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.............................................................................................................................................................. for 8–10 days after discontinuation of maternal OACs, and may need to be given fresh frozen plasma as well as vitamin K.

3.8.6 Haemodynamic monitoring during delivery Maternal BP and heart rate should be monitored in all patients with cardiac disease. In women with more severe heart disease, an arterial line provides more accurate data. Pulse oximetry and continuous ECG monitoring are advised to detect early signs of decompensation, and to identify those in whom delivery should be expedited. A Swan- Ganz catheter is of uncertain benefit, is associated with complications, and should be avoided in most cases.100 In some high-risk patients (PH), right atrial pressure monitoring may be considered.

3.8.7 Anaesthesia/analgesia Epidural analgesia reduces labour pain and can be used to provide anaesthesia for caesarean section if necessary. However, it can cause systemic hypotension (10%) and must be carefully titrated, especially in patients with obstructive valve lesions or diminished ventricular function who may benefit from invasive BP monitoring. All i.v. fluids need to be used carefully.101

3.8.8 Labour Mobilization may facilitate foetal head descent and a lateral decubitus position can attenuate the haemodynamic impact of cava compression by the gravid uterus.102 The active phase of the second stage should be delayed for 2 h to allow maximal descent of the foetal head, as this will shorten the active phase of the second stage.103,104 Assisted delivery with forceps or a ventouse may be used to further reduce maternal effort, as indicated by the underlying cardiac lesion. Continuous electronic foetal heart rate monitoring is recommended.

3.8.9 Perimortem caesarean section In the case of an acute life-threatening maternal event, immediate delivery should be considered. The aim of delivery is to improve the chance of successfully resuscitating the mother and, only secondarily, of improving foetal survival. It should be considered from 24 weeks of gestation, as prior to this time the degree of uterine vena cava compression is limited and the baby is not considered to be viable. The delivery should be performed within 4 min of the cardiac arrest.

3.8.10 Post-partum care A slow i.v. infusion of oxytocin (2 U of oxytocin given over 10 min immediately after birth, followed by 12 mU/min for 4 h) reduces the risk of post-partum haemorrhage and has a minimal impact on cardiovascular parameters.105 PGE106 analogues [sulprostone (100–500 mg/h) and misoprostol (200–1000 mg)] can be used to treat postpartum haemorrhage; however, ergometrine and prostaglandin F analogues should be avoided.107,108 Sulprostone should be used with caution, given its association with cardiovascular or respiratory symptoms. Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of thrombo-embolism. The post-partum period is associated with significant haemodynamic changes and fluid shifts, particularly in the first 24–48 h after delivery, which may precipitate HF. Haemodynamic monitoring should therefore be continued for at least 24–48 h in those at risk.43 With preceding beta-blockade, infant monitoring for 48 h is recommended.109

3.8.11 Breastfeeding Lactation is associated with a low-risk of bacteraemia secondary to mastitis and should be encouraged in patients with heart disease whenever possible. Any specific concerns or contraindications are discussed in the disease section (i.e. section 8). Most drugs used in patients enter the milk and could thus contraindicate breastfeeding (see Table 7 for details of drugs and safety data). If needed, inhibition of lactation can be obtained with standard doses of cabergoline (0.25 mg every 12 h for 2 days), or bromocriptine (2.5 mg on the day of delivery, followed by 2.5 mg twice daily for 14 days) if cabergoline is not available.

3.9 Infective endocarditis

IE is rare, with an overall annual incidence estimated at 1 per 1000 in patients with congenital heart disease,110,111 and between 3 and 12 per 1000 in patients with prosthetic valves.112

3.9.1 Prophylaxis The same measures apply as in non-pregnant patients.112 During delivery, the indication for prophylaxis has been controversial and, given the lack of convincing evidence, antibiotic prophylaxis is not recommended during vaginal or caesarean delivery. Non-specific hygiene and asepsis measures are also important to prevent endocarditis.112

3.9.2 Diagnosis and risk assessment The diagnosis of IE during pregnancy involves the same criteria as in the non-pregnant patient.112 The scarcity of data accounts for wide ranges in estimations of maternal and foetal mortality of 11–33 and 14–29%, respectively.111,113,114 Unlike chronic valvular regurgitations, acute regurgitations due to IE are poorly tolerated and often cause severe HF. Cerebral and peripheral embolisms are also frequent.111 Every pregnant patient with IE should be discussed by an endocarditis team.

3.9.3 Treatment IE should be treated in the same way as in the non-pregnant patient.112 Antibiotics should be given according to guidelines, guided by culture and antibiotic sensitivity results, considering the potential foetotoxic effects of antibiotics (see Table 7 for details of drugs and safety data).115 Antibiotics that can be given during all trimesters of pregnancy are penicillin, ampicillin, amoxicillin, daptomycin, erythromycin, mezlocillin, oxacillin, and cephalosporins. There is a definite risk to the foetus in all trimesters of pregnancy with aminoglycosides Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026