Structural and functional
changes in the heart during
pregnancy in women with
cardiovascular diseases
2021-08-13 14:03
In a healthy woman with a normal pregnancy,
structural and functional changes in the heart are
adaptive in nature, slightly expressed and
completely normalized after childbirth.
#07/21 Keywords: Angiology , Pregnancy ,
Gynecology , Cardiology , Peripartal
cardiomyopathy , Heart defects ,
Cardiovascular risk , Echocardiography ,
Pregnancy , Gynecology , Cardiology ,
Peripartal cardiomyopathy , Heart diseases
, Cardiovascular risk , Echocardiography
NO ADS
Summary. In a healthy woman with a normal
pregnancy, structural and functional changes
in the heart are adaptive in nature, slightly
expressed and completely normalized after
childbirth. In a pregnant woman with certain
heart diseases, adaptive capabilities are
reduced, therefore, at any stage of pregnancy,
pathological changes can occur that
complicate its course and lead to adverse
outcomes. In addition, any pregnancy can
develop new heart conditions that can be fatal.
That is why an echocardiographic assessment
of structural and functional changes in the
heart is necessary both during normal
pregnancy and against the background of
concomitant cardiovascular diseases.
The importance of echocardiography (EchoCG)
in the examination of pregnant women for the
detection of structural and functional changes in
the heart today is beyond doubt, and its place is
determined by a number of modern clinical
recommendations. Thus, in 2018, the revised
recommendations of the European Society of
Cardiology (ESC) for the management of
patients with cardiovascular diseases (CVD)
during pregnancy were published [1], which
confirmed and clarified the main provisions for
the use of echocardiography in this group of
women. . A little earlier, the Russian national
guidelines “Diagnostics and treatment of
cardiovascular diseases during pregnancy” [2]
were approved, summarizing domestic and
most significant foreign clinical
recommendations for 2011-2017. In addition,
systemic reviews and meta-analyses have been
published in recent years, devoted to
intracardiac hemodynamics, cardiac
remodeling, cardiovascular pathology in
pregnant women, to some extent considering
issues related to the analysis and interpretation
of data obtained from echocardiography. In this
regard, the purpose of this article is to consider
the key points that doctors of the so-called
“multidisciplinary team” (cardiologist,
obstetrician-gynecologist, anesthesiologistresuscitator and other involved specialists) need
to know to assess the state of the heart during
planning, during and after pregnancy.
Determination of cardiovascular risk
when planning pregnancy
To date, according to health statistics and
based on clinical practice, it has been
established that, in general, cardiovascular
pathology is detected in at least 10% of
pregnant women and steadily occupies the
second place, after anemia, among extragenital
pathologies [2, 3]. These are arterial
hypertension (AH), congenital and acquired
heart defects (CHD and PPS, respectively),
cardiac arrhythmias, cardiomyopathy and some
other diseases. The nature of the disease and
the functional state of the heart determine the
course of pregnancy, the risk of complications,
and sometimes contraindications for pregnancy.
In this regard, when planning pregnancy, it is
advisable to assess the cardiovascular maternal
risk.
Determination of risk in women of childbearing
age with CVD should be carried out according
to the modified classification of the World Health
Organization (WHO) (Table 1) [1]. Along with
this, the risk should be clarified by the presence
of predictors of complications, the significance
of which has been proven in the CARPREG,
ZAHARA and ROPAC studies. These predictors
of the risk of complications in a mother with
cardiovascular pathology are summarized in
Table 1. 2.
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As can be seen from the tables, both the WHO
classification and the list of predictors of
complications are largely based on the structural
and morphological signs of heart and aorta
damage, ventricular dysfunction, and pressure in
the pulmonary artery detected and calculated by
echocardiography. So, for example, in diseases
of the aorta (this group includes the bicuspid
aortic valve, Marfan, Ehlers-Danlos syndromes
and others), in the absence of its dilatation, the
maternal risk is considered low, but it is
assessed as very high with dilatation over 45-50
mm, depending on pathology. Based on the
combination of signs indicating the possibility of
aortic dissection, pregnancy is contraindicated.
Quantitative echocardiographic parameters,
such as left ventricular ejection fraction (LVEF),
valve orifice area are of the same importance.
The risk is assessed not only before the first, but
also with each subsequent pregnancy. The need
for reassessment is understandable, since the
state of the heart can change both during the
onset of pregnancy and after it due to various
circumstances.
