Cardiomyopathy and Pregnancy: Planning, Risks, and Newborn Care

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• Pre-Pregnancy Planning for Cardiomyopathy
• The Spectrum of Cardiomyopathy Risk in Pregnancy
• Monitoring and Treatment During Pregnancy
• Fetal Growth and Birth Considerations
• Newborn Care After Birth
• Genetic Counseling and Inheritance Risks
• Team-Based Care and Communication

Pre-Pregnancy Planning for Cardiomyopathy

A comprehensive cardiology workup is the essential first step for any woman with a history or genetic risk of cardiomyopathy who is considering pregnancy. Dr. Marc Dommergues, MD, emphasizes that this evaluation determines the need for critical interventions like an implantable defibrillator to prevent sudden death or beta-blocker medications to manage heart rhythm and function. This pre-pregnancy planning phase is vital for assessing maternal risk and establishing a management plan to protect both the mother and the future child.

The Spectrum of Cardiomyopathy Risk in Pregnancy

Pregnancy risk for women with cardiomyopathy exists on a wide spectrum and is not the same for every patient. Dr. Marc Dommergues, MD, illustrates this with examples, from a woman with a normal heart ultrasound who merely carries the gene to a patient with severely poor heart function and a high risk of sudden death. The management and potential outcomes differ drastically. For a patient with very poor ventricular function, pregnancy may carry a significant risk of maternal death, making awareness and counseling paramount.

Monitoring and Treatment During Pregnancy

Patients with moderate heart function alteration require very careful monitoring throughout their pregnancy. Dr. Marc Dommergues, MD, notes that these women often need to continue essential heart medications. Beta-blockers are commonly used but require a specialized approach during pregnancy because they can cross the placenta and affect the developing fetus. This necessitates a tightly coordinated care plan between the cardiologist and the obstetric team to balance maternal cardiac health with fetal well-being.

Fetal Growth and Birth Considerations

A key consequence of beta-blocker use in pregnancy is its impact on fetal growth. Dr. Marc Dommergues, MD, states that babies exposed to these medications in utero are often small for gestational age (SGA). This requires more intensive monitoring via fetal ultrasound to track growth patterns. In some cases, this leads to a decision to induce labor slightly earlier. The rationale is that the baby may thrive better outside the mother's uterus than inside, where medication exposure continues.

Newborn Care After Birth

Immediate newborn care for babies born to mothers on cardiac medications is specialized and crucial. Dr. Marc Dommergues, MD, explains that the neonatal team must focus on checking for hypoglycemia (low blood glucose) and hypotension (low blood pressure). These are potential side effects of the baby's exposure to medications like beta-blockers during pregnancy. It is important to note that these medications carry a very low risk of causing congenital malformations; the primary concerns are these transient metabolic and cardiovascular adjustments after birth.

Genetic Counseling and Inheritance Risks

For inherited cardiomyopathies, genetic counseling is a difficult but essential part of family planning. Dr. Marc Dommergues, MD, highlights that there is a 50% (1 in 2) risk of transmitting the causative gene to the child. However, a major challenge is the unpredictable expressivity of the gene—it is impossible to predict if a child who inherits the gene will develop heart problems at age 30 or 80, or how severe the symptoms will be. This uncertainty requires Dr. Marc Dommergues, MD, involvement of geneticists alongside the medical team.

Team-Based Care and Communication

The successful management of a high-risk pregnancy with cardiomyopathy hinges on breaking down silos between medical disciplines. Dr. Dommergues stresses that good communication between all professionals—obstetricians, anesthetists, pediatricians, and cardiologists—is the most important factor. He describes how his team worked to develop a common language, a process that takes time but is ultimately rewarding and vital for patient safety. As Dr. Anton Titov, MD, concludes, this communication is indeed the key to managing any complex medical problem effectively.

Full Transcript

Dr. Anton Titov, MD: What can a woman with heart disease do to plan the pregnancy? What should she do during her pregnancy to ensure the health of the mother and her future child?

If we go one step further and consider dilated cardiomyopathy, within the same group of diseases with the same name, you may have very different things. The first example could be a woman whose father just died from dilated cardiomyopathy. The family was studied; she has a normal heart ultrasound but is carrying the gene for cardiomyopathy. She might be at risk of having a rhythm abnormality if she's pregnant, but it's very unlikely that she's going to have heart failure.

However, her father just died of cardiomyopathy, and sudden death is possible. There will be a lot of diagnostic workup by the cardiologist before pregnancy. It's important to know whether she needs an implantable defibrillator or beta-blockers or not. This is the job of the cardiologist, but usually, things are going to be okay.

At the other end of the spectrum, you've got the same cardiomyopathy gene, the same disease, but a very poor heart function and a very high risk of sudden death due to ventricular fibrillation. In this situation, if it occurs and presents like this, it will be very important that a woman be aware that pregnancy may cause death. The situation will be different.

There could be a mid-point scenario. You have a patient with a very moderate alteration of her ventricular function. Maybe she already has an implantable defibrillator, so we do not fear a sudden death. Then the situation will certainly be better, but we will need very careful monitoring throughout pregnancy.

Usually, those patients may require medicines. For example, they may require beta-blockers, which may have an impact on fetal growth. Babies born to mothers taking beta-blockers are usually a little small for gestational age, but this does not impact their development in the long run.

This means that we're going to follow their growth by fetal ultrasound more carefully. Sometimes the birth is induced a little bit earlier because we believe the baby will thrive more outside the mom's uterus than inside.

Dr. Marc Dommergues, MD: In the neonatal period, we'll need to focus on the baby's health. You need to check for hypoglycemia, for example, low blood glucose or low blood pressure in the baby, which may be the consequence of having been exposed inside the mother's uterus to those medications. In contrast, there's very little risk of having malformations due to these medications.

Another issue then will be the genetic transmission of cardiomyopathy. It's important that people know that there's a 1 in 2 risk of transmitting the cardiomyopathy gene. But how this gene is going to be expressed? What the heart disease symptoms will be? Will the child have a heart problem at 30 or 80 years of age? It's impossible to predict.

This is difficult genetic counseling. Obviously, we need the help of the geneticists in addition to the help of the cardiologists, pediatricians, and anesthetists to manage this pregnancy.

Dr. Anton Titov, MD: So these are examples of managing pregnancy when a mother has a heart disease. You could have a huge number of different examples, of course, because cardiology is a very vast area. It shows you how different management may be.

Dr. Marc Dommergues, MD: And how the most important thing in the whole story is good communication between all professionals. In our group, it took us time to understand how we could speak to each other, how we could find a common language between obstetricians, anesthetists, pediatricians, and cardiologists. But hopefully, we succeeded now.

We are very happy with it! But it's a question of speaking out and being able to communicate despite the silos of medical disciplines. Of course, it's important to break across the silos of disciplines.

Dr. Anton Titov, MD: What I hear is communication is key to the successful management of any medical problem. It is certain.