Katherine A. Singh, MD

Katherine A. Singh, MD

Thursday, August 25, 2016


During pregnancy, changes occur to the heart and blood vessels. These changes put extra stress on a woman’s body and require the heart to work harder. Some heart changes, such as increase in blood volume and heart rate, are normal during pregnancy and help ensure that the baby will get enough oxygen and nutrients. If you have a heart condition you may need to take special precautions before and during pregnancy. Cardiologist Dr. Majdalany and Obstetrician Dr. Singh answers your questions.

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Congenital Heart Disease and Pregnancy

Karin: If a person has a congenital heart problem - what is the likelihood the baby will have the problem?

Katherine_Singh,_MD: If there is no known genetic cause of the mother's heart disease, then the risk to her children is maybe as low as 2-5 percent. When our patients are known to have congenital heart disease, we do recommend a fetal echo during the pregnancy to make sure the baby's; heart looks healthy. If there is a genetic cause association, the risk is much higher.

JessieG: I was recently diagnosed with an AVSD and pulmonary hypertension. I am a 27-year-old female. I experienced shortness of breath throughout my pregnancy. My daughter was born a month ago and my appointment is next week to plan out the next steps. Is it better to close this type of defect by surgery or a non-surgical procedure? After closure will I be able to go through pregnancy again?

David_Majdalany,_MD: Pulmonary hypertension poses a risk during pregnancy as well as after delivery for the mom.  I would recommend you get assessment with experts at a congenital heart disease center including echo and cardiac cath to assess the reversibility and severity of the pulmonary hypertension as well as the significance of the AVSD shunt. Depending on these results surgical intervention may be considered. It would be worthwhile to have this completed prior to next pregnancy. We would be happy to see you and evaluate you here.

Katherine_Singh,_MD: It is very important to optimize your health before next pregnancy and consider family planning and spacing out pregnancy to allow recovery between pregnancies. It needs to be addressed sooner rather than later.

Carla3659: If I am worried about congenital heart disease in my baby (we have it in our family) - when will it show up in the pregnancy? What can they see in the ultrasound? I understand there are some things that can even be fixed before the baby is born - is that true?

Katherine_Singh,_MD: Usually we can do a screening ultrasound to look for signs of a heart defect at 11 - 13 weeks called a nuchal translucency ultrasound - but the details of the baby's heart cannot be seen this early on. At 18-20 weeks we recommend a detailed anatomy survey done by a fetal maternal medicine specialist. In women at high risk for having a baby with congenital heart defects, we recommend a fetal echo often done by a pediatric cardiologist to do a more detailed evaluation of the baby's heart. A large portion of congenital heart disease can be detected prenatally by this approach. However, there are still many cardiac defects which cannot be diagnosed before a baby is born.

SummerFL: Hello - I lost my first child due to hypoplastic left heart; my second child has a heart murmur, watching. I do have a history of DVT but no other heart problems - should I see a cardiologist? Not sure if I should have more children - would like another - but what is the likelihood for future problems with these conditions?

David_Majdalany,_MD: I would recommend that you at least have an echocardiogram to evaluate any congenital heart disease and seek vascular medicine testing for possible hypercoagulable state if this DVT was unprovoked. There is an increase in developing blood clots during pregnancy and testing for thick blood conditions would be prudent.

Katherine_Singh,_MD: You may want to see a maternal fetal specialist and genetic consultation before conceiving your next child. We may continue anticoagulation during your next pregnancy due to increased risk of clots during pregnancy and postpartum. Regarding the child you lost, we would recommend in future pregnancy we do a detailed fetal anatomic survey and fetal echo. I am sorry for your loss.

ylcs32: I have a PFO - but it is small and not treated. I am thinking about pregnancy. Will that affect my pregnancy?

David_Majdalany,_MD: Patent foramen ovale is a normal variant with small communication between top two chambers of the heart. It is present in about 25% of the population. In view of increased risk of clots during pregnancy, it would be prudent to be on low dose aspirin and take measures to prevent blood clots during pregnancy such as early ambulation after delivery and avoiding being sedentary on long trips.

Katherine_Singh,_MD: My patients with PFO do very well during pregnancy. I usually do the same approach with low dose aspirin daily and in most women encourage they stay active, watch weight and avoid risk factors for blood clots in legs or lungs. At the time of delivery, before they place an IV line. Let your provider know about the history so other complications can be prevented. All IVs should have an air filter.

Symptoms and Pregnancy

LauraK: My friend is pregnant and had to go to the doctor for heart rate fast and dizziness - they sent her to the cardiologist. Is this common to have heart problems during pregnancy? What does that mean for rest of pregnancy?

