Heart Disease in Pregnancy. Second Edition.
Celia Oakley and Carole A. Warnes, eds
354 pages. Oxford, UK: Blackwell Publishing; 2007. $114.95. ISBN: 1-4051-3488-7
Oakley and Warnes’ second edition of Heart Disease in Pregnancy is a concise portable text that incorporates the views and practices of international experts to aid the reader in caring for the unique patient population of gravid women with heart disease. The highly readable text has a logical framework, starting with physiological changes in pregnancy and flowing through common, then rare, high-risk cardiovascular states. The chapters culminate in labor and delivery, with anesthetic approaches, then transition to the important issues of genetic counseling and contraception. Providing quick, easy access to information on basic physiology, disease states, and management strategies, it will be of interest to a very broad professional base.
The first few chapters offer standard reviews of the response of the heart to pregnancy and physiological rather than pathological secondary changes in the physical examination. Cardiac testing during pregnancy is detailed. Importantly, the first pathology addressed is congenital heart disease, which has overtaken rheumatic valvular disease as the most common preexisting cardiac condition in women of childbearing age. The British perspective is illuminating, with subtle changes in nomenclature, such as PAD for patent arterial duct, and incorporation of UK trials and registries to support common practices.
After cyanotic congenital heart disease, pulmonary hypertension is an important addition to the text, and is addressed in its own chapter as well as in chapters devoted to cor pulmonale and pulmonary embolism. Some of the studies on management of primary pulmonary hypertension with newer agents are not included in the references, but that would be beyond the purpose of the text. Most of the references are from 2004 and earlier, omitting some recent developments in this rapidly growing field. Pulmonary Embolism Graph 17.3 on the use of D-dimer unfortunately made it through editing with the perfusion scan “normal” arrow misplaced; graphics are otherwise exceptional, including algorithms for use of more current diagnostic tools.
Rheumatic heart disease, mitral valve prolapse, and prosthetic heart valves are successive chapters that incorporate good graphics in an objective manner to illustrate the risks and benefits of valve surgery options and timing for young women contemplating pregnancy. The rheumatic heart disease chapter is the first that concludes with “keypoints” for the hurried reader, a feature that is available in several of the better written chapters. The new 2007 guidelines for infective endocarditis1 were not available at the time of printing, but the international practice appears to favor generous antibiotic coverage in high-risk patients during both vaginal and caesarean deliveries. Standard algorithms are presented for monitoring prosthetic valves during pregnancy. Although no “best practice” for anticoagulation management has yet been defined on either side of the Atlantic, the authors provide a detailed review of the differences between UK and US literature, with a cogent argument recognizing Chest 2004 guidelines.2 The references could have been a bit more current, but the chapter still concludes that trials of new anticoagulation options are needed.
Vascular components of heart disease are reviewed in dedicated chapters on Marfan syndromes and other connective tissue disorders. The genetics of these diseases are briefly explored, although references in this chapter, based on a similar chapter in the 1997 edition, are somewhat dated, as well. The systemic and autoimmune disease chapter is well written and current, with well-summarized topics, easy-to-follow tables, and reassuring concluding paragraphs.
Hypertrophic, peripartum, and other cardiomyopathies, including pericardial disease, are reviewed basically. Atrial and brain natriuretic peptides and transplantation are only briefly mentioned. The chapter on coronary artery disease appropriately recognizes newer risk factors in the development of atherosclerosis, such as cocaine use. The chapter on percutaneous intervention and surgery during pregnancy includes an important compilation of current indications and data supporting nonmedical management. Percutaneous closure of patent foramen ovales and atrial septal defects may become more common in those contemplating pregnancy.
Cardiac rhythms are reviewed thoroughly, with outstanding practice points, mechanical diagrams, tables, and 12-lead electrocardiogram rhythm examples. The safety and efficacy of antiarrhythmics is also broadly detailed. The chapter on hypertensive disorders clearly distinguishes among the types of hypertension associated with pregnancy and their treatments, identifying medications commonly used in pregnancy but not in other hypertensive arenas. A common emphasis, spanning multiple chapters, is on avoiding angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, although no chapter is devoted specifically to cardiac medications in pregnancy. In this era of online drug information and active pharmacy management, the reader likely has access to other convenient sources for information about drug safety during pregnancy and lactation.
The chapters on labor and delivery and anesthesia will be of interest chiefly to obstetricians and obstetric anesthesiologists, although the cardiologist may recommend a cardiac anesthesiologist for certain high-risk deliveries. To reinforce anticoagulation, the text recommends that all anticoagulated patients should be on intravenous unfractionated heparin at the time of delivery.
After this concise tour of cardiac issues in pregnancy, the chapter on genetic counseling is an important reminder that all women of childbearing age should be educated on the maternal and fetal risks of pregnancy. From a practical standpoint, this educational responsibility resides in multiple realms: at home, in school, in pediatrics, gynecology, family practice, primary care, and pediatric and adult cardiology. The final chapter, on contraception, is a reminder and aid to all providers who care for these women.
This text successfully reflects both US and UK practices of caring for the pregnant patient with heart disease. Though clinicians still see patients from developing countries with undiagnosed heart disease, the population of treated patients who are surviving to become pregnant is growing. This text is replete with international experts’ insights into maternal and fetal care, emphasizing the teamwork of providers who work together for a healthy delivery. I would recommend it as a practical guide to all who find themselves caring for this growing population of patients.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT. Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation. 2007; 116: 1736–1754.