ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists

NUMBER 212

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Presidential Task Force on Pregnancy and Heart Disease

Committee on Practice Bulletins–Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and
Gynecologists’ Committee on Practice Bulletins–Obstetrics in collaboration with the Presidential Task Force on Pregnancy and Heart
Disease members Lisa M. Hollier, MD, James N. Martin Jr., MD, Heidi Connolly, MD, Mark Turrentine, MD, Afshan Hameed, MD,
Katherine W. Arendt, MD, Octavia Cannon, DO, Lastascia Coleman, ARNP, CNM, Uri Elkayam, MD, Anthony Gregg, MD, MBA,
Alison Haddock, MD, Stacy M. Higgins, MD, FACP, Sue Kendig, JD, Robyn Liu, MD, MPH, FAAFP, Stephanie R. Martin, DO,
Dennis McNamara, MD, Wanda Nicholson, MD, Patrick S. Ramsey, MD, MSPH, Laura Riley, MD, Elizabeth Rochin, PhD, RN,
NE-BC, Stacey E. Rosen, MD, Rachel G. Sinkey, MD, Graeme Smith, MD, PhD, Calondra Tibbs, MPH, Eleni Z. Tsigas, Rachel
Villanueva, MD, Janet Wei, MD, and Carolyn Zelop, MD.

Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women’s long-term cardiovascular health. In
the United States, disease and dysfunction of the heart and vascular system as “cardiovascular disease” is now the leading
cause of death in pregnant women and women in the postpartum period (1, 2) accounting for 4.23 deaths per 100,000 live
births, a rate almost twice that of the United Kingdom (3, 4). The most recent data indicate that cardiovascular diseases
constitute 26.5% of U.S. pregnancy-related deaths (5). Of further concern are the disparities in cardiovascular disease
outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors
include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease
risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease
symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease
among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification
and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the
puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset
acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

VOL. 133, NO. 5, MAY 2019 OBSTETRICS & GYNECOLOGY 1067

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Clinical Management Questions
< What are the prerequisites of pregnancy preparation and prepregnancy counseling for patients with
known heart disease?
< Why is risk assessment indicated, what types are recommended, and which patients should be referred to
centers with a high level of care?
< What are the indicated tests and how should these tests be interpreted for the pregnant patient with
possible heart disease?
< Which types of preexisting maternal cardiac disease have the greatest effect on pregnancy and the
postpartum period?
< How should women at high risk of peripartum cardiomyopathy be identified, assessed, and managed?
< How should acute coronary events, including maternal cardiac arrest, be managed during pregnancy?
< What are the general approaches to pregnancy management antepartum, intrapartum, and postpartum
for the patient with cardiovascular disease?
< How should in-hospital postpartum care be altered for women with or at risk of cardiovascular disease?
< What are the contraceptive options and considerations for women with heart or cardiovascular disease,
or both?
< What are the long-term considerations and implications after pregnancy for women with cardiovascular
disease?

or class III/IV heart failure, severe valvular stenosis,

Summary of Marfan syndrome with aortic diameter more than
Recommendations 45 mm, bicuspid aortic valve with aortic diameter
more than 50 mm, or pulmonary arterial
and Conclusions hypertension.
The following recommendations and conclusions are The following recommendations and conclusions are
based on limited or inconsistent scientific evidence based primarily on consensus and expert opinion
(Level B): (Level C):

< Referral to a hospital setting that represents an appro- < Health care providers should become familiar with
priate maternal level of care dependent upon the specific the signs and symptoms of cardiovascular disease as
cardiac lesion is recommended for all pregnant patients an important step toward improving maternal
with moderate- to high-risk cardiac conditions (modified outcomes.
WHO risk classes III and IV) because outcomes are < Women with known cardiovascular disease should be
significantly better for women in these facilities. evaluated by a cardiologist ideally before pregnancy or
< It may be helpful to obtain a baseline BNP level as early as possible during the pregnancy for an
during pregnancy in women at high risk of or with accurate diagnosis and assessment of the effect preg-
known heart disease, such as dilated cardiomyopathy nancy will have on the underlying cardiovascular dis-
and congenital heart disease. ease, to assess the potential risks to the woman and
< All pregnant and postpartum patients with chest pain fetus, and to optimize the underlying cardiac condition.
should undergo standard troponin testing and an elec- < Patients with moderate and high-risk cardiovascular
trocardiogram to evaluate for acute coronary syndrome. disease should be managed during pregnancy, deliv-
< Patients should be counseled to avoid pregnancy or ery, and the postpartum period in medical centers with
consider induced abortion if they have severe heart a multidisciplinary Pregnancy Heart Team that in-
disease, including an ejection fraction less than 30% cludes obstetric providers, maternal–fetal medicine