Katherine_Singh,_MD: Luckily it is not common to have new onset heart problems during pregnancy. It can happen but is thankfully rare. The risks of the remainder of the pregnancy are dependent on what was determined to be the problem and how well controlled it is. It is most likely that your friend will be okay as long as she is getting good care.

High Blood Pressure and Pregnancy

mamafran: I had high blood pressure during pregnancy and was on bed rest. Thank goodness healthy baby born. I have read recently that this can cause problems later in life - for example, risk of heart disease in the future. And - what about future pregnancies - can I continue with my current OB or do you think I need to switch to a high-risk OB?

Katherine_Singh,_MD: It depends on what other complications occurred and how early you delivered and how well your blood pressure remains controlled before your next pregnancy. Most cases of high blood pressure and pregnancy can be controlled by a general OB in the future but sometimes co-management is required by a specialist.

Heart Medications and Pregnancy

avlosh8: Do I need to stop taking certain heart medications during my pregnancy? Is there any way they could affect my baby's development?

Katherine_Singh,_MD: There are some medications that are considered to be safe in pregnancy - there are some medications that pose a greater risk to mom and baby - it depends on what the medication is and why they are needed, and if there are alternatives available that may be less risky.

David_Majdalany,_MD: Concerning drugs would include blood thinners (Coumadin), blood pressure medications (ACE inhibitors/angiotensin receptor blockers), certain medications for rhythm control and certain medications for cholesterol control are a few examples where alternative medications would need to be considered.

Valve Disease and Pregnancy

KittyHalp: Hello, I'm a 34-year-old female, athletic and otherwise in great health. Recent stress test showed BAV dilation of 4.2 (first diagnosis in 2010 of 3.1). I'm ready to start a family and concerned about extra blood volume/pressure.
1. Should I consider valve replacement before pregnancy? Should I consider a surrogate?
2. Does pregnancy often increase BAV diameter?
3. What types of pre-pregnancy and pregnancy steps and precautions do you recommend?
4. At what measurement is replacement valve recommended.
Thank you!

David_Majdalany,_MD: 1) We know bicuspid valves are associated with valve dysfunction - leakiness or narrowing as well as dilation of aorta. In the setting of a dilated aorta >4 cm there is concern for more dilation during pregnancy.  I would recommend you have Cardiac MRI to better assess the whole aorta. A recent echo would be important to make sure you don't have significant valve narrowing or leakiness before pursuing pregnancy. 2) Would recommend meeting with a Cardio OB Center prior to pregnancy. Yes, the aorta usually increases in size (~2 mm is expected in normal pregnancy).  I would recommend optimal blood pressure control - that is the preventive measure to avoid/limit further dilation of the aorta.

Katherine_Singh,_MD: Tomographic imaging (CT and MR) monitoring, see a high-risk OB specialist to make sure diet, weight is healthy, appropriate medications is a great step - and I applaud you for thinking about these things before pregnancy.

KittyHalp: 34-year-old female with BAV (4.2)

  • At what point do you propose valve replacement surgery (I am currently at 4.2)?
  • Please speak about exercise. I'm an endurance athlete (frequently cycle 60-120 miles). I have been told by some cardiologists to tone it down. Others encourage it and say as long as I feel fine, I'm free to continue. Would value your thoughts and opinion.
  • Some cardiologists have said the BAV valve WILL increase during pregnancy. But will decrease within 6 months postpartum. Others have said once valve increases, it does not (ever) decrease. What has been your experience?
  • BAV at 4.2, would you recommend a surrogate?

David_Majdalany,_MD: Interventions for surgical intervention would include: symptomatic; significant valve disease with either severe narrowing or leakiness of valve; progressive decrease in heart function or dilation; progressive increase in the size of the aorta (more than 0.5 cm/year). We would certainly consider surgical intervention if the aortic size is nearing 5 - 5.5 cm. At the level of your dilation with a normally functioning aortic valve - I would not restrict a patient from aerobic exercise. - but I would advise that they avoid isometric exercises such as weight lifting or exercises where you have to persistently strain to complete. Would recommend maintaining optimal blood pressure as a preventive measure. We do expect some dilation of the aorta during pregnancy (1-2 mm) and I usually follow patients with echo during pregnancy to monitor aorta size. The increased demands on the heart with increased blood volume during pregnancy may alter our assessment of the valve function during pregnancy and those changes will subside post-pregnancy. Your last question would be an individualized decision and would recommend a follow up with our cardio obstetrics clinic to discuss this further.

Katherine_Singh,_MD: For women who do decide to conceive with a BAV or any heart disease luckily we have a multidisciplinary approach - and many resources to take care of these women. The decision to have a baby with a cardiac condition should take into account OB input and cardiology input and also the women's own beliefs about what is important for her.

I applaud your involvement in your heart care and your physical fitness for sure!

