100 QUESTIONS IN CARDIOLOGY

93 Which cardiac patients should never get

pregnant? Which cardiac patients should undergo

elective Caesarean section?

Sara Thorne

Which women should never get pregnant?

11 Those with significant pulmonary hypertension (pulmonary

vascular resistance >2/3 of systemic), especially cyanotic patients

and those with Eisenmenger reaction (maternal mortality ~50%)

and those with residual pulmonary hypertension after e.g. VSD

closure. NB: Even women with modest pulmonary vascular

disease ~1/2 systemic are at risk of death.

22 Those with grade 4 systemic ventricular function (EF <20%).

Which women should not get pregnant until operated upon?

11 Marfan’s syndrome patients with aortic aneurysm/dilated

aortic root.

22 Those with severe left sided obstructive lesions (AS, MS,

coarctation).

Which women should undergo elective Caesarean section?

11 Those with independent obstetric indications.

22 Caesarean section should be strongly considered for the

following women:

• Those with mechanical valves, especially tilting disc in the

mitral position. The key here is to leave the mother off

warfarin for the minimum time possible. An elective section

is performed at 38 weeks’ gestation, replacing the warfarin

with unfractionated heparin for the minimum time possible

• Severe aortic or mitral stenosis.

If the mother’s life is at risk, section followed by valve

replacement may be necessary.

Controversy remains over whether the following patients

should undergo elective Caesarean section:

11 Cyanotic congenital heart disease with impaired fetal growth.

Section may help to avoid further fetal hypoxaemia, but at the