Structural and functional changes in
the heart during a normal pregnancy
The first EchoCG examination of a pregnant
woman is usually carried out at 12 weeks and
repeated in subsequent trimesters as necessary
if indicated [2].
During pregnancy in a healthy woman, the
volume of fluid increases by 40-100%, and the
volume of circulating blood - by 30-50%, which
inevitably leads to an increase in preload [4].
The first changes can be determined with
echocardiography already at the 5th week of
gestation, when an increase in stroke volume
and cardiac output by an average of 20% is
determined. By the 20th week of gestation, the
shifts increase, and the increase in these
indicators can be 30–50% higher compared to
the initial ones. By the end of the first trimester,
an increase in the size of the left atrium is clearly
recorded, by the end of the second trimester, an
increase in the size and volume of the left
ventricle is possible, which gradually increase
until childbirth [5]. In the third trimester, the LV
sphericity index increases. When comparing
indicators, LV volumes increase to the greatest
extent - by 30-50%, to a lesser extent, its size by an average of 11% [5]. However, they do not
go beyond the generally accepted norm.
At the same time, “physiological hypertrophy of
pregnant women” (pregnancy-induced
hypertrophy) is described, in which the thickness
of the walls of the left ventricle and the mass of
the myocardium increase. The maximum mass
of the myocardium is determined in the III
trimester of pregnancy. The total increase in
myocardial mass is sometimes up to 70-80%
relative to the original [6, 7]. It is important that
there are no violations of the function of the
heart.
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In the first trimester, Doppler sonography can
detect an increase in early diastolic filling
velocity (Ve) and a decrease in atrial systole
blood flow velocity (Va) of the transmitral
diastolic flow. At the end of the II and III
trimesters, the contribution of left atrial
contraction to left ventricular filling increases,
which is reflected in an increase in the Va
velocity and, accordingly, a relative decrease in
the E/A ratio. The isovolumetric contraction time
(IVRT) and flow deceleration time (DT) are
lengthened, but the acceleration time (AT)
remains stable [7]. In the first trimester, the rate
of systolic blood flow slightly increases and, at
the same time, the rate of diastolic blood flow in
the pulmonary veins decreases. It is important
that these changes occur in pregnant women
with normal blood pressure or slightly elevated
diastolic blood pressure due to the expression
of fetal genes, physiological hormonal changes.
A decrease in systolic longitudinal strain of the
basal, middle and apical segments of the left
ventricle and systolic strain of the right ventricle,
which are detected during a more in-depth study
using the strain, strain-rate modes, is described.
At the same time, no significant changes in the
radial and circular deformation of the ventricles
are recorded [8]. It should be noted that this
decrease is insignificant, short-term, not
accompanied by any clinical symptoms and
spontaneously resolves without treatment. At the
same time, no significant changes in the radial
and circular deformation of the ventricles are
recorded [8]. It should be noted that this
decrease is insignificant, short-term, not
accompanied by any clinical symptoms and
spontaneously resolves without treatment. At the
same time, no significant changes in the radial
and circular deformation of the ventricles are
recorded [8]. It should be noted that this
decrease is insignificant, short-term, not
accompanied by any clinical symptoms and
spontaneously resolves without treatment.
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Systolic pressure in the pulmonary artery
sometimes increases to 40 mm Hg. Art. Slightly,
by 2-3 mm, the size of the aortic root increases.
The appearance of mitral and tricuspid
regurgitation of 1-2 degrees is possible [1].
All these changes are reversible. Full
normalization is noted by 3-6 months after
delivery. Observations are described in which
recovery was recorded only after 1 year.
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Cardiac hemodynamics in multiple
pregnancy
Cardiac hemodynamics in singleton and
multiple pregnancies has a number of
differences. This is due to higher levels of
peripheral vascular resistance to arterial blood
flow in the fetal-placental circulation, which can
be considered as an adaptive reaction in
conditions of its increased functional stress in
multiple pregnancies. If in the first trimester of
pregnancy, the indicators of uteroplacental
hemodynamics in multiple and singleton
pregnancies do not differ significantly, then in
the future there is an intensive decrease in
vascular resistance of blood flow in the uterine
arteries, which leads to a change in
hemodynamic parameters, which are more
pronounced in multiple pregnancies. So,
In multiple pregnancy, the volume of circulating
blood rapidly increases in the II-III trimesters of
pregnancy and by the 34th week increases by
50-70% of the initial values. Such changes lead
to a significant increase in the work of the heart,
while the stroke volume of the heart increases
by more than 30%, the heart rate increases by
15-20%, and the total peripheral resistance
decreases by about 25%.
