Cardiac Patients in Pregnancy

Generally, patients in labor and delivery are healthy. They have asthma or migraines or low back pain or most of the time, no other medical problems. It's easy for health care professionals - obstetricians, anesthesiologists, nurses - to simply assume all pregnant patients are healthy. But these kinds of assumptions can get us in trouble, especially at a tertiary care center like Stanford.

We see a lot of high risk obstetric patients. One of the biggest groups we see are patients with cardiac problems. Although it's rare for a woman of reproductive age to have heart disease, when it does happen, it is a major concern. The process of pregnancy and labor put a lot of stress on the heart. The natural changes with pregnancy include a dilutional anemia, increased intravascular volume, an increase in heart rate and cardiac output, and diversion of blood flow to the uterus and placenta. The growing placenta compresses the inferior vena cava leading to decrease of blood flow to the heart. Labor is like a stress test for the heart which has to increase to match increasing oxygen demands. The most dangerous lesions actually involve the lungs and manifest after delivery. After the baby is delivered, the release of vena caval compression causes a dramatic increase in venous return. A compromised heart cannot cope with this and can go into heart failure. A lesion like pulmonary hypertension can spiral out of control. Most maternal cardiac deaths happen after delivery, and many could be preventable with adequate knowledge and appropriate care.

The cornerstone of peripartum care for complex diseases is interdisciplinary, longitudinal, collaborative treatment. We have monthly meetings with obstetrics, maternal-fetal medicine, cardiology, anesthesiology, and nursing about patients with heart disease. This way, we ensure that we have the right tests, understand the obstetric and fetal plan, learn from each other, and plan the delivery. As a group we can discuss the advantages or disadvantages of a vaginal delivery versus C-section, an epidural, peripartum medication management, and contingency plans.