Management of the critically ill cardiac patient

The decline in rheumatic fever has made heart disease in pregnancy an uncommon problem in the developed world but it remains an important cause of maternal morbidity and mortality in developing countries. Pregnancy is particularly dangerous in the presence of cyanotic congenital heart disease, Eisenmenger's syndrome, primary pulmonary hypertension, Marfan's syndrome, dilated cardiomyopathy and significant mitral stenosis. Severe stenosis is often complicated by pulmonary hypertension and atrial fibrillation. Maternal disease status should be determined using echocardiography to define cardiac anatomy, assess ventricular function and estimate intracardiac pressure gradients. Patients in the New York Heart Association functional classes 1 and 2 generally have a favourable outcome. Closed mitral commissurotomy is safe and effective in relieving stenosis across the mitral valve in selected patients. More recently the technique of percutaneous balloon mitral valvotomy has successfully been used in the treatment of mitral stenosis. Termination of pregnancy is advised in patients with severe pulmonary hypertension, including Eisenmenger's syndrome.