Pregnancy and heart conditions

What should I know?

Having a heart condition can affect the way your body copes with pregnancy. Many women with a heart condition will tolerate pregnancy well. However, depending on the nature of your heart condition, there may be some risks to you and your baby.

There are a small number of cases where pregnancy would be considered high risk and in some very high risk cases we might advise a woman to avoid becoming pregnant.

For most people this risk is low but we would always advise speaking to your healthcare professional before thinking about getting pregnant so that you can get advice which is individual to you. This is called “preconception counselling”.

We would usually advise that women with a heart condition avoid an unplanned pregnancy where possible, you should ensure that you have an appropriate plan in place in relation to contraception.

Complications in pregnancy can be reduced and prevented by preconception assessment and planning. This may not always be possible therefore this leaflet will also provide guidance on what to do if you become pregnant without prior planning.

What are the risks during pregnancy?

Any pregnancy carries a small risk of problems or complications for the mother or baby. In most cases this risk is very low, but the presence of any heart condition can increase the chance of problems during pregnancy, delivery or after the pregnancy. The risks will vary depending on the nature and severity of your heart condition.

What factors can increase risk?

Your potential risk in pregnancy is dependent on a few factors:

• Your ventricular function (the strength of the pumping chambers of your heart)
• Any leaky or narrowed heart valves or a mechanical heart valve replacement
• Your oxygen levels
• Any heart rhythm problems you have had or continue to have
• Any heart problems in previous pregnancies
• Previous problems with the blood vessels that supply your heart with blood
• Your symptoms before pregnancy
• The medications you are prescribed

How is risk in pregnancy assessed?

• Healthcare professionals have experience managing women throughout pregnancy with a variety of heart conditions. They have access to international consensus expert guidance.
• Pregnancy related risk is also often assessed using the modified World Health Organisation (mWHO) classification.
• Women who have a heart condition and wish to become pregnant should speak to their cardiologist and/or be referred to a specialist Cardio-Obstetrics clinic for pre- conception counselling. This will allow for a formal assessment of pregnancy risk by a multidisciplinary specialist team.

What does pre-conception counselling involve?

• The goal of pre-conception care is to improve the long and short-term health outcomes of women and their children. If a woman has a chronic medical condition, specific pre-conception management advice including specialist referral may be offered.
• In many cases the discussion at this appointment will be straightforward, particularly if you have a mild or minor heart condition. It will involve talking to a cardiologist experienced in caring for women during pregnancy, you may also meet an obstetrician and a clinical nurse specialist to support you during this time.
• Your doctor or other health professional should take account of your background and other health conditions, they are likely to discuss any current symptoms you experience which are related to your heart condition.
• In some cases, you may require further tests such as an ECG (heart tracing), echocardiogram (heart scan), ambulatory ECG (a more prolonged recording of your heart) or exercise test to assess the risk of complications.
• You may be advised to address other factors such as smoking or weight loss which can help reduce the risks to you and the baby. You may also be asked to consider treatments to improve the symptoms of your heart condition prior to getting pregnant.
• You should have been advised if your heart condition is considered to be inherited. In such cases, and where there is an identified disease causing genetic mutation, you may want to discuss pre-implantation genetic diagnosis (PGD) and testing.
• Mental health and well-being support is also available through these specialist clinics.
• During pregnancy, follow up for woman with heart conditions is recommended and is often organised through the Cardio-Obstetrics clinic. The same team can monitor your heart condition throughout pregnancy, make a plan for the later stages of pregnancy and advise on the safest approach to delivery.

Contraception

• Some forms of contraception may be unsuitable for use in certain heart conditions. For example, oral contraceptives such as the combined pill contain oestrogen, this may increase blood pressure and can increase the risk of developing deep vein thrombosis (DVT’s). In some heart conditions this would need to be avoided.
• In general, long-acting reversible contraceptives such as the progesterone injection or implant are safe, reliable and are well tolerated.
• More information about using contraceptives safely when you have a heart condition can be found at: www.bhf.org.uk

What about my cardiac medications during pregnancy?

• It is important that you do not to stop any of your cardiac medications without first consulting your cardiology team.
• Some medications are safe to use in pregnancy and while breast feeding.
• Other medications may need to be stopped for safety, in this case and depending on your heart condition, it may be important to take an alternative medication.
• A medication review will take place at pre-conception counselling and you will have the opportunity to discuss the implications of continuing cardiac medications throughout pregnancy with your cardiology team.
• If you become pregnant without the opportunity to have this discussion it is important that you contact your cardiology team as soon as possible for advice but do not stop any medications in the meantime.

I might be pregnant – what should I do?

• If you become pregnant and you have a heart condition, it is important to be in touch with your cardiology team as soon as possible.
• You could contact your cardiology consultant or your cardiac nurse specialist if you have one.
• Your cardiology team will offer you some initial advice, this may be the time to ask about your medications. They may then arrange for you to attend a specialist clinic which combines both cardiology and obstetric support.
• You will be monitored in this clinic at regular intervals throughout your pregnancy. You will be monitored as much or as little as is required depending on your heart condition.
• You should also notify your GP of your pregnancy and contact your midwife to arrange a booking in appointment as you usually would.

Where can I find more information?

References

The following resources contributed to the production of this leaflet.

Scottish Obstetric Cardiology Network
Website: www.socn.scot.nhs.uk

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Cardiovascular-Diseases-during-Pregnancy-Management-of

Intrapartum care: existing medical conditions and obstetric complications Quality Standard [QS192] 2020 https://www.nice.org.uk/guidance/qs192

Pregnancy with a heart condition, BHF guidance https://www.bhf.org.uk/informationsupport/support/practical-support/pregnancy-with-a-heart-condition