10 Questions Women Ask: Know Your Green and Red Lights for Effective Prevention

Women’s Cardiovascular Healthcare Foundation has compiled a list of 10 frequently asked questions for this important time in a woman’s life: before conception, during pregnancy, and after delivery with a special focus on women who already have a cardiovascular disease before becoming pregnant.

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1. When should I have a screening and cardiovascular check-up before or during my pregnancy?
You should do this the following contexts:
• Personal or family history of heart or aortic disease (dissection, aneurysm, surgery)
• Personal history of chemotherapy or radiotherapy, high blood pressure, phlebitis or pulmonary embolism, diabetes or gestational diabetes, heart murmur or vascular complications during a previous pregnancy
• Family history of sudden death in a first-degree relative
• Late pregnancy after age 40.

2. What symptoms should alert me?
• The appearance of shortness of breath on exertion, persistent nausea, exhaustion, palpitations, pain or tightness in the chest, a feeling of suffocating.
• The feeling of having to sit down to breathe properly at night.
• More specific signs of a placenta disorder: recent severe headaches (fairly strong headaches), sensation of bright spots in front of the eyes, tinnitus (ringing in the ears), ongoing pain and tightness in the pit of the stomach, convulsions.
• Weight gain in a few days associated with rapid onset edema. - Uterine bleeding with abrupt onset stomach pain (placental abruption).
• Feeling that the baby is not moving or is moving less. Call 911 if you aren’t feeling well. The teams will be able to take care of you immediately. Don’t wait!

3. What cardiovascular tests will I have?
Fortunately, a check-up with a cardiologist will be enough most of the time. They will ask questions, examine you, and do an EKG and a heart ultrasound. These tests are very simple, painless, and safe for your baby. They will also contact your OB/GYN or midwife. If you have high blood pressure during your consultation, your cardiologist will ask you to wear a Holter blood pressure device for 24 hours (to measure your blood pressure every 15 minutes day and night) or to take your own blood pressure measurements at home (measure your blood pressure morning and evening three times in a row for three days). They will also prescribe a test of albumin levels in your urine.

4. Can I have a baby if I have heart or artery disease?
Yes, in the vast majority of cases. If you’re planning to get pregnant, a cardio-obstetrics team will give you the go-ahead during a pre-conception appointment. In complex cases, pregnancy and childbirth care is discussed in multidisciplinary consultations with experts in cardiology and obstetrics. The World Health Organization (WHO) classification (Roos-Hesselinck EHJ 2013) makes it possible to assess the risks your heart or vascular disease may pose if you get pregnant. Situations where pregnancy is contraindicated are rare and apply to very high-risk heart diseases (classified WHO IV). [table] The body’s cardiac and vascular systems adapt very well to pregnancy and absolute contraindications are very rare. Precautions should be taken before pregnancy, treatments should be adapted, and follow-up should be scheduled based on the risks associated with your heart or vascular disorder. In all cases, contraception is advised while you wait for guidance from the cardio-obstetrics team.

5. Is my heart or arterial disease dangerous for my baby?
A low- or moderate-risk heart disease (WHO I and II) is a very low risk for your baby. On the other hand, if you have a higher-risk disease (classified WHO III and IV), the risk of complications, induced prematurity, malformations, growth restriction, and miscarriage is increased. The risk is also increased if you’ve taken certain drugs, especially oral blood thinners (vitamin K antagonists), had multiple pregnancies, or experienced abnormal development of the placenta during a previous pregnancy. Appropriate management of your pregnancy and close monitoring by a specialized team will reduce this risk and protect you and your baby.
6. Is my pregnancy risky if I have high blood pressure?

Having chronic high blood pressure before getting pregnant (blood pressure greater than 140/90 mm Hg at an office visit, greater than or equal to 135/85 mm Hg when measured at home) puts you at a slightly higher risk of placental insufficiency. Nevertheless, by preparing well for the pregnancy during a preconception check-up, by adapting the blood pressure medications allowed during pregnancy, and by regularly checking your blood pressure, you can have a relatively normally pregnancy and the placenta will develop normally like it does for non-hypertensive mothers. On the other hand, having uncontrolled high blood pressure or developing severe hypertension during pregnancy (above 160/110 mm Hg) can be dangerous for your health. In that case, you’ll need to start or adjust your blood pressure medications. When high blood pressure medication is prescribed, experts from the French Society of Hypertension (www.sfhta.eu) recommend targeting a reasonable goal of blood pressure below 160 mm Hg for the top number (systolic pressure), and between 85 and 100 mm Hg for the bottom number (diastolic pressure) in a medical setting, while avoiding low blood pressure that is harmful for placenta perfusion and the baby’s growth and heartbeat. If you had a placental development disorder during a previous pregnancy that led to cardiovascular complications for you or your baby (growth restriction, prematurity, death of the baby), your obstetrician may prescribe small doses of aspirin (75 to 100 mg/J) to prevent the risk of placental disorder recurrence. In this case, it’s best to receive care in a special pregnancy unit.

7. Are my heart or blood pressure medications dangerous for my baby?
If you’re on a long-term control medication, it’s important to consult your doctor before starting your pregnancy to switch any medications that can’t be used during pregnancy to drugs that are safe for your baby. In any case, it is not recommended that you stop your treatment without talking to your doctor. Some drugs may be responsible for malformations (vitamin K antagonists), or kidney failure in your baby (converting enzyme inhibitors, angiotensin 2 receptor antagonists, aldosterone antagonists). These classes of drugs need to be replaced. Others are too recent to have sufficient data (Sacubitril or direct oral blood thinners) and are therefore not recommended during pregnancy as a precautionary measure. Approved medications for chronic high blood pressure have been used for a long time (labetalol, nicardipine, nifedipine, alpha-methyldopa, clonidine) and have been proven safe for your baby. More information on precautions for medication use during pregnancy and breastfeeding are available at the CDC’s Treating for Two website https://www.cdc.gov/pregnancy/meds/treatingfortwo/. You can discuss this information with your doctor. Be sure to bring all your prescriptions to your pre-conception and pregnancy check-ups and never self-medicate. Let your pharmacist know when you get pregnant so they can provide appropriate guidance about your medications.

