By Jackie de Burca
What is coronary heart disease?
Coronary heart disease, is a narrowing of the coronary artery: a large blood vessel that supplies blood to the heart. This narrowing is caused by fatty deposits in the artery itself and is the leading cause of heart attacks in the developed world. Cardiac disease of all types is, indirectly, the leading cause of maternal death in the UK. The risk of developing coronary heart disease increases significantly with age beyond 35 years and more significantly still in those over 50 years.
Large scale social changes have led to the increase in the number of pregnant women who suffer with coronary heart disease. The age at which women are able to conceive and sustain a pregnancy has, on average, increased with many factors driving this, not least, increases in health care and fertility medicine. Career and financial pressures also mean women are delaying having their first child and fluidity of family structures also have contributed to older women wishing to conceive with their second or third partners/spouse.
Lifestyle changes have, without doubt, contributed to the rise in younger women developing coronary heart disease. The huge rise in obesity is an obvious starting point and, according to current statistics, the number of young women who smoke far exceeds the number of young men who partake in this unhealthy habit.
Working and leisure patterns have also played their part with more and more jobs being sedentary and desk based in their nature and women far less likely than men to take part in organised sports but increasingly likely to drink more alcohol than is recommended on a regular basis.
Should women with coronary heart disease risk pregnancy at all?
This is a rather vexing question. It is only in recent times that the number of women with coronary heart disease has reached any significant level. The greatest risk posed by embarking upon a pregnancy with coronary heart disease is the risk of heart attack particularly during labour. Other diseases and conditions associated with coronary heart disease such as hypertension (high blood pressure) and diabetes serve only to increase the risk to mother and child. It is also possible that some medications you are taking to control your heart condition may not be suitable for use during pregnancy. Stopping or changing them may further increase the risk of heart attack.
Pregnancy itself may worsen symptoms of coronary heart disease. This exacerbated form of the disease is known as acute coronary syndrome and is three to four times more common in pregnant women compared to non-pregnant women of the same age. It is estimated that acute coronary syndrome affects one in every ten thousand pregnancies in the USA. The rates are assumed to be lower in the UK but large scale studies have yet to be conducted. This is likely the result of a host of factors common in pregnancy: mobility may become restricted in later stages, drug absorption may be affected particularly in mothers who suffer morning sickness and blood pressure may increase to dangerous levels.
Choosing to conceive if you have coronary heart disease is not a decision that should be taken lightly and certainly not without consultation with your doctor and cardiologist.
Risks of coronary heart disease during pregnancy
As already indicated, the greatest risk is that of heart attack. This could, of course be fatal or leave your baby starved of oxygen (hypoxia) which, in turn, can lead to permanent brain damage. The risk of heart attack is increased during labour and you may be advised to have a caesarian delivery.
Hypertension (high blood pressure) is a predisposing factor for coronary heart disease and a condition that develops in the last twenty weeks of pregnancy, pre-eclampsia can increase the risk of heart attack many-fold. Indeed, pre-eclampsia alone has the potential to be fatal. Pre-eclampsia superimposed on (chronic) hypertension has been seen to develop in as many as one quarter of women with pre-existing hypertension. Early detection is important to ensure a good outcome in this scenario so frequent and regular blood pressure monitoring is essential for pregnant women with hypertension and coronary heart disease.
Reducing the risks
Should you choose, on balance of risk, to try to conceive then you should prepare for pregnancy by taking folic acid supplements for at least three months before conception and throughout pregnancy, try to keep weight within a healthy range, eat a healthy and balanced diet, take exercise and avoid alcohol, caffeine and tobacco products – these are sensible steps for any woman wishing to conceive and have a healthy pregnancy but are especially important for women with coronary heart disease.
Consult with your cardiologist to establish which drugs will be safest for you during pregnancy. For those who are prescribed it Aspirin is, generally safe to use. It may be that your doctor will not change your medication so it is important to discuss the risk and rates of potential side effects for your baby if these drugs are generally not recommended during pregnancy. Discuss whether or not you should attempt to breast feed your baby. Do not stop taking medication you have been prescribed without consulting your cardiologist.
Birth choices for women with coronary heart disease are limited in the extreme and you should be under the care of a consultant obstetrician led (as opposed to midwife led) team. You should plan to give birth in a maternity unit within a hospital. Under no circumstances should you attempt a home birth or even birth at a birthing centre though, for most women with coronary heart disease vaginal delivery is possible. Wear medical alert jewellery and carry a medical alert card in case of an emergency and ensure those who you spend most time with are educated in how to properly conduct CPR.
A note to all women
Certain heart conditions, including but not limited to coronary heart disease, have symptoms not unlike those many women experience in pregnancy such as nausea, chest pain, indigestion like symptoms and breathlessness. For this reason, cardiac conditions in pregnant women often go undetected. If you are struck by a sudden breathlessness, pain in the centre of the chest especially pain radiating to the arm or jaw seek medical attention immediately.