Management principles

Consult expert advice.

• mothers with 'at risk' heart disease should consult with their GP about referral to a specialist centre with experience in managing Grown Up Congenital Heart Disease (GUCH)
  • antenal management dependent on risk associated with cardiac lesions and generic risk factors
    • level of antenatal care and monitoring required should be determined before pregnancy, or when this is not possible as soon as pregnancy is confirmed. Note that many general obstetricians will see only a few patients with moderate to severe congenital heart disease, referral to a specialist centre for counselling is advisable (1,2)
      • low risk patients can be managed locally taking into consideration specialist advice and recommendations
      • moderate to high risk patients
        • should ideally be cared for in a tertiary, multidisciplinary environment where a 24 hour service of experienced obstetricians, anaesthetists, cardiologists, cardiac surgeons, and neonatologists can be provided
• ensure patients are not taking teratogenic drugs. ACE inhibitors need to be stopped (under specialist advice) pre-pregnancy
• it is desirable to have cardiac scanning of the fetus
• certain anomalies require specific management e.g. there is a need for aspirin in patients with an atrial septal defect
• protection from endocarditis
  • when the membranes rupture intravenous amoxycillin is given for all GUCH except atrial septal defect, a closed duct, pulmonary valve stenosis
  • if patient is penicillin allergic then erythromycin is an alternative
• expert supervision must continue after pregnancy because cardiac function may deteriorate in certain patients in the year following pregnancy
• issues regarding further potential pregnancies must be addressed

Notes:

• women with Eisenmenger syndrome (or other forms of pulmonary arterial hypertension), Marfan syndrome with aortic root diameter > 4 cm, or severe left side obstructive lesions should be informed of the high maternal morbidity and mortality associated with pregnancy
  • if a pregnancy is unplanned then early termination should be considered. If the patient chooses to proceed with pregnancy, however, there is a need for care in a tertiary, multidisciplinary unit

Reference:

1. British Heart Foundation (1/2000). Factfile.
2. Uebing A et al. Pregnancy and congenital heart disease. BMJ 2006; 332:401-6.