CARDIAC DISEASE

A   30-year-old multigravida    with    a   childhood   history of  rheumatic   fever   has

echocardiography-diagnosed  mitral  stenosis.   She is  now at  20  weeks’

gestation   and has no  symptoms    at  rest    but has mild    shortness   of  breath  and

dyspnea with    activity.   On  examination she has a   diastolic   murmur.

Cardiac disease includes general types of heart disease.

Coronary    heart   disease (rarely found   in  women   of  childbearing    age).

Adverse consequences    of  hypoxic heart   disease include miscarriage,    fetal

death,  preterm delivery,   and increased   perinatal   morbidity   and mortality.

Rheumatic   heart   disease (most   common  acquired    lesion  in  pregnancy). The

most    common  rheumatic   heart   disease is  mitral  stenosis.   With    severe  stenosis

(mitral valve   area    <2  cm^2 ), the main    problem is  inadequate  diastolic

flow    from    the left    atrium  to  the left    ventricle.  Obstruction to  left    ventricular

filling may lead    to  left    atrial  enlargement,    pulmonary   congestion, atrial

fibrillation,   and subacute    bacterial   endocarditis    (SBE)   with    valvular

vegetations causing thromboemboli.  Tachycardia and increased   plasma

volume, which   are normal  changes of  pregnancy,  will    only    exacerbate  these

problems.   Treatment   includes    minimizing  tachycardia and excessive

intravascular   volume. Balloon valvuloplasty   may need    to  be  performed   as  a

last    resort.

Congenital  heart   disease (most   common  congenital  lesions are atrial  and

ventricular septal  defects [ASDs/VSDs]).   The most    common  cyanotic

congenital  heart   disease in  pregnancy   is  tetralogy   of  Fallot. ASDs    and VSDs

are tolerated   well    with    pregnancy,  as  are any regurgitation   lesions.