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Management Strategies
Preconception counseling/Contraceptive methods
A comprehensive cardiovascular examination should be undertaken before embarking on pregnancy. This includes a careful history and physical examination with saturation by pulse oximetry, an echocardiogram and an electrocardiogram.
Most women with a PDA can have a successful pregnancy. In the absence of ventricular dysfunction or pulmonary hypertension, heart related complications are rare.
In general, contraceptive selection is not limited by a woman’s heart condition. In the setting of a PDA with concomitant pulmonary hypertension, contraception choices are more limited and estrogen-containing birth control formulations are contraindicated. (see Contraception).
Medication use should be reviewed if a woman is contemplating pregnancy or is pregnant. The MOTHERISK website is an excellent resource.
Ante-partum Care
The place and frequency of antenatal visits depends on the cardiac status of the women, the degree of left ventricular dilation or systolic dysfunction, and the pulmonary artery pressures. Women without the high-risk characteristics listed above do not need to be followed in high-risk specialized centers.
In women with a large PDA, (significant ventricular dysfunction or pulmonary hypertension), antenatal care should be provided by a dedicated multidisciplinary team of experienced cardiologists, obstetricians, and anesthetists at a high-risk pregnancy center. In women without high-risk features, antenatal care and delivery can be performed at non-specialized centers.
Women should be offered fetal echocardiography at approximately 20 weeks gestation.
Labour and Delivery
In women with small PDA no special precautions are necessary.
In women with high-risk characteristics, labour and delivery should be planned carefully with a multidisciplinary team well in advance. It is important to communicate the delivery plan to the woman as well as other physicians involved in her care. The best delivery plan is not useful if information is not readily available when needed.
Vaginal delivery is preferred. Women with large PDA with ventricular systolic dysfunction or pulmonary hypertension are at high risk for complications. In these women, decreased maternal expulsive efforts during the second stage of labour and forceps or vacuum delivery is often utilized. To decrease potential harmful complications from difficult mid cavity-assisted delivery, uterine contractions are often utilized to facilitate the initial descent of the presenting part.
Most women with PDA do not require special monitoring. The need for maternal monitoring is dictated by and the functional status of woman, the systolic function of the left ventricle, the degree of pulmonary artery hypertension and the oxygen saturations.
In general, endocarditis prophylaxis at the time of labour and delivery is not recommended in women with PDA.
