100 QUESTIONS IN CARDIOLOGY

92 How do I manage the pregnant woman with

valve disease?

Sara Thorne

Native or tissue valves

In general, regurgitant lesions are well tolerated during

pregnancy, whereas left sided stenotic lesions are not (increased

circulating volume and cardiac output lead to a rise in left atrial

pressure). Tissue valves can deteriorate rapidly during pregnancy.

Management of patients with significant mitral and aortic stenosis

11 Bedrest:

• Reduced heart rate allows time for LV filling and ejection


• Reduced venous return due to IVC compression by the

uterus reduces LA pressure (also increases risk of throm-

bosis: patients must be heparinised).

22 Dyspnoea and angina: slow the heart rate with beta blockers or

digoxin. Nitrates may be useful, but should be used with

caution in those with aortic stenosis.

33 Intractable pulmonary oedema:

• Balloon valvotomy


• Closed mitral valvotomy (advantage as no cardiopulmonary

bypass, but few surgeons nowadays have experience)

• If valvotomy not possible, then deliver fetus by Caesarean

section followed by cardiopulmonary bypass and valve

replacement.

Mechanical valves

Anticoagulation is the issue here: in particular, the risk of

warfarin embryopathy vs risk of valve thrombosis.

The choice lies between:

11 Warfarin throughout pregnancy, stopping it for a minimal

length of time for delivery

22 Convert to heparin during the first trimester with hospital

admission and meticulous control of APTT. Return to warfarin

for the second trimester and reinstate heparin at ~34/40.