Pregnant women with arterial
hypertension
The following clinical variants of hypertension
during pregnancy are distinguished:
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• Hypertension before pregnancy;
• chronic hypertension;
• hypertension or symptomatic hypertension;
• gestational hypertension;
• chronic hypertension complicated by
preeclampsia;
• preeclampsia/eclampsia.
Determination or clarification of heart damage
as a target organ in hypertension, i.e. detection
of LV hypertrophy in conjunction with the
assessment of systolic and diastolic myocardial
function, are the primary tasks of
echocardiography in the management of
patients with hypertension and are necessary to
obtain additional information about prognosis
and risk. When hypertrophy is detected, it is
necessary to carry out a differential diagnosis
with physiological myocardial hypertrophy
(pregnancy-induced hypertrophy), which is
detected from the second trimester, and this
hypertrophy is usually concentric. In addition,
data from a number of studies demonstrate that
during pregnancy complicated by hypertension,
left ventricular myocardial mass and relative wall
thickness increase more than during
normotensive pregnancy [9].
Peripartum cardiomyopathy
A disease that occurs exclusively during
pregnancy or in the postpartum period (between
the last months of pregnancy and up to 5 months
after childbirth). Data on its frequency are
contradictory: from 1 case per 3000-4000
pregnancies to 1 case per 15,000 births [10],
which may indicate the difficulties of diagnosis.
This pathology is suspected in all cases when a
pregnant woman has signs of heart failure, heart
rhythm disturbances, and also if the condition
after childbirth slowly returns to normal. The risk
of peripartum cardiomyopathy is increased in
women over 30 years of age with multiple
pregnancies, preeclampsia, in patients with
bronchial asthma, and anemia.
Echocardiography is of priority in the detection
of peripartum cardiomyopathy. The diagnosis is
established on the basis of a set of clinical and
echocardiographic criteria [10, 11]:
1. Heart failure:
• last month of pregnancy;
• 5 months postpartum.
2. No previous heart disease.
3. The absence of a specific cause of the
disease, other than pregnancy.
4. Obvious echocardiographic signs of LV
dysfunction:
• ejection fraction less than 45% and/or
fractional shortening less than 30%;
• end-diastolic LV diameter greater than
2
2.7 cm/m
.
With a reduced ejection fraction (<35%),
thrombi form in the LV cavity, which is the cause
of thromboembolism.
Recovery and return to normal is achieved in
most, but not all women, and in some cases,
heart function has a positive trend, but only up to
certain values o
​ f the ejection fraction. With
incomplete recovery (“recovery with a defect”),
peripartum cardiomyopathy may reappear in
subsequent pregnancies [10].
Thus, the diagnosis of peripartum
cardiomyopathy is made by exclusion in the
absence of evidence of all other possible
causes of systolic insufficiency. That is why, in
each case, a very careful EchoCG assessment
of the structure and function of the heart is
necessary, a comparison of the obtained data
with the previous ones (the best is with the
EchoCG protocol before pregnancy) in order to
differentiate the existing picture with changes
occurring in severe preeclampsia, other forms
of cardiomyopathies, congenital and acquired
pathology of the heart, as well as with pulmonary
embolism, myocardial infarction, intracardiac
formations, sepsis.
Pregnant women with heart defects
In the structure of all CVD in pregnant women,
according to various sources, 30-50% are CHD,
about 15% - PPS [12, 13].
Establishing a diagnosis, assessing the
anatomy of the valve, hemodynamics, the
severity of the defect, including in terms of
indications for cardiac surgical correction during
pregnancy (for example, balloon
commissurotomy), monitoring pregnant women
in the postoperative period - these are the tasks
that face echocardiography [2]. ].
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In recent decades, the number of pregnant
women with congenital heart disease has
increased significantly due to the widespread
introduction of cardiosurgical methods of
correction. Girls operated on in early childhood
reach childbearing age. Their clinical condition,
quality of life are often quite satisfactory in order
to plan a pregnancy.
