What you need to know about starting a family when you have valve disease
By Dr. Marla Mendelson, Northwestern Medical Chicago
As a cardiologist, I work with many women living with valve disease who want to become pregnant and grow their family, but who worry about how their valve disease may affect or even prohibit that. One of my patients, Christine Rekash, an American Heart Association Heart Valve Ambassador, suggested I share a little about what women with valve disease need to know before getting pregnant.
FACT ONE: If you have cardiovascular disease, you do carry more risks into pregnancy than a woman without heart issues. However, this risk is usually not so great so as to be prohibitive.
For all women, blood volume increases during the first half of pregnancy to support the placenta. At the same time, blood pressure drops as the woman’s vascular system relaxes. During the second half of pregnancy, a woman’s heart rate goes up to ensure enough blood is circulating for the mother, the baby and the placenta.
Heart valve issues are categorized as either regurgitation (leaky valves) or stenosis (a narrowing of the valves. The type of valve disease you have determines the recommendation for pregnancy. Valve stenosis may be caused by rheumatic heart disease, which is not often seen in developed countries. If a woman has a history of rheumatic heart disease, she must be closely monitored during pregnancy as she is at a higher risk for heart failure as blood volume increases because the aortic valve is narrowed and not enough blood leaves the heart. In pregnancy, blood demands are greater and if blood gets backed up, it can cause HF. Women with leaky valves, we often see their valve issues improve during pregnancy as the mother’s blood pressure remains low.
FACT TWO: If you have cardiovascular disease, you will want to schedule a preconception appointment with your cardiologist.
No matter which type of valve disease you have – narrowed arteries, leaky valves or previously replaced or repaired valves– you will want to meet with your cardiologist to fully understand the risks of your specific situation. In some cases, it will make sense to surgically fix your valve problem before pregnancy.
By meeting with your medical team before getting pregnant, you will be able to understand the potential risks and treatments for your specific situation. Your doctor will take into account your history of surgeries and procedures, your heart function and capacity, and you can discuss if an intervention might make you a better candidate for pregnancy.
You and your doctor will discuss your risks. For example, many women with isolated mitral valve regurgitation can go on to have relatively low-risk pregnancies. Cardiomyopathy or impaired heart function, on the other hand, often has more risk associated with it. Based on this, your doctor will explain what you can anticipate during pregnancy in terms of managing cardiac issues and monitoring changes.
Your doctor may recommend an electrocardiogram (ECG or EKG); echocardiogram, stress test, cardiac cath or other invasive tests to determine your risk associated with pregnancy. These are best done before getting pregnant so as to avoid increased risk to mother and baby.
You will also discuss the medications you are on and what is recommended during pregnancy. Some medications, like ACE inhibitors, improve heart function but cannot be continued during pregnancy. In that case, you will want to work with your cardiologist to find new medications prior to pregnancy. In other cases, the medicine and dosage may be beneficial to continue during pregnancy to prevent complications. You should NEVER simply stop taking a medication without consulting with your cardiologist.
FACT THREE: You will need to be monitored closely by your cardiologist during pregnancy and seek attention with certain symptoms.
Our biggest task is ensuring pregnancy doesn’t negatively affect a woman’s current heart function. The hardest part of having children isn’t pregnancy – it’s the next 18 years and we want you to be in good health to care for your family!
Your situation may be different, but generally, the recommendations for pregnancies where the mother has had a valve replacement vary based on the type of valve you received.
If you have a bioprothesis or tissue valve and do not need long-term anti-coagulants, the pregnancy is pretty straightforward, but you need to be monitored to ensure there is no change in valve function. You will probably need to stay on aspirin therapy and will be monitored to ensure you do not have arrhythmia, which may be signaled by lightheadedness and palpitations. If you develop extreme fatigue, fever or anemia, you will need to be evaluated for endocarditis, as this can come on quickly and cause complications.
If your valve is mechanical and you need to stay on anti-coagulants, pregnancy can be more complicated and should be very well-planned. You will likely need heparin injections throughout the first trimester as high doses of warfarin can cause birth defects. Once you are into the second trimester, you will likely be able to go back on your normal medication and continue aspirin therapy. You will need to have a planned delivery, and will likely enter the hospital a week prior to go off your anti-coagulant and begin IV heparin treatment.
For almost all valve patients, staying on aspirin throughout pregnancy is recommended as the blood thickens during pregnancy, increasing your risk for blood clots.
FACT FOUR: Often, women with heart disease think they must have C-section, but actually, vaginal birth is almost always preferred from a cardiac perspective.
And, we must think beyond labor and delivery. After the baby is born, a woman’s body needs to remove a lot of excess fluid. Your cardiologist will monitor you to ensure your heart is strong enough to do this efficiently.
If you developed any pregnancy-related conditions such as hypertension, preeclampsia or gestational diabetes, your risk for cardiovascular disease and events increases later in life – way beyond pregnancy. Women are usually good about seeing their doctors in the weeks and months after pregnancy, but they must continue to care for themselves beyond that. If you had a pregnancy-related condition, you should be following up with your doctor once or twice a year and living a healthy lifestyle to manage your risks.