Which cardiac patients should never get pregnant? Which cardiac patients should undergo elective Caesarean section?

Which women should never get pregnant?

1. 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.
2. Those with grade 4 systemic ventricular function (EF <20%).>

Which women should not get pregnant until operated upon?

1. Marfan’s syndrome patients with aortic aneurysm/dilated aortic root.
2. Those with severe left sided obstructive lesions (AS, MS, coarctation).

Which women should undergo elective Caesarean section?

1. 1 Those with independent obstetric indications.
2. 2 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:

1. Cyanotic congenital heart disease with impaired fetal growth. Section may help to avoid further fetal hypoxaemia, but at the expense of excessive maternal haemorrhage to which cyanotic patients are prone.
2. Pulmonary hypertension. See comments above.
   

A balance has to be made between a spontaneous vaginal delivery with the mother in the lateral decubitus position to attenuate haemodynamic fluctuations, forceps assistance and the smaller volume of blood lost during this type of delivery, and the controlled timing of an elective section. Probably more important than the route of delivery is peri-partum planning and teamwork: delivery must be planned in advance, and the patient intensively monitored, kept well hydrated and not allowed to drop her systemic vascular resistance. Consultant obstetric and anaesthetic staff experienced in these conditions should be present, and the cardiologist readily available.