Initially, pregnant women with previously
confirmed congenital heart diseases should be
examined by echocardiography up to 10-12
weeks of gestation to determine the prognosis
of the possibility of carrying a pregnancy [2].
Based on the results of the examination,
together with a cardiologist, an obstetrician-
gynecologist and, if necessary, a cardiac
surgeon, a conclusion is made on the presence
or absence of contraindications to pregnancy,
the need for cardiac surgical treatment.
Further, in the normal course of pregnancy, no
risk or low risk, echocardiography is performed
at 18-22 and 27-32 weeks, as well as before
childbirth. A large frequency of
echocardiography is determined by the clinical
condition, the type of heart disease. Often, it is
the EchoCG conclusion that is decisive in
matters of further tactics of pregnancy
management and early delivery for medical
reasons. Caesarean section is reasonable in
patients with acute refractory heart failure,
severe aortic stenosis, severe pulmonary
hypertension (including Eisenmenger's
syndrome), or acute heart failure.
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mitral stenosis
In the structure of PPS in pregnant women,
mitral stenosis occupies the first place (about
60%) and is the most dangerous, with serious,
sometimes fatal complications associated with
it [14]. Often this defect is first diagnosed during
pregnancy. This is due to the fact that he
remains asymptomatic for a long time. When the
area of t​ he mitral orifice is more than 1.5 cm2,
the course of pregnancy is close to normal.
However, moderate and severe stenosis
(valvular orifice area less than 1.5 cm2) is
associated with clinical manifestations (primarily
shortness of breath) and a high risk of
complications such as pulmonary edema,
cardiac arrhythmias, and progressive heart
failure.
Echocardiography - assessment of valve
morphology in pregnant women with mitral
stenosis is of particular importance. The need
for balloon mitral commissurotomy depends on
the changes in the valve, whether there is
calcification of the leaflets. Currently, this
operation is performed successfully at any stage
of pregnancy, while the overall maternal mortality
does not exceed 1% (slightly higher, up to 2%,
with calcification of the valves), fetal death is
about 2%, and the level of postoperative
complications is low. At the same time, with
open commissurotomy and valve replacement,
fetal death occurs in 10-30% of cases. In
addition, when installing valve prostheses,
anticoagulants will be required in the future [15].
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The frequency of echocardiography depends on
the severity of mitral stenosis, the state of
hemodynamics. With mild mitral stenosis, a
stable condition of the pregnant woman,
examinations are performed in each trimester
and before childbirth. In moderate and severe at least once every two months or monthly [2,
14].
Mitral insufficiency
Mitral valve insufficiency in pregnant women is
usually of rheumatic origin, as well as due to
mitral valve prolapse, including due to
myxomatous degeneration. There is also
functional regurgitation in congenital heart
defects, including those operated on in
childhood.
Unlike mitral stenosis, complications in pregnant
women with this defect are infrequent, which is
explained by good adaptation to volume load as
a result of a decrease in total peripheral
vascular resistance during pregnancy and,
accordingly, a decrease in the volume of
regurgitation.
Echocardiography determines the severity of
regurgitation, the size of the cavities of the heart.
When planning pregnancy, patients with
moderate to severe regurgitation are advised to
perform an exercise test.
During pregnancy, in almost all cases, there is
an increase in the degree of regurgitation, the
size of the left cavities of the heart. The risk of
complications depends on the severity of
regurgitation and LV function. Note that mitral
regurgitation prevents the formation of blood
clots in the left heart. With mild and moderate
regurgitation, echocardiography is repeated
every month, with severe - at least once every 2
months [2, 14].
Aortic valve stenosis
When planning pregnancy, it is recommended to
determine the degree of aortic stenosis, as well
as to clarify the adaptive reserve of the
cardiovascular system by conducting a test with
physical activity. Thus, mild aortic stenosis is
characterized by good adaptation to volume
load, the absence of symptoms, and a favorable
course of pregnancy. On the contrary, in severe
aortic stenosis, the adaptation of the heart to the
load is much worse, but despite this, a favorable
course of pregnancy is also possible. With
echocardiography in patients planning
pregnancy with aortic stenosis, attention is paid
to LV function. In case of impaired systolic
function, according to the recommendations,
valvuloplasty or aortic valve replacement is
reasonable in all patients with severe aortic
stenosis with clinical symptoms, as well as with
asymptomatic disease, but impaired LV function
or decreased exercise tolerance. Otherwise,
pregnancy is not recommended.
