Pregnancy Planning and Management for Women with Congenital Heart Disease

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• Pre-Pregnancy Counseling Importance
• Atrial Septal Defect and Pregnancy
• Transposition of the Great Arteries Overview
• Atrial Switch Surgery and Pregnancy Risks
• Arterial Switch Surgery and Positive Outcomes
• Multidisciplinary Care Necessity

Pre-Pregnancy Counseling Importance

Pre-pregnancy counseling is the most critical first step for any woman with a history of heart disease. Dr. Marc Dommergues, MD, emphasizes that this specialized clinic should involve both a cardiologist experienced in congenital conditions and an obstetrician familiar with cardiac defects. This collaborative assessment before conception allows for a thorough evaluation of cardiac function and the specific risks associated with the patient's unique heart condition, creating a tailored management plan for a safer pregnancy journey.

Atrial Septal Defect and Pregnancy

Pregnancy prognosis is excellent for women with a successfully repaired atrial septal defect (ASD). Dr. Marc Dommergues, MD, notes that if the surgery corrected the hole between the heart's atria without complications and the patient has normal heart ventricles and a normal heart rate, the pregnancy experience is typically very similar to that of a woman without heart disease. The primary concern in these cases is often managing anxiety, either from the patient herself or from medical providers who may be unfamiliar with her specific corrected condition.

Transposition of the Great Arteries Overview

Transposition of the great arteries (TGA) is a complex congenital heart defect where the aorta and pulmonary artery are switched, arising from the wrong ventricles. Dr. Marc Dommergues, MD, explains that this condition causes severe hypoxia in a newborn, requiring emergency surgery to survive. The long-term impact on a future pregnancy is not determined by the defect itself but almost entirely by the specific type of corrective surgery the woman received as an infant, which dictates her cardiac physiology as an adult.

Atrial Switch Surgery and Pregnancy Risks

An atrial switch surgery, an older corrective procedure for TGA, leaves the right ventricle as the main pumping chamber for the body's circulation. Dr. Marc Dommergues, MD, highlights the significant risk this poses during pregnancy. The right ventricle is not anatomically designed to handle high-pressure loads, and the increased blood volume and cardiac output of pregnancy can lead to heart failure. The risk level depends entirely on pre-pregnancy cardiac function; a "tired" right ventricle presents a high risk of decompensation during pregnancy or even in the postpartum period, necessitating extremely close monitoring.

Arterial Switch Surgery and Positive Outcomes

In contrast, the arterial switch operation for TGA creates a more anatomically normal heart by reconnecting the great arteries to their correct ventricles. Dr. Dommergues describes this as an extraordinary surgical achievement that results in a virtually normal cardiac physiology. While these patients will still require careful obstetrical and cardiac monitoring due to the rarity of the condition, their pregnancy prognosis is typically excellent, and most experience normal outcomes, as the left ventricle remains the primary pump.

Multidisciplinary Care Necessity

Close, coordinated follow-up by a dedicated team is non-negotiable for pregnant women with complex cardiac histories. Dr. Marc Dommergues, MD, stresses that this involves both the obstetrician and the cardiologist monitoring for critical complications throughout gestation and postpartum. Key concerns they vigilantly check for include signs of heart failure and cardiac rhythm abnormalities, which can be life-threatening if not managed promptly and expertly by specialists who understand the unique hemodynamics of pregnancy in a compromised heart.

Full Transcript

Dr. Anton Titov, MD: What can a woman with heart disease do to plan the pregnancy? What should she do during pregnancy to ensure the health of the mother and her future child?

Dr. Marc Dommergues, MD: To start with, it's very important to plan the pregnancy and beforehand to have a clinic devoted to pre-pregnancy counseling by the cardiologist in charge and by an obstetrician who is familiar with heart defects. Things may be extremely different according to the type of heart disease.

First of all, I must apologize. I'm not a cardiologist, so I'm going to oversimplify heart-related matters. But we might consider a few examples.

First, let's discuss a pregnant woman who has been operated for an atrial septal defect (ASD). It means there was a hole between her heart atria when she was born, and this hole was corrected by surgery. If we imagine a woman who had no complication of that surgery, who has normal heart ventricles and a normal heart rate, then the pregnancy is going to be very similar in her to pregnancy in anybody else.

However, there might be some anxiety either from the patient or from doctors. This is something that must be taken into account. But this pregnant woman with the atrial septal defect has been cured by heart surgery.

Suppose we consider another heart defect, which is the transposition of the great arteries. Transposition of the great arteries means that the pulmonary artery rises from the left ventricle and the aorta arises from the right ventricle. When you're a baby, when you are just a newborn, this means you are going to be blue, hypoxic, because the blood is not going to move correctly between the heart and the lungs and the heart and the rest of the body. You need to have emergency surgery.

Once you have been operated on for this heart problem, the impact on pregnancy will depend on the type of surgery you had. If you had one of the older types of surgery, which is called "atrial switch," that means that your aorta is still going to come out of your right ventricle. But the surgeon has managed to switch the blood flow at the level of the atria.

This means that the blood coming from the lung is going to go to the right ventricle. And from the right ventricle, blood goes to the rest of the body. This means the body is going to get blood full of oxygen.

Dr. Anton Titov, MD: So that's all very nice!

Dr. Marc Dommergues, MD: The only problem is that the right ventricle has to pump a huge load of blood under high pressure. The right ventricle is not made for that, and you may have a certain degree of heart failure. This will be very important to assess before pregnancy because things will be very different if your right ventricle is still pumping the blood perfectly well or if it's a little bit tired.

In the former case, it is likely that the pregnancy will be without any problem. In the latter case, it will be quite different.

Dr. Anton Titov, MD: There will be a risk of heart failure during pregnancy.

Dr. Marc Dommergues, MD: However, even with the first situation, it is not unusual that all doesn't work as well by the end of the pregnancy when the right ventricle has a lot of loads to manage. You may also have heart failure following delivery.

This means that a very close follow-up is going to be needed by the obstetrician but also by the cardiologist throughout pregnancy. They have to check for heart failure or abnormality of the rhythm of the heart.

If, in contrast, the surgery was an arterial switch, then the surgeon succeeded in doing something that I always find extraordinary. The aorta was put back to the right place, and the pulmonary artery is back to the right ventricle. Then you have a virtually normal heart.

Everybody is going to be worried because this is a rare condition. And there's going to be a very close obstetrical and cardiac monitoring. But by the end of the day, usually everything ends up normally.