Valvular heart disease and pregnancy
Pr Bernard Iung
Pregnancy causes a significant and sustained increased in cardiac output that may be poorly tolerated in cases of underlying heart disease. Valvular heart disease is the second most frequent heart disease encountered in pregnant women and is the most frequent heart disease in developing countries. Valvular stenosis, in particular mitral stenosis, is often poorly tolerated. First-line treatment is the use of beta-blockers. Percutaneous balloon mitral commissurotomy may be required during pregnancy in women who remain symptomatic despite medical therapy. Aortic stenosis is better tolerated and seldom requires intervention during pregnancy. Regurgitant valve disease is well tolerated in most cases provided left ventricular function is preserved and should be managed medically during pregnancy. Pregnancy in patients who have previously undergone valve replacement using a mechanical prosthesis raises specific problems linked to anticoagulant therapy. The choice is difficult between oral anticoagulation, which carries a risk of embryopathy, and heparin therapy, which is safer for the fetus but associated with a high thromboembolic risk for the mother and higher mortality. Maternal and fetal outcome are more favourable in women with a bioprosthesis but the risk of bioprosthetic degeneration is high in young women. The diversity of cases highlights the need for appropriate evaluation of heart disease before pregnancy, close follow-up and planning of delivery by specialized multidisciplinary teams.
