Last year, when Shana Melanson was four months pregnant with her second child, she was standing outside a light rail station waiting for the shuttle she takes to work when, suddenly, she fainted. She fell on the concrete and broke her nose.
Shana spent the next five days at University of Washington Medical Center while her cardiology and maternity care team adjusted her medications and made sure she—and her baby—would be OK.
This wasn’t the first time during her pregnancy that Shana’s heart had caused her to lose consciousness. Three months earlier, it happened at a conference in Canada.
“I was eating lunch having a conversation with another attendee and I just passed out and fell on the floor,” she recalls.
Shana, 38, has a heart condition that causes her heart to lose its normal rhythm and stop pumping blood—a form of cardiac arrest—that her doctors believe is triggered by pregnancy.
Her heart troubles started when she went into sudden cardiac arrest three months after giving birth to her first child. That was three years ago, and until the conference room episode, she had never had symptoms.
Pregnancy with heart disease can be complicated
Heart disease in pregnancy can come in many forms: It ranges from women who were born with a structural heart problem, such as a faulty heart valve, to women who have underlying health problems and have developed heart disease as a result, says Catherine Albright, M.D, M.S., an obstetrician at the Maternal and Infant Care Clinic at UW Medical Center who cared for Shana.
And while concerns with pregnancy can vary based on the nature of her heart problem, the things providers are concerned about are often the same.
During the course of pregnancy, the amount of blood in circulation increases by about 50 percent, greatly increasing the amount of work the heart must do, Albright explains. That, combined with other changes in the body and the physical work of carrying a child, puts a lot of demand on a mother’s body.
On the flip side, if a woman has already been diagnosed with heart disease and tolerates pregnancy well, that’s a good sign. It indicates that her heart can withstand at least a certain amount of stress over time.
In Shana’s case, her doctors believe that her heart condition was being triggered by the demands the pregnancy was putting on her heart, which was why she had no symptoms the rest of the time.
Another concern is that pregnancy changes the way the body handles medications. That means the dosage of heart medications, like beta blockers, may need to be adjusted to ensure they are still working as they were before pregnancy.
Planning for pregnancy with heart disease
When Shana’s first child was born, she and her husband were living in Chicago. While she was well cared for, she says her care team didn’t dig into the root cause of her cardiac arrest.
Not long after, she and her husband moved their young family back to Seattle, where they both grew up.
When she and her husband started planning for another child, Shana sought out the care of cardiologists at UW Medical Center. A battery of tests and genetic screenings came back inconclusive, so she scheduled an appointment with a provider in the high-risk maternal care group who gave her the green light based on her excellent health and lack of symptoms.
Albright started caring for Shana once she conceived and, as she puts it, Shana did everything “by the book.”
“If all of our patients, especially those with cardiac disease, were able to plan their pregnancies and see us prior to pregnancy to optimize their care, I think we’d have even better outcomes for both mom and baby,” she says.
The risks of delivering when you have heart disease
When 2018 rolled around and Shana’s due date approached, it was time to start thinking about the challenges that make delivery high-risk for mothers with heart disease.
By the third trimester, the increase in blood volume tends to have stabilized. But delivery causes another very large volume increase plus a whole extra set of stressors, including an increased heart rate and increased pain response. Immediately after birth, as the placenta delivers, there is an autotransfusion of blood that gets dumped back into the maternal system and stresses the heart, Albright explains.
If Shana were to have an abnormal cardiac event while delivering, it could have harmed her baby. But as long as she was kept stable during delivery, there would be no complications for the baby.
Because of the high risk, Shana delivered in the intensive care unit where providers with cardiac and high-risk maternity expertise could be available to intervene if necessary. And while she may not have had all the amenities of a birthing suite, Shana says the individual attention she received made her feel safe and comfortable.
To everyone’s delight, the delivery went off without incident, and Shana delivered a healthy baby in the new year.
It was all worth it
Nearly two months after giving birth, Shana is still in regular contact with her doctors to monitor her heart and the efficacy of her medications. And while her doctors recommend she not stress her heart by having another child, she hopes her experience can help other women with heart disease who are considering have a child.
“Remember that the primary concern is that you and your baby are healthy at the end of this journey,” she says. “There are bumps along the way and there can be bad news, but at the end of the day, everyone is rooting for you—and your baby—to come out healthy and strong after this experience.”