1068 Practice Bulletin No. 212 Summary OBSTETRICS & GYNECOLOGY

© 2019 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
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 subspecialists, cardiologists, and an anesthesiologist tional testing or care during pregnancy. The fre-
at a minimum. quency of monitoring necessary is indicated in the
< Discussion of cardiovascular disease with the woman patient’s modified WHO classification.
should include the possibilities that 1) pregnancy can < Any pregnant woman who presents with an arrhyth-
contribute to a decline in cardiac status that may not mia should undergo evaluation to assess the cause
return to baseline after the pregnancy; 2) maternal and the possibility of underlying structural heart
morbidity or mortality is possible; and 3) fetal risk of disease.
congenital heart or genetic conditions, fetal growth
< Pregnant or postpartum women who present with
restriction, preterm birth, intrauterine fetal demise, shortness of breath, chest discomfort, palpitations,
and perinatal mortality is higher when compared with arrhythmias, or fluid retention should be evaluated
risk when cardiovascular disease is not present. for peripartum cardiomyopathy. An echocardio-
< A personalized approach estimating the maternal and gram is generally the most important diagnostic
fetal hazards related to the patient’s specific cardiac test.
disorder and the patient’s pregnancy plans can pro-
vide anticipatory guidance to help support her deci- < Every pregnant or postpartum patient with chest pain
or cardiac symptoms should have consideration of
sion making. For some patients, the prepregnancy
acute coronary syndrome.
evaluation may suggest a pregnancy risk that is
unacceptable. For those women, reproductive alter- < Although maternal cardiac arrest occurs infrequently,
natives, such as surrogacy or adoption, and effective the health care provider should be prepared to man-
contraceptive methods should be discussed. age this situation in any health care facility.
< All women should be assessed for cardiovascular < The infrequency of maternal cardiac arrest under-
disease in the antepartum and postpartum periods scores the need for regular team training and practice
using the California Improving Health Care Response of resuscitation skills and scenarios through simula-
to Cardiovascular Disease in Pregnancy and Post- tion training.
partum toolkit algorithm. < Women with complex congenital or noncongenital
< All pregnant and postpartum women with known or heart disease should be treated by a Pregnancy Heart
suspected cardiovascular disease should proceed with Team.
further evaluation by a Pregnancy Heart Team con- < Women with stable cardiac disease can undergo
sisting of a cardiologist and maternal–fetal medicine a vaginal delivery at 39 weeks of gestation, with
subspecialist, or both, and other subspecialists as cesarean delivery reserved for obstetric indications.
necessary. < Health care providers should be aware of cardiac
< Testing of maternal cardiac status is warranted medications with obstetric implications as well as
during pregnancy or postpartum in women who obstetric medications with cardiac implications.
present with symptoms such as shortness of breath, < A postpartum follow-up visit (early postpartum visit)
chest pain, or palpitations and known cardiovascu- with either the primary care provider or cardiologist is
lar disease whether symptomatic or asymptomatic, recommended within 7–10 days of delivery for
or both. women with hypertensive disorders or 7–14 days of
< An echocardiogram should be performed in pregnant delivery for women with heart disease/cardiovascular
or postpartum women with known or suspected disorders.
congenital heart disease (including presumed cor- < All postpartum women with cardiovascular disease
rected cardiac malformations), valvular and aortic and those identified as at high risk of cardiovascular
disease, cardiomyopathies, and those with a history of disease should be educated on their individual risk.
exposure to cardiotoxic chemotherapy (eg, doxoru- < Decisions regarding the most appropriate contracep-
bicin hydrochloride). tive option for a woman require discussion of her
< Congenital heart disease in the woman should prompt future pregnancy desires and personal preferences, as
fetal echocardiography, and conversely, identification well as critical assessment of the patient’s underlying
of congenital heart disease in a fetus or neonate may disease and the relative risks and benefits of the
prompt screening for parental congenital heart contraceptive option considered.
disease. < Intrauterine devices are the recommended non-
< Women with asymptomatic valve disease should be permanent option for women with high-risk cardio-
monitored by a cardiologist and may require addi- vascular conditions.

VOL. 133, NO. 5, MAY 2019 Practice Bulletin No. 212 Summary 1069

© 2019 by the American College of Obstetricians

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[Table 2] How to Differentiate Common Signs and Symptoms of Normal Pregnancy Versus
Those That Are Abnormal and Indicative of Underlying Cardiac Disease

Abbreviations: BP, blood pressure; CVD, cardiovascular disease; CXR, chest x-ray; HR, heart rate; JVP, jugular venous pressure;
OSA, obstructive sleep apnea; RR, respiratory rate.
*If unclear, any combination of factors in the yellow column that add up to 4 or more should prompt further evaluation.
†
Data in this column from Afshan B. Hameed, Christine H. Morton, and Allana Moore. Improving Health Care Response to
Cardiovascular Disease in Pregnancy and Postpartum. Developed under contract #11-10006 with the California Department of
Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health,
2017. Available at https://www.cmqcc.org/resources-toolkits/toolkits/improving-health-care-response-cardiovascular-disease-
pregnancy-and.
z
History of CVD or signs and symptoms in the red column should lead to urgent evaluation by the Pregnancy Heart Team.
§
Should raise concern about heart failure and should promptly be evaluated.
Modified from Thorne S. Pregnancy and native heart valve disease. Heart 2016;102:1410–7.

1070 Practice Bulletin No. 212 Summary OBSTETRICS & GYNECOLOGY

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[Table 4] The Pregnancy Heart Team

Modified WHO Modified WHO

Pregnancy Risk Pregnancy Risk Modified WHO Pregnancy Risk
Classification I Classification II Classifications III and IV

Pregnancy Obstetrician, family Obstetrician, family Obstetrician, family medicine practitioner,

Heart Team medicine practitioner, medicine practitioner, maternal–fetal medicine subspecialist, internist,
Members internist internist obstetric anesthesiologist, cardiology sub-
specialists in adult congenital/aortopathy*, heart
Maternal–fetal medi-
rhythm*, heart failure*, pulmonary hypertension*,
cine subspecialist
and cardiac imaging*
Cardiologist Cardiologist Interventional cardiologist*
consultation consultation Cardiac surgeon*
Neonatologist*
Geneticist*
Mental health specialist*
Pharmacist*
Abbreviation: WHO, World Health Organization.
*Ad Hoc members of a Pregnancy Heart Team.

Studies were reviewed and evaluated for quality

according to the method outlined by the U.S.
Preventive Services Task Force. Based on the highest
level of evidence found in the data, recommendations are
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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by
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© 2019 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.