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Echocardiography in cases of aortic stenosis
shows an increase in the size of the left ventricle
and atrium, as well as an increase in the
average and maximum pressure gradient from
trimester to trimester [16]. The area of t​ he aortic
orifice, ejection fraction, as a rule, do not
change.
Echocardiography is performed monthly in
severe aortic stenosis, in other cases once a
trimester [2, 14].
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Aortic insufficiency
In severe aortic regurgitation with LV dysfunction
and acute aortic regurgitation, pregnancy is
poorly tolerated. Therefore, such patients need
to be examined before pregnancy. Focus on
determining the severity of regurgitation,
measuring the size and function of the left
ventricle, the size of the aorta. If severe
regurgitation is detected in combination with
dysfunction or dilatation of the left ventricle, the
defect needs to be corrected before pregnancy
[16] due to the high risk of developing heart
failure. Echocardiography in patients with mild
and moderate regurgitation is performed every
3 months, but in severe regurgitation, the
frequency is set individually, based on the
woman's condition and the course of pregnancy
[2, 14].
Tricuspid insufficiency
Tricuspid regurgitation in pregnant women in the
vast majority of cases is functional due to
pressure and / or volume overload of the right
ventricle. However, with severe dilatation of the
valve ring (≥ 40 mm), moderate and severe
tricuspid regurgitation, the patient should be
consulted with cardiac surgeons to decide on
surgical intervention. When planning a
pregnancy in patients with severe regurgitation,
surgery before pregnancy is recommended.
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Dilatation of the ascending aorta
Dilatation of the ascending aorta is detected in
approximately 50% of pregnant women with a
bicuspid aortic valve. In these cases, the size of
the aorta is especially closely monitored during
each EchoCG examination [17]. If a woman
planning pregnancy has a diameter of the
2
ascending aorta ≥ 50 mm (27.5 mm/m ), then,
regardless of the presence of symptoms, it is
necessary to discuss the possibility of surgery
before pregnancy, since the degree of dilatation
may increase and there is a risk of its
dissection. The risk of aortic dissection is higher
in Marfan-Ehlers-Danlos syndrome.
Women with aortic root dilatation over 40 mm,
dilatation of the ascending aorta are
recommended to undergo echocardiography
every 4-8 weeks and 6 months after delivery
[17]. Increase in size during pregnancy is
considered a risk factor for aortic dissection.
For patients with an aortic diameter of more
than 45 mm, with Marfan's syndrome, in which
the aortic diameter is 40-45 mm, acute or
chronic dissecting aortic aneurysm, operative
delivery is advisable.
Conclusion
Thus, echocardiography is necessary to assess
the structural and functional state of the heart
during pregnancy, especially in women with a
history of cardiovascular pathology. The
frequency of examination and the algorithm are
individual and depend on the severity of
comorbidity [18]. The correct interpretation of
the obtained EchoCG changes allows the
doctor to conclude that the changes in the
woman's body have a normal or pathological
effect on the heart. An echocardiogram is
mandatory to assess maternal risk, determine
indications / contraindications for pregnancy, as
well as the method of delivery.
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CONFLICT OF INTEREST. The authors of the
article confirmed the absence of a conflict of
interest, which must be reported.
CONFLICT OF INTERESTS. not declared.
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А. А. Аракелянц 1 , кандидат медицинских
наук
Т. Е. Морозова, доктор медицинских наук,
профессор
Е. А. Барабанова, кандидат медицинских
наук
Е. О. Самохина, кандидат медицинских
наук
РЕКЛАМА
ФГАОУ ВО Первый МГМУ им. И. М.
Сеченова Минздрава России, Москва,
Россия
1 Контактная
информация:
nxrrimma@mail.ru
Структурно-функциональные изменения
сердца при беременности у женщин с
сердечно-сосудистыми заболеваниями/ А. А.
Аракелянц, Т. Е. Морозова, Е. А.
Барабанова, Е. О. Самохина
Для цитирования: Аракелянц А. А., Морозова
Т. Е., Барабанова Е. А., Самохина Е. О.
Структурно-функциональные изменения
сердца при беременности у женщин с
сердечно-сосудистыми заболеваниями //
Лечащий Врач. 2021; 7 (24): 18-23. DOI:
10.51793/OS.2021.24.7.004
Теги: женщины, беременные, сердечнососудистые заболевания
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