Correspondence

Valvular Heart Disease in Pregnancy

N Engl J Med 2003; 349:1387October 2, 2003

Article

To the Editor:

In their review of valvular heart disease in pregnancy, Reimold and Rutherford (July 3 issue)1 do not address the early puerperium. In our opinion, this period may be crucial. Many clinicians tend to believe that pregnancy in a patient at risk has been successfully completed after an uncomplicated delivery. Although the authors briefly discuss issues related to cardiovascular physiology immediately after delivery, the literature emphasizes the importance of the puerperium.2,3 Confidential inquiries into maternal deaths have revealed that care may be suboptimal during the postnatal period, since the intensity of monitoring is often decreased at this time, despite the fact that the majority of deaths occur after delivery.4,5

The early puerperium may be a period associated with a risk of heart failure because of the physiologic return of extravascular fluid from the limbs and lower body to the systemic circulation. This mobilization phase may take nearly a week. Clinicians should be aware of this risk and be advised to conduct continuous, close monitoring for a minimum of 72 hours after delivery, preferably in a multidisciplinary setting.

Barbara J.M. Mulder, M.D., Ph.D.
Otto P. Bleker, M.D., Ph.D.
Academic Medical Center, 1105 AZ Amsterdam, the Netherlands
b.j.mulder@amc.uva.nl

5 References

1. 1

   Reimold SC, Rutherford JD. Valvular heart disease in pregnancy. N Engl J Med 2003;349:52-59
   Full Text | Web of Science | Medline

2. 2

   Kaemmerer H, Bauer U, Stein J-I, et al. Pregnancy in congenital cardiac disease: an increasing challenge for cardiologists and obstetricians -- a prospective multicenter study. Z Kardiol 2003;92:16-23
   CrossRef | Medline

3. 3

   Silversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol 2003;91:1386-1389
   CrossRef | Web of Science | Medline

4. 4

   Lupton M, Oteng-Ntim E, Ayida G, Steer PJ. Cardiac disease in pregnancy. Curr Opin Obstet Gynecol 2002;14:137-143
   CrossRef | Web of Science | Medline

5. 5

   Cooper GM, Lewis G, Neilson J. Confidential enquiries into maternal deaths, 1997-1999. Br J Anaesth 2002;89:369-372
   CrossRef | Web of Science | Medline