Cardiovascular disease in pregnancy — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 28-year-old woman with a mechanical mitral valve wants to become pregnant. She is in sinus rhythm with normal LV function and takes warfarin 7 mg daily with stable therapeutic INRs. Anti-factor Xa testing is available at her hospital.^[1]

1. What is her mWHO 2.0 risk, and who should provide her care before and during pregnancy? (2)^[1]
2. What first-trimester anticoagulation does ESC 2025 Table 10 give for her warfarin dose, why, and how is it monitored? (3)^[1]
3. What do the ESC 2025 rows say about anticoagulation from week 13 to the 36th week, and which of her features is relevant? (2)^[1]
4. Outline her anticoagulation around delivery and after birth. (3)^[1]

Model answers — SAQ 1

1. Pregnant women with mechanical valves are exposed to a high risk of complications (mWHO 2.0 class III or higher) (1 mark).^[1] ESC 2025 recommends that women with CVD of mWHO 2.0 class II–III and above are evaluated and managed by a Pregnancy Heart Team from pre-pregnancy onwards through pregnancy and post-partum, that pregnant women with a mechanical valve are managed by the Pregnancy Heart Team, and that a care plan documenting the agreed anticoagulant strategy is in place before pregnancy or as soon as pregnancy is recognised (all Class I, Level C) (1 mark).^[1]
2. Her 7 mg warfarin dose is above the low-dose limit of 5 mg, so Table 10 says switch to LMWH, dose adjusted to peak anti-factor Xa level, twice daily (1 mark).^[1] Why: VKA embryopathy is highest in the first trimester (0.6%–12%) and depends on dose; when switching is chosen, it should take place as soon after conception as possible (1 mark).^[1] Monitoring: checking peak anti-factor Xa and targeting levels to individual risk is recommended (Class I, Level C), at least weekly until the target level is achieved or whenever a level is below target, and regularly thereafter (for example every 2–4 weeks depending on stability); the ESC/EACTS 2025 valve text likewise recommends dose-adjusted LMWH at least twice daily with strict anti-Xa monitoring in the first trimester for higher doses (no class or level given); ACC/AHA valve rows were not checked for this topic (1 mark).^[1][10]
3. Continuing VKAs should be considered in women at higher risk of thrombosis until the 36th week (Class IIa, Level C); continuing LMWH with anti-factor Xa monitoring may be considered at lower risk (Class IIb, Level C), and LMWH is not recommended without anti-factor Xa monitoring (Class III, Level C) (1 mark).^[1] Mitral valve replacement is one of the ESC 2025 Figure 21 features of a higher risk of valve thrombosis, so the VKA row is the relevant one (1 mark).^[1]
4. At the 36th week, or 2 weeks before planned delivery, discontinuing VKAs and starting therapeutic-dose LMWH or adjusted-dose i.v. UFH is recommended (Class I, Level C) (1 mark).^[1] With a mechanical valve she is at high thrombosis risk (Table 10), so converting LMWH to i.v. UFH at least 36 h before delivery and stopping UFH 4–6 h before anticipated delivery is recommended (Class I, Level C); if labour starts on a VKA or less than 2 weeks after stopping it, caesarean section is recommended for foetal protection (Class I, Level C) (1 mark).^[1] After birth, it is recommended that the decision to restart LMWH or UFH is made with the Pregnancy Heart Team and the woman (Class I, Level C), and that the switch back to an oral anticoagulant is postponed until 7–14 days post-partum when the wound has healed, in consultation with the Pregnancy Heart Team (Class I, Level C) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 34-year-old woman, 3 weeks after an uncomplicated vaginal delivery, has a week of breathlessness lying flat and ankle swelling. She had no previous heart disease. Echocardiography shows an LVEF of 30%; no other cause of heart failure is found. She is breastfeeding.^[1]

1. How does ESC 2025 define peripartum cardiomyopathy, and which differential diagnosis must be excluded, and how? (2)^[1]
2. Which investigations does ESC 2025 list for suspected PPCM, and what further testing should be considered for her? (2)^[1]
3. Outline her treatment after delivery, including bromocriptine, lactation and arrhythmic protection. (4)^[1]
4. What is her outlook, and how should she be counselled about another pregnancy? (2)^[1]

Model answers — SAQ 2

1. PPCM is HF with LVEF below 45%, without any other cause of HF, occurring mainly in the peripartum period or in the months after delivery, termination or miscarriage; it is essentially a diagnosis of exclusion (1 mark).^[1] Myocarditis is a differential diagnosis and should be excluded by CMR (1 mark).^[1]
2. ECG, natriuretic peptides and echocardiography (1 mark).^[1] Genetic counselling and testing should be considered in women with PPCM (Class IIa, Level C) (1 mark).^[1]
3. Optimising HF guideline-directed therapy after delivery is recommended, taking drugs contraindicated in lactation into account (Class I, Level C); while she breastfeeds for nutritional reasons, ARBs and SGLT2 inhibitors should be avoided (1 mark).^[1] Bromocriptine may be considered in addition to optimal HF treatment to enhance LV recovery (Class IIb, Level B), starting at 2.5 mg twice daily with up-titration if needed, and adding at least prophylactic LMWH should be considered (Class IIa, Level C) (1 mark).^[1] Bromocriptine stops lactation, which allows full HF treatment but has psychological downsides for the mother and removes a source of infant nutrition, so ESC 2025 names women with moderate and severe HF as the preferred candidates; in severe HF, avoiding or preventing lactation may be considered (Class IIb, Level C; Class IIb, Level B) (1 mark).^[1] With LVEF below 35%, a wearable cardioverter defibrillator may be considered (Class IIb, Level C), and PPCM may cause ventricular tachyarrhythmias, so she should be monitored; the therapeutic LMWH row for EF below 35% applies to pregnant women, and she has delivered (1 mark).^[1]
4. Recovery to LVEF above 50% occurred in 46% of women at 6 months (25%–62% by region); if a reversible course is assumed, HF treatment should be considered for at least 12 months after complete LV recovery (Class IIa, Level C) (1 mark).^[1] Counselling about recurrence risk in a subsequent pregnancy and about contraception is recommended in all cases, even after recovery (Class I, Level C); ESC 2026 HF also recommends pre-conception care and counselling for patients with HF, to facilitate decision-making surrounding HF treatments, pregnancy, contraception, pre-implantation genetic screening and assisted reproductive therapies (Class I, Level C), and women with recovered LV function remain at risk of relapse (1 mark).^[1][3]