine specialist (high-risk obstetrician) and a cardiologist who is knowledgeable about CHD.

The new guidelines overturn the idea that women with complex CHD should avoid pregnancy out of concern about potential risks to the mother and child.

A plan for complex pregnancies

The new statement helps your cardiologist by providing a treatment framework. It covers everything from pre-pregnancy counseling to pregnancy care to post-delivery care.

“The process makes it easy for your doctors to assess your risk before pregnancy, determine the frequency of follow-up needed once you become pregnant, and identify disease that warrants a higher level of care,” says Jeff Chapa, MD, Head of the Section of Maternal-Fetal Medicine at Cleveland Clinic.

It’s important for patients with CHD to plan carefully for pregnancy, as pregnancy increases the amount of blood pumped by your heart by up to 50 percent. Dr. Chapa says, “Ideally, patients with CHD should be evaluated before conception or early in pregnancy. This may include an echocardiogram, cardiac MRI or stress testing.”

The new guidelines also help doctors consider:

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  • Heart medications of concern during pregnancy
  • When they should consider genetic counseling to determine risk to the fetus
  • When they should consider fetal echocardiography
  • Defects that make pregnancy a dangerous choice

Keeping mom and baby safe

The new guidelines also make sense to David Majdalany, MD, a cardiologist and Director of the Adult Congenital Heart Disease Center.  Drs. Majdalany and Chapa see patients together in Cleveland Clinic’s Cardio-Obstetrics Clinic, where patients have the opportunity to speak to and get the perspectives of both physicians in the same setting.

Some things the doctors would typically consider include whether it is safe for you to get pregnant or to continue the pregnancy, the frequency of follow-up visits during the pregnancy,  what type of facility you should deliver at, the safest type of delivery for you and your baby, and what is the safest place in the hospital to monitor the mother and the baby.

While most patients can safely be managed through pregnancy, some require more intensive monitoring throughout pregnancy and more available resources at the time of delivery.  Most patients can have a vaginal delivery (rather than a cesarean section), but there are some exceptions.

“For example, if a patient has a connective tissue defect with  an enlarged aorta, we would suggest avoiding natural delivery,” Dr. Majdalany says.

Easy access to expert care

In addition to Drs. Majdalany and Chapa, the Cardio-Obstetrics Clinic  is supported by experts in any area of cardiovascular care, including arrhythmias, heart failure, vascular medicine, genetics, anesthesiology, pediatric cardiology and cardiac surgery.

For example, anesthesiologists with specialized training in obstetrics or in cardiac care can help determine the type of sedation to be used during labor and delivery that offers the lowest risk.

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The use of a Special Delivery Unit (SDU), a small labor and delivery unit specifically designed for mothers with serious medical conditions, also helps lower risk. The SDU  is located with immediate access to specialty care. After delivery, the mother can be sent to the ICU or to a regular hospital room, depending on the type of monitoring she will need.

Together, all these interventions make pregnancy and labor much safer for women with CHD.

Dr. Majdalany describes a patient with severe valvular narrowing from rheumatic heart disease who had undergone multiple valve interventions and whose pregnancy at age 32 was considered very high-risk.

“She was followed regularly throughout her pregnancy and had an uncomplicated delivery in the SDU followed by monitoring in the cardiac care unit for a day,” he says. “She did well and went home as if it was a routine pregnancy.”

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