AAAAA
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At her annual visit, a 28-year-old woman with known aortic regurgitation indicates she is considering become pregnant in the next year or two. She is asymptomatic and exercises vigorously 5 times a week with no limitations. Her echocardiogram shows a bicuspid aortic valve with moderate to severe aortic regurgitation. Left ventricular size is normal with an ejection fraction of 65%. The aortic root size is normal, and her pulmonary systolic pressure is 25 mm Hg.
Which is the most appropriate recommendation regarding pregnancy in this patient?
A Strongly discourage pregnancy B Undergo aortic valve replacement prior to conception C Begin enalapril prior to conception D No additional therapy is needed This question has been answered. To clear answers, open the Answer Sheet. Answer and Critique (Correct Answer = D) Key Points - Regurgitant valve lesions are well tolerated in pregnancy.
- Functional status before pregnancy is a strong predictor of maternal risk.
In women with heart disease, the clinical factors associated with increased risk during pregnancy are symptoms or functional impairment before pregnancy, severe left-sided obstructive lesions (aortic and mitral stenosis), ventricular dysfunction, and pulmonary hypertension. Regurgitant lesions typically are well tolerated during pregnancy. Although this patient has anatomic aortic valve disease with significant regurgitation, ventricular function and pulmonary pressures are normal; the risk of pregnancy in this patient, therefore is only slightly higher than in a woman without heart disease, and no additional therapy is required.
At this time, this patient does not meet any of the criteria for surgical intervention. In fact, surgical intervention should be avoided until after the childbearing years because of the risks associated with anticoagulation for mechanical valve prostheses and the limited durability of tissue valves in younger adults. Although afterload reduction therapy is beneficial in patients with chronic severe aortic regurgitation, initiation of therapy can be delayed until after pregnancy, especially given the low systemic resistance state associated with pregnancy. If drug therapy is necessary during pregnancy, angiotensin-converting enzyme inhibitors should be avoided.
Bibliography - Sermer M, Colman J, Siu S. Pregnancy complicated by heart disease: a review of Canadian experience. J Obstet Gynaecol. 2003;23:540-4. [PMID: 12963517] [PubMed]
- Siu SC, Colman JM, Sorensen S, Smallhorn JF, Farine D, Amankwah KS, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation. 2002;105:2179-84. [PMID: 11994252] [PubMed]
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| AAAAA
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In women with heart disease, the clinical factors associated with increased risk during pregnancy are symptoms or functional impairment before pregnancy, severe left-sided obstructive lesions (aortic and mitral stenosis), ventricular dysfunction, and pulmonary hypertension. Regurgitant lesions typically are well tolerated during pregnancy. Although this patient has anatomic aortic valve disease with significant regurgitation, ventricular function and pulmonary pressures are normal; the risk of pregnancy in this patient, therefore is only slightly higher than in a woman without heart disease, and no additional therapy is required.
At this time, this patient does not meet any of the criteria for surgical intervention. In fact, surgical intervention should be avoided until after the childbearing years because of the risks associated with anticoagulation for mechanical valve prostheses and the limited durability of tissue valves in younger adults. Although afterload reduction therapy is beneficial in patients with chronic severe aortic regurgitation, initiation of therapy can be delayed until after pregnancy, especially given the low systemic resistance state associated with pregnancy. If drug therapy is necessary during pregnancy, angiotensin-converting enzyme inhibitors should be avoided.
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| amirhossein
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Nice case ... 
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