While many expectant parents see pregnancy as an exciting start to parenthood, it can be challenging to navigate the various considerations around starting a family.

For women with heart disease in particular, the subject of pregnancy can be more fraught: is it safe for them to undergo a pregnancy in the first place? According to Institut Jantung Negara’s (IJN) Clinical Director of Women’s Health and Consultant Cardiologist Dr Emily Tan, the short answer is yes – provided they have enough information on managing their pregnancy and receive the specialised care they need.

“Most women with heart disease can have a safe pregnancy, but careful pre-pregnancy planning is very important,” says Dr Tan.

“Pre-pregnancy counselling in particular is crucial for prospective mothers so they have the information they need on the feasibility of the pregancy, as well as any potential risks they or the baby might face. Only after careful deliberation on the potential risks of pregnancy, with the advice of a cardiologist, can potential mothers make an informed decision regarding their pregnancy.”

On this note, Dr Tan adds that there is still a lack of awareness amongst Malaysian women with heart disease on the important pre-pregnancy preparation and planning.

“This is evidenced by the number of unplanned pregnancies, which can lead to complications. Some women may also have limited accessibility to specialised care that offer such pre-pregnancy counselling services,” she says.

Dr. Emily Tan, Clinical Director of Women’s Health & Consultant Cardiologist

Pregnancy and the heart

In general, pregnancy causes some stress to the heart and circulatory system. An expectant mother’s blood volume increases to support the growing fetus, and her heart rate can increase by 20%, accompanied by a slight drop in blood pressure. While a normal heart is able to withstand these changes, the increased strains on an already compromised heart can be problematic.

Among the problems that could occur amongst mothers with pre-existing heart conditions are heart failure and heart rhythm issues (also known as arrhythmia).

Another commonly encountered problem are mothers who have mechanical heart valves, as they need to take blood thinning medication to maintain normal heart function. “These medications can pose serious risks to the developing baby,” says Dr Tan. “Some of the potential dangers include bleeding complications, miscarriage, stillbirth, and embryopathy.”

Dr Tan adds that treatment in expectant mothers with underlying heart condition often include medications that are deemed safe in pregnancy, while at other times invasive procedures may need to be performed, such as in the case of a heart attack and severe valvular heart disease,” she says.

Some women however may even be unaware that they have an underlying heart condition, especially if they’ve not experienced any symptoms beforehand.

“Cardiac disease can sometimes manifest for the first time in pregnancy, due to the circulatory changes in an already compromised heart. Among the most common conditions are valvular heart diseases that may have remained without symptoms otherwise,” explains Dr Tan. Valvular heart disease is when one or more valves in the heart is damaged and unable to work properly.

In rare cases, heart disease can occur due to the pregnancy itself. One such uncommon condition is peripartum cardiomyopathy, which is a weakness of the heart muscle that develops during late pregnancy and in the early postpartum period. While the severity of this condition can range from mild to severe with many having a near complete recovery, some unfortunately goes on to develop heart failure.

Another uncommon occurrence is an increased risk of heart attacks, as a result of the physiological changes that happen during pregnancy. While rare, this increased risk is particularly seen among older women, smokers, as well as those with other conditions such as hypertension, diabetes, high cholesterol levels and obesity.

Awareness and specialised care

Dr Tan reiterates that the care provided must be aimed at helping women with heart disease fully understand the various risks and treatment options available to them.

Pre-pregnancy counselling for example, can help guide women with heart disease through all the factors that come into play during a pregnancy. “This includes looking at the potential harm to the baby if maternal heart medications need to be continued; the potential problems pregnancy may pose to the mother; and the chances of the baby inheriting its mother’s heart condition,” says Dr Tan.

Such counselling may also include broader family planning considerations, as a small number of women with heart disease may be completely unsuitable for pregnancy. In addition, some women may also need to space out their subsequent pregnancies (or avoid a second pregnancy completely) to maintain good heart health.

Dr Tan adds that a discussion of contraceptive choices is crucial in these cases to ensure women have safe and effective choices. “Combined oral contraceptive pills for example, can increase the risk of blood clots in the vessels and hypertension, so these should be avoided in women with heart disease,” she says. “However, there are plenty of other options, such as subdermal implants and intra-uterine contraceptive devices, which are reliable and reversible methods. Vasectomy and tubal ligation are also reliable irreversible methods that women with heart disease can consider.”

Meanwhile, expecting mothers with heart disease not only need to be monitored throughout their pregnancy, but also require suitable methods of delivery as well.

“Aside from regular antenatal follow-ups, mothers also need a tailored post-partum care plan,” adds Dr Tan. “Mothers need to be closely monitored even after delivery, as heart complications can occur during the post-partum period from circulatory and physiological changes. Ultimately, many women with heart disease can have safe and healthy pregnancies – they just need the right medical support.”

Early detection makes the treatment of health problems more effective. For more information, head to IJN’s Health and Wellness packages as they offer more comprehensive testing and consultations.