KittyHalp: Who are the specialists that handle BAV issues during pregnancy?

David_Majdalany,_MD: At Cleveland Clinic, we have a combined clinic - Cardio OB Clinic - which includes cardiologists and high-risk obstetrics. You are welcome to come see me at Cleveland Clinic. We do have other colleagues in our cardiology division who see patients with BAV.

Sharon30: I am 30 and have a mechanical heart valve - is it possible to have a safe pregnancy?

David_Majdalany,_MD: Anticoagulation regimen during pregnancy is still somewhat controversial and there are multiple approaches. There is no optimal anticoagulation regimen during pregnancy - all options have risks with it. Coumadin has risks of embryopathy during first trimester. Heparin (unfractionated or low molecular) has risks of valve thrombosis - so the approach we have been following is no Coumadin for first trimester (start as Lovenox) and transition to Coumadin second trimester to almost to delivery and then put back on heparin or Lovenox. Both heparin and Lovenox require monitoring. We would closely follow your anticoagulation parameter during all stages of pregnancy.

Katherine_Singh,_MD: I totally agree. It is a high-risk pregnancy that requires intensive monitoring and close and intensive care with multiple sub-specialists. Such as cardiac, OB and sometimes vascular medicine. We have had good outcomes but it does require a lot of care.

Post-Partum Cardiomyopathy

LawrenceKay: My wife had twins with hypertension treated throughout pregnancy. After the birth of the twins, she was rushed to hospital with cardiac distress and diagnosed as postpartum cardiomyopathy. She is now on medications and was discharged from the hospital. Will this improve or go away with time, or will her condition always be there?  She is very tired, controlling swelling and heart with medications. We are hoping for a long happy family and wonder what prognosis is after this?

Katherine_Singh,_MD: Most women do greatly improve and recover - it may require medications and close follow-up with a cardiologist. It will be important to assess the health of your heart prior to a future pregnancy and it will be important to have an appointment with a high-risk OB to discuss any high risk - risk factors.

David_Majdalany,_MD: Some of the best medications we use for cardiomyopathy are contraindicated during future pregnancy - even if the heart recovers we would want to assess and determine the types of medications you should be on prior to any future pregnancies.

Arrhythmia (Heart Rhythm Problem) and Pregnancy

royal77: I am a 35-year-old woman in my first trimester of pregnancy. I was diagnosed as having 3rd degree complete heart block and scheduled for a pacemaker. The cardiologist thinks that the heart block may be congenital? Is this common to develop heart block during pregnancy? Is there anything I should know about getting a pacemaker during pregnancy - which I should ask the doctor about before the procedure?

David_Majdalany,_MD: Third-degree heart block is an indication for pacemaker implantation to optimize the timing of the contraction between the top and bottom chambers of the heart and optimizing cardiac output. I would recommend having it done with an electrophysiologist (cardiologist that specializes in rhythm problems) and they can follow protective measures to limit radiation exposure during the procedure. There are increased demands of the heart during pregnancy - the cardiac output is increased - so optimizing the heart output would be important for you to have a successful pregnancy and proper growth of the baby.  We would recommend that you also get an echocardiogram if not done before to screen for structural heart disease.

Coronary Artery Disease (CAD) and Pregnancy

valgriff: What are the risks with CAD and pregnancy? Are there any?

Katherine_Singh,_MD: If you have known coronary artery disease there is a risk of worsening disease and decreased blood flow to the heart. If someone has an event such as heart attack during pregnancy there is a risk to the baby.

Coronary artery disease is not a common cause of heart attacks for women in child bearing age although there has been increased incidence with increasing risk factors such as metabolic syndrome, diabetes, obesity, older maternal age, hypertension, high cholesterol, and smoking. One of the concerns would also be the etiology of the heart attack if this is due to blockage of the heart artery vs. dissection of the artery. Ischemic evaluation (stress testing) would be suggested prior to future pregnancies in patients with CAD; depending on their symptoms and what prior interventions have been performed for their CAD. If someone is trying to have a baby and has CAD, they definitely should have a visit with a high-risk OB and cardiologist. Patients who have CAD are typically on cholesterol-lowering drugs, drugs to control blood pressure and anti-platelet meds. Reviewing standard medications for CAD and determining safer alternatives during pregnancy may be necessary.

IVF (In Vitro Fertilization) and Pregnancy

ballashrd: Is there an increased risk of heart disease with IVF?

Katherine_Singh,_MD: That is a hard question. There are a few studies that suggest that may be true but other studies that speak against it. There are some experts that may suggest that the only reason that there are some congenital heart disease in babies conceived via IVF is due to increase in twin pregnancies or underlying maternal conditions that predispose women to have babies with heart defects, for example, diabetes or pre-diabetes, obesity.

Reviewed: 09/16

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