Review Question - QID 103453

Cyanotic heart disease is a contraindication to pregnancy. Thus, the correct answer is to advise against pregnancy with this mother's heart condition.

Pregnancy results in dramatic changes in maternal circulatory physiology, such as decreased systemic vascular resistance, increased circulatory volume, and increased venous return (due to increased metabolic demands of end organs). Pregnancy in a woman with congenital heart disease (such as unrepaired patent ductus arterioses, atrial septal defects, and VSDs) can result in Eisenmenger's syndrome; the reversal of a baseline left-to-right shunt to a right-to-left shunt. This reversal of flow can result in profound hypoxia and severe complications for both the mother and fetus. Maternal mortality under these conditions can reach 30-50%.

Ho et al. discuss radiographic evaluation of adults with congenital heart defects, reporting "radiologic imaging is critical for the initial assessment and for surveillance in this population. Chest radiography and echocardiography are valuable first-line tools for evaluation. However, magnetic resonance imaging and computed tomography are often necessary, particularly for assessment of extracardiac anatomy or specific vascular connections or relationships, which may be complex in postoperative patients."

Anaanaba et al. discuss the complex management of pregnant patients with cyanotic heart diseases, reporting "it is well known that pregnancy may result in circulatory changes that could adversely affect the health status of a healthy patient. In a patient with [congenital heart disease], with or without repair, the normal change in circulatory burden could increase adverse effects.

Illustration A depicts the progression of a VSD into Eisenmenger's Syndrome with resulting hypoxia. Initially the shunt is left-to-right which does not result in cyanosis but eventually the pressures of the pulmonary circuit overcome that of the systemic circuit resulting in cyanosis as a result of right-to-left shunting.

Incorrect Answers:
Answer 1: The unplanned nature of a pregnancy on its own is not a medical indication for termination. Rather, the mother should be presented all available options in an unbiased fashion.
Answer 2: The patient's use of alcohol early in her pregnancy increases the risk of fetal alcohol syndrome (FAS), but FAS is not an absolute indication for termination of the pregnancy.
Answer 3: Advanced maternal age (> 35 years) increases the risk of congenital defects but is not in itself an absolute indication for termination of the pregnancy.
Answer 5: Family history of cystic fibrosis increases the risk of cystic fibrosis in the fetus, but is not a contraindication to pregnancy. The patient should be offered prenatal genetic testing.