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Page 10 of 17 Saxena et al. Vessel Plus 2022;6:15 https://dx.doi.org/10.20517/2574-1209.2021.96

Table 3. Indications for caesarean delivery in women with congenital heart disease [1]
Indications for caesarean delivery
Significant aortopathy with ascending aorta dilation > 45 mm
Severe forms of pulmonary hypertension (including Eisenmenger’s syndrome)
Severe left heart obstruction
Severe ventricular dysfunction with heart failure
Pre-term labor on oral anticoagulation

and signs of apparently minor problems must be taken seriously and managed promptly. Ergometrine is
best avoided in the third stage of labor. Lactation should be encouraged whenever possible as it is associated
with a low risk of bacteremia secondary to mastitis. In women with moderate to severe CHD, mixed feeding
(artificial and breast feeding) is better than breastfeeding alone.

Interventions for CHD during pregnancy
The decision to perform intervention during pregnancy requires careful assessment by the cardio-obstetric
team. The indication of intervention is usually severe cardiac failure with significant risk to both the mother
and fetus. Procedures should be performed by experienced teams at tertiary care centers only.

Percutaneous therapy
Women with CHD having an absolute indication for percutaneous intervention (e.g., symptomatic severe
aortic stenosis/severe pulmonary stenosis/coarctation of aorta, mitral stenosis, and refractory arrhythmias
amenable to ablation) should preferably undergo the procedure in the second trimester. This is because
organogenesis is complete by this time and the uterus is still small and away from the chest which is exposed
to radiation. The principle of “as low as reasonably achievable” radiation dose must be followed. Some of
the maneuvers for minimizing radiation exposure include use of alternative imaging such as
echocardiography, using low-dose fluoroscopy, avoiding oblique and lateral projections, and minimizing
the area exposed and fluoroscopy time [1,39] . Abdominal shielding also helps to lower the radiation dose to the
fetus.

Cardiac surgery under cardiopulmonary bypass
Open heart surgery is recommended only if medical therapy and percutaneous intervention fail and the
mother’s life is threatened. Some of the indications for surgery during pregnancy include aortic aneurysm
with impending rupture, worsening heart failure due to infective endocarditis, and severe symptomatic left
heart obstruction. Optimal time for surgery is between 13 and 28 weeks of gestation. When gestational age
is more than 28 weeks, delivery after fetal lung maturity induction should be considered before cardiac
surgery. Surgery under cardiopulmonary bypass (CPB) carries about 20% risk of fetal loss, while the
[1]
maternal mortality is not higher than usual . To diminish the risk of fetal loss during CPB, it is
recommended to minimize CPB time, maintain pump flow > 2.5 L/min/m and perfusion pressure of
2
> 70 mmHg, and use pulsatile flow and normothermic perfusion [1,40] .

MANAGEMENT OF COMMON COMPLICATIONS SEEN IN WOMEN WITH CHD
Heart failure
The results from the European registry revealed the overall incidence of heart failure as 6.6% of all pregnant
women with CHD, with a higher risk of 8.7% in those with uncorrected CHD [12,22] . The peak incidence of
heart failure is towards the end of the second trimester and during or just after delivery . It should be
[38]
emphasized that the manifestation of heart failure may differ between different CHDs. Women with
systemic right ventricle (RV), history of Fontan surgery, and dysfunctional RV after Tetralogy of Fallot