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OBSTETRICS
Professor and Chair, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Queens University, Kingston ON
William Norman Thornton Professor and Chair, Department of Obstetrics and Gynecology University of Virginia, Charlottesville VA USA
Abstract
The incidence of rheumatic heart disease in most industrialized
countries is decreasing. Those women who have regurgitant
lesions will commonly experience an improvement in symptoms,
and therapy is required only in the most severe cases. Women
with mild to moderate stenotic lesions can usually expect a good
outcome to pregnancy, but women with severe stenotic lesions
require close monitoring by both their obstetricians and their
cardiologists, especially during the third trimester, labour and
delivery, and the early postpartum period.
This is the third in a series of five articles reviewing in detail the
assessment and management of specific cardiac disorders in
pregnancy.
Rsum
Lincidence de la cardiopathie rhumatismale est en baisse dans la
plupart des pays industrialiss. Les femmes qui prsentent des
lsions reflux connatront gnralement une amlioration des
symptmes; le traitement nest requis que dans les cas les plus
graves. Les femmes qui prsentent des lsions stnoses allant
de lgres modres peuvent habituellement sattendre de
bonnes issues de grossesse; toutefois, les femmes qui prsentent
de graves lsions stnoses ncessitent un suivi troit de la part
de leurs obsttriciens et de leurs cardiologues, particulirement
pendant le troisime trimestre, le travail et laccouchement, et les
dbuts de la priode post-partum.
Il sagit du troisime article dune srie de cinq analysant en dtail
lvaluation et la prise en charge de troubles cardiaques
particuliers au cours de la grossesse.
J Obstet Gynaecol Can 2007;29(6):507509
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OBSTETRICS
Aortic stenosis in pregnancy is described in detail in the article on congenital heart disease.22 Most patients with aortic
stenosis of rheumatic origin also have associated mitral stenosis.10 Some authors have found that a higher maternal
mortality is associated with aortic stenosis of rheumatic origin than with aortic stenosis of congenital origin.11 The rate
of maternal mortality associated with severe aortic stenosis
in pregnancy is most commonly cited as 17%, with a fetal
mortality of 32%.23 This series also identified a maternal
mortality of 40% associated with termination of pregnancy.23 This widely quoted statistic was derived from a
description of two maternal deaths in five patients undergoing termination of pregnancy and may not represent the
total population with aortic stenosis. Decisions regarding
anaesthesia and mode of delivery for patients with aortic
stenosis must be individualized on the basis of severity of
symptoms and urgency of delivery.
AORTIC REGURGITATION
As with aortic stenosis, most patients with aortic regurgitation of rheumatic origin have associated mitral valve disease.11 Their clinical course, therefore, is probably determined more by the extent of their mitral valve disease than
by their aortic regurgitation. When aortic regurgitation is
the predominant lesion, pregnancy is usually well tolerated.9
It has been suggested that aortic regurgitation may actually
improve in pregnancy because of the decrease in systemic
vascular resistance.9 Also, the physiologic tachycardia of
pregnancy may reduce regurgitant flow as diastolic filling
times are shortened.1,11 It has also been recognized that the
murmurs normally associated with both aortic and mitral
regurgitation may be reduced in pregnancy.24
For patients with severe aortic regurgitation and symptoms
of left-sided heart failure, the mainstay of therapy is
decreasing cardiac work. Patients should limit their activity,
and bed rest may be necessary. Sodium restriction may also
be helpful.10 Diuresis and inotropic therapy with digitalis
have been suggested in difficult cases.14 Despite aggressive
medical therapy, some patients will require aortic valve
replacement in pregnancy.25,26 Case reports suggest that
pulsatile perfusion at bypass may help preserve placental
hemodynamic function.2729
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