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  • Pregnancy.
  • History of heart disease.
  • Symptoms and signs of heart disease.
  • Echocardiographic or other objective evidence of heart disease.


Cardiovascular disease occurs in approximately 1% of pregnancies, but the incidence is increasing due to improved prognosis of women with congenital heart disease and a trend toward older maternal age. The unique hemodynamic changes associated with pregnancy make diagnosis and management of heart disease in pregnant patients a challenge to the physicians, who must consider not only the patient but also the risks to the fetus.


In general, the normal hemodynamic changes associated with pregnancy are well tolerated by those who have a normal cardiovascular system, valvular regurgitation, and left-to-right intracardiac shunts. On the other hand, the highest maternal and fetal morbidity and mortality is seen with severe obstructive valvular lesions, severe aortic disease (dilated thoracic aorta or uncorrected coarctation), New York Heart Association (NYHA) class III or IV heart failure, uncontrolled hypertension, and cyanotic congenital heart disease. As a rule, spontaneous vaginal delivery, often with use of vacuum extraction or forceps to facilitate stage 2 of labor to avoid the hemodynamic stress associated with pushing, is preferred. Cesarean section, with few exceptions, should be reserved for obstetric indications.

Stout KK et al. Pregnancy in women with valvular heart disease. Heart. 2007 May;93(5):552–8.  [PubMed: 16905631]


Normal pregnancy is accompanied by significant physiologic changes, although underlying mechanisms remain virtually unknown (Table 31–1). The normal signs and symptoms associated with pregnancy, such as shortness of breath, fatigue, and exercise intolerance, may obscure the diagnosis of heart disease. The clinician must, therefore, have a thorough knowledge of these normal changes and the aspects of the history and physical examination that suggest the presence of heart disease.

Table Graphic Jump Location
Table 31–1. Cardiovascular Changes in Normal Pregnancy.

Blood Volume


The increase in maternal blood volume begins as early as the sixth week of pregnancy, peaks at approximately 32 weeks of gestation, and stays at that level (40–50% higher than pregestational levels) until delivery. The plasma volume shows a more rapid and ...

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