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repair are more predisposed to develop heart failure. Reversible factors such as arrhythmia and anemia
should be actively looked for. Management includes bed rest, supplemental oxygen, fluid balance, and
careful diuretic use. Some of the drugs used in the treatment of heart failure, such as angiotensin converting
enzyme inhibitors, angiotensin receptor blockers, and spironolactone, are contraindicated during
pregnancy, although beta-blockers can be used if indicated. Hydralazine and nitrates can be used for
[1]
afterload reduction, but angiotensin converting enzyme inhibitors are best started after delivery . In the
case of refractory heart failure in the mother, baby should be delivered irrespective of duration of gestation.
Corticosteroid use for fetal lung maturity is avoided due to risk of fluid retention and worsening of heart
failure .
[5]

Arrhythmias
Arrhythmias are one of the common complications in adults with CHD and complicate a substantial
number of pregnancies [3,22,29] . The most common types of tachyarrhythmias are intra-atrial re-entrant
tachycardia caused by atrial scars, and atrial fibrillation. The incidence of arrhythmia depends on time since
surgery, underlying cardiac condition, and aging. Tachyarrhythmias can be associated with life threatening
symptoms and increase the risk of thromboembolic complications and occurrence of heart failure.
Therefore, in women with significant tachyarrhythmias, catheter ablation or implantable cardiac
defibrillator implantation should be performed before conception, if clinically indicated . If the indication
[1]
emerges during pregnancy, then it is recommended to use echocardiographic guidance and 3D mapping to
prevent radiation-induced fetal adverse effects.

Direct cardioversion is recommended in the case of hemodynamically unstable arrhythmias and is reported
to be safe and effective during pregnancy . Regarding antiarrhythmic therapy, beta-blockers are the first
[1]
choice for most arrhythmias as most other anti-arrhythmic drugs come under United States Food and Drug
Administration category C and therefore their use depends on the risk-benefit ratio [5,20] .

Anticoagulation
Women with prosthetic heart valves, previous history of thromboembolic complications, or high-risk
anatomy such as post-Fontan surgery may require anticoagulation during pregnancy. It is important to
highlight that all anticoagulant regimes have an inherent risk of causing subplacental bleed leading to
[41]
pregnancy loss . Anticoagulation with warfarin provides the lowest risk for thrombosis but has a risk of
causing warfarin embryopathy if used in the first trimester. Current guidelines recommend continuation of
warfarin throughout pregnancy in women requiring low doses (< 5 mg) to maintain therapeutic
international normalized ratio due to low risk of embryopathy [1,42] . These women should be mandatorily
switched to unfractionated heparin after 36 weeks of gestation due to the risk of lethal intracranial
hemorrhage in the fetus during vaginal delivery.

Infective endocarditis
[43]
IE is rare with an annual incidence of 1 per 1000 in patients with CHD . Women with uncorrected
cyanotic CHD or repaired CHD using artificial patch or prosthetic valve or previous history of endocarditis
are eligible for IE prophylaxis, but the guidelines do not recommend antibiotic prophylaxis during delivery
due to lack of convincing evidence . The diagnosis and treatment of IE during pregnancy is the same as in
[1]
the non-pregnant patient, but due consideration needs to be given to fetotoxic potential of antibiotics.

MANAGEMENT OF SPECIFIC CONGENITAL HEART DISEASES
Pulmonary hypertension and Eisenmenger syndrome
Pulmonary hypertension (PH) in the mother could be due to Eisenmenger syndrome, idiopathic pulmonary
arterial hypertension and PH related to lungs, or left heart disease. Maternal mortality has classically been