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British Journal of Anaesthe sia 93 (3): 428–39 (2004) DOI: 10.10 93/bja /aeh19 4 Advance Ac cess publication June 11, 2004 REVIEW ARTICLES Recognition and management of maternal cardiac disease in pregnancy P. Ray*, G. J. Murphy and L. E. Shutt Department of Anaesthesia, St Michaels Hospital, Bristol and Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK *Corresponding author: E-mail: [email protected] Heart disease is a leading cause of maternal death. The aim of this study is to review the most common causes of cardiac disease, highlight factors that should be recognized by the clinician, and addr ess recen t advan ces in the anaes theti c manag emen t of thesepatients. Incipie nt cardia c disea se, including peripartum cardiomyopathy, myocardial infarction and aortic dissection, accounts for appro ximat ely one in six mater nal deaths. The keys to succes sful diagnosis and manageme nt of incipient disease are: a high index of suspicion, particularly in women with known risk factors for cardiovascular disease; a low threshold for radiological investigations; early cardiology input; and invasive monitoring during labour and delivery. Echocardiography is a safe, non-invasive test, under -used in pregn ancy. Manageme nt of preg nant wome n with pre-existi ng cardiac prob lems should be undertaken by multidisciplinary teams in tertiary centres. In women with pre-existing cardiac disease wishing to proceed to term, cardiac status must be optimized preoperatively and planned elective delivery is preferable. Vaginal delivery is preferable, and with careful incremental reg ional ana esthesia is saf e in mos t women withcardi ac dis eas e.Thepresence of ade quate sys tems for early detection, appropriate referral to specialist centres, and timely delivery with multidisciplinary support can minimize the serious consequences of poorly controlled heart disease in pregnancy. Br J Anaesth 2004; 93: 428–39 Keywords: complications, aortic dissection; complications, maternal death; complications, peripartum cardiomyopathy; complications, pulmonary hypertension Heart disease is a leading indirect cause of maternal death in theUK, accountin g for35 (16 .5%) of allmater naldeath s ove r the period 1997–99, 18 and equalled only by the number of deaths due to thromboembolism. The relative incidences of various types of cardiac disease as a cause of maternal death are listed in Table 1. Three of these deaths were attributed to deviations from standard practice. 18 Less than standard care is not ea sy to de termine and is of te n comple x in aeti ol ogybut the recurring themes are: failure of communication between memb ers of mult idisci plina ry teams; lack of clearpolicies for the management of cardiac problems; and failure of indivi- dual clinicians to diagnose cardiac problems accurately or to appreciate the severity of these conditions when identified. The purpose of this ar ti cleis tore vi ew the cl inical fe at ur es of incipient maternal cardiac disease that should be recognized by the ana esth eti st, and add ress rec ent advances in the management of these patients, and to consider the management of pregnant women known to have cardiac disease before delivery. Incipient maternal cardiac disease In the eve nt tha t a pre gna nt woman presents wit h acu te-ons et cardi oresp irator y sympt oms, the anaest hetis t is freq uentl y consulted early in the course of the patient’s management. The main different ial diagn oses for acute cardiova scular deterioration in pregnant women include thromboembolism, pre-eclampsia, haemorrhage, cardiac disease and sepsis. 83 Perhaps the least expected of these diagnoses in a young mother is underlying heart disease. Peripartum cardiomyopathy Peri partu m cardi omyop athyis a poor ly understoodcondition, with an incidence of 1:1500 to 1:4000 live births. It has been defi ned cli nic all y as the ons et of car dia c fai lur e wit h no ide n- tifiablecauseinthelastmonthofpregnancyorwithin5months after delivery, in the absence of heart disease before the last month of pregnancy. 23 It is associated with older maternal age, greater parity, black race and mult iple gestatio ns. 96 # The Board of Management and Trustees of the British Journal of Anaesthesia 2004 a t I n k h o s i A l b e r t L u t h u l i C e n t r e H o s p i t a l o n a r c h 1 4 , 2 0 1 2 h t t p : / / b j a . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d f r o m

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