Clinical Pearls & Morning Reports
Health care professionals are increasingly tasked with caring for pregnant woman with cardiovascular disease, which has become one of the leading causes of maternal complications and death in the United States. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: Is there an increased frequency of arrhythmias during pregnancy?
A: New onset or increased frequency of arrhythmias is often noted during pregnancy for multiple reasons, including dilatation of the cardiac chambers, a higher resting heart rate, hormonal effects, increased adrenergic responsiveness, and the hyperdynamic state of pregnancy. However, ventricular tachycardia is not common during pregnancy, especially in the absence of preexisting structural heart disease. When ventricular tachycardia occurs during pregnancy, it is most likely to originate from the right ventricular outflow tract (in such cases, it is generally benign), and it does not typically result in cardiac arrest.
Q: What are some of the risk factors for peripartum cardiomyopathy?
A: Peripartum cardiomyopathy is characterized by a left ventricular ejection fraction below 45% that occurs toward the end of pregnancy or during the months after delivery and without another identifiable cause. Predisposing risk factors include twin pregnancy, Black race, advanced maternal age, traditional cardiovascular risk factors, and preeclampsia.
A: Pregnancy-associated myocardial infarction is an increasingly recognized entity that occurs in 9.5 per 100,000 hospitalizations. The leading cause of myocardial infarction during pregnancy is spontaneous coronary-artery dissection, followed by atherosclerosis and coronary thrombosis. Pregnant women tend to have a more severe presentation of spontaneous coronary-artery dissection than nonpregnant women and are more likely to have multivessel coronary involvement, a reduced ejection fraction, and ST-segment elevation.
A: Amniotic-fluid embolism is a rare catastrophic condition that occurs when amniotic fluid enters the maternal circulation. This results in acute pulmonary hypertension with right ventricular failure, followed by left ventricular systolic dysfunction, hypoxemic respiratory failure, and ultimately cardiovascular collapse. The embolus develops during labor or immediately after delivery and is associated with disseminated intravascular coagulation.