Abigail Khan, M.D.
Dr. Khan specializes in adult congenital heart disease, cardiac disease in pregnancy, echocardiography and adult general cardiology. She works with patients who are making the transition from childhood to adult care. She also has a strong interest in caring for women with heart problems of all types who are pregnant or contemplating pregnancy.
Pregnancy and Heart Health
In the case of heart disease and pregnancy, two groups of patients warrant your particular concern: patients with known heart disease who have not been actively followed by a heart specialist and patients with cardiac symptoms who are pregnant or contemplating pregnancy.
In the first case, your patient may be one of the many patients with congenital heart disease who is lost to follow-up after leaving pediatric care, and who may not have received regular primary care. In the second case, your patient may have shortness of breath, palpitations or other symptoms. Could these be a result of pregnancy, or signs of undiagnosed acquired heart disease or untreated congenital heart disease?
Will my patient have to deliver in a specialty center?
Patients referred for cardiac consultation during pregnancy can return to your care if the risk of cardiac events during pregnancy and delivery is low. The cardiologist should work closely with the patient’s primary provider to determine the safest location for the patient to deliver. Patients at high risk may deliver in a tertiary care referral center, but contact should be maintained with the primary provider.
Most patients with cardiac conditions are eligible for vaginal delivery, or assisted vaginal delivery if the pushing stage of labor should be minimized to reduce cardiac risk.
Patients who have tolerated one pregnancy can generally have another child. However, because cardiac disease changes over time, assessment is important at the time of each pregnancy.
Risks and testing
Ideally, patients with congenital heart disease or another known cardiac condition will see a cardiologist before becoming pregnant to assess their risks. Once pregnant, they should see a cardiologist in the first trimester of pregnancy. Some cardiac medications can be safely used in pregnancy, if needed.
Exercise stress testing is not routinely necessary, but may be helpful for patients with complex cardiac conditions.
Women with congenital heart disease pass on a higher risk of congenital heart disease to the baby. The fetus also has a higher risk of intrauterine growth restriction and other complications.
For patients with congenital heart disease, we recommend fetal echography in the second trimester of pregnancy to look for defects. If a fetus has complex congenital heart disease, the mother should deliver at a center that has the appropriate resources to care for the baby immediately after delivery.
A mother who develops significant hypertension or preeclampsia has a higher risk of delivering a baby that is small for gestational age or born prematurely. Patients with acquired or congenital heart disease also have a higher risk of these pregnancy conditions, so coordinated maternal-fetal medicine and cardiac care is the best route to a safe outcome for mother and baby.
|Pregnancy not recommended for women with these conditions|
|Severe pulmonary hypertension, e.g., Eisenmenger syndrome|
|Severe aortic stenosis, left ventricular outflow tract obstruction or mitral stenosis|
|Conditions that lead to significant aortic dilation, e.g., Marfan syndrome if the aorta reaches a specific dimension or is severely enlarged|
|Native severe coarctation|
|Systemic ventricular dysfunction with ejection fraction <30% or NYHA Class III–IV heart failure symptoms|
Obstetrical complications raise later cardiac risk
Data now show that patients with obstetrical complications, even in the absence of current cardiac disease, are at greater risk of long-term heart problems. For example, a connection is becoming apparent between preeclampsia, gestational hypertension and acquired heart disease. These patients do not necessarily require specialty referral, but as a primary provider, you may wish to discuss long-term heart health.
The OHSU Knight Cardiovascular Institute includes specialists in all types of cardiac disease and is developing a Maternal Cardiac Disease program offering same-day, same-clinic heart evaluation and maternal-fetal evaluation. Many patients, including those traveling from a distance, can have all tests and appointments in one day. If you have questions or would like to refer a patient, please call the OHSU Physician Consult & Referral Service at 800-245-6478 or fax to 503-346-6854.Back to articles