8. If I have a cardiovascular disease, will I always need to have a cesarean section?
Cesarean delivery is more common in cases of pre-existing cardiovascular disease: 41% of cases versus 23% in the general population in the international ROPAC registry. However, a vaginal delivery is always preferred in situations with minimal to moderate cardiovascular risk, whenever obstetrical conditions allow it. Cardiovascular situations that generally require a cesarean section, besides obstetrical emergencies, are high cardiovascular risk situations (WHO IV), signs of severe pre-eclampsia or cardiac decompensation for example. Delivery is sometimes scheduled and an epidural is often administered for greater safety in certain high-risk situations, but the health care team will follow your birthing plan when it’s safe to do so. If there are severe placenta complications, your medical team may decide to do an emergency c-section after discussions with the obstetrical team, depending on the pregnancy’s term and presentation, the seriousness of the clinical situation and the potential for your baby to be in pain. These complications can happen in any pregnancy.

9. After giving birth, will I be able to breastfeed my baby?
Breastfeeding is always encouraged, as prematurity is more common if you have cardiovascular disease. Most medications can be changed to drugs that don’t pass into breast milk at harmful levels, so you can enjoy these moments with your baby with peace of mind and no worries. Women with high blood pressure can breastfeed. Certain blood pressure drugs are better, including beta-blockers (labetalol, propranolol), calcium channel blockers (nicardipine, nifedipine), alpha-methyldopa, and certain enzyme conversion inhibitors (benazepril, captopril, enalapril, quinapril) unless the child was born prematurely or has kidney failure. The rare situations where breastfeeding is not allowed involve medications that are contraindicated during breastfeeding and that are absolutely essential for treating your disease, such as Nadolol, a beta-blocker used in certain heart rhythm diseases or immunosuppressive drugs in heart transplant patients. In every case, it’s important to talk with your medical team so they can provide guidance.

10. When should I see a cardiologist after my pregnancy?
• Certain pregnancy complications justify cardiovascular check-ups:
• discovery of heart or vascular disease
• development of hypertension or diabetes during pregnancy
• unexplained growth restriction of the baby, severe low birth weight
• pre-eclampsia, HELLP syndrome (renal and hepatic complications of placental disorders)
• phlebitis or pulmonary embolism (large blood clot in the pulmonary veins or arteries) during pregnancy or right after delivery
• fetal or neonatal death  

World Health Organization (WHO) Classification of Maternal Heart Disease
Low-risk heart disease (2.5-5% maternal events)
- Stenosis of the pulmonary artery, persistence of the arterial canal
- Leakage of the mitral valve (between atrium and left ventricle) or aortic valve (between left ventricle and aorta) minimal or moderate without repercussion
- Simple lesions treated successfully (communication between atria or ventricles, persistence of ductus arteriosus, abnormal pulmonary venous return)
- Isolated atrial or ventricular extrasystoles

Moderate-risk heart disease (5.7 to 10.5% of maternal events)
- Untreated communication between atria or ventricles
- Tetralogy of Fallot repaired (constitutional malformation of the heart chambers)
- Most supra-ventricular arrhythmias
- Aorta <20 mm/m2 if Turner syndrome (disease due to karyotype abnormality)

Moderate to high risk heart disease (10 to 19% maternal events)
- Moderate left heart failure with ejection fraction > 45%
- Hypertrophic cardiomyopathy (disease of the heart muscle),
- Native or treated cardiac valvulopathy (heart valve disease) not considered WHO I or IV
- Treated aortic coarctation (malformation with congenital narrowing of the aorta)
- Aorta < 40mm if Marfan syndrome, < 45 mm if aortic bicuspid (two valves instead of three that constitute the aortic valve, between left ventricle and aorta).

High-risk heart disease (19 to 27% maternal events)
- Moderate left heart failure with ejection fraction of 30 to 45%.
- History of peripartum cardiomyopathy (period surrounding childbirth) with recovery of left ventricular function.
- Systemic right ventricle with preserved function, Fontan operation
- Untreated cyanogenic heart disease, complex congenital heart disease
- Mechanical valve
- Asymptomatic tight aortic valve narrowing, moderate mitral valve narrowing
- Increase in aortic size 40 to 45 mm if Marfan syndrome, 45 to 50 mm if bicuspid, 20 to 25 mm/m2 if Turner
- Ventricular tachycardia.

Very high-risk heart disease contraindicating pregnancy (40 to 100% maternal events)
- Pulmonary arterial hypertension of any origin
- Severe left heart failure with ejection fraction < 30%
- 45 mm if Marfan syndrome or equivalent, > 50 mm if aortic valve bicuspid, > 25 mm/m2 if Turner syndrome.
- History of peripartum cardiomyopathy with persistent heart failure
- Systemic right ventricle with impaired function, complicated Fontan’s shunt
- Symptomatic tight aortic narrowing, tight mitral narrowing
- Severe untreated aortic coarctation
- Aortic size > 45 mm if Marfan’s syndrome or equivalent, > 50 mm if aortic valve bicuspid, > 25 mm/m2 if Turner’s syndrome.




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