INFORMATION FOR WOMEN WHO HAVE CYANOSIS DURING PREGNANCY OR BREASTFEEDING
What is cyanosis during pregnancy?
Cyanosis is a bluish discoloration of the skin or mucous membranes due to an inadequate supply of oxygen to body tissues. Cyanosis can be peripheral or central. Peripheral cyanosis means that distal (outlying) parts of the body, such as fingers, toes, hands, or feet, are cyanotic, due to restrictions of blood flow to that region. Central cyanosis means that either there is extremely low blood pressure (due to blood loss or heart problems), or the blood is deficient in oxygen, which can happen for a variety of reasons, including problems with the heart and great vessels, problems with the lungs, and various poisons. In the context of pregnancy, the concern is the possibility of central cyanosis due to heart disease. Sometimes this means problems with a heart valve that you acquired growing up as a result of an infection. Still, often it means congenital heart disease, heart disease related to malformations present since you were born.
In many cases, a womans heart disease can be mild before she is pregnant but can produce cyanosis during pregnancy as the demands on the heart and lungs increase. A common way to develop cyanosis is due to a congenital condition that causes shunting of blood from the right side of the heart to the left side, meaning that not all the blood that enters the right side of the heart after returning from body tissues passes through the lungs before it is pumped again through the body. A relatively common way for this to happen involves whats called Eisenmenger syndrome. In this condition, a congenital malformation of the heart or great vessels, such as a hole between the left and right side of the heart (atrial septal defect or ventricular septal defect), allows some blood to flow from the left side of the heart to the right side (a left-to-right shunt) because pressure is much higher on the left than the right side of the heart. Over time, this phenomenon increases the pressure in the right side of the heart and the lungs, leading to pulmonary hypertension (high blood pressure in the pulmonary blood vessels) and the high pressure now causes blood to move the other way, from the right side of the heart to the left (right-to-left shunt). Cyanosis also can develop due to congenital disorders of connective tissue, such as Marfan syndrome, which can cause problems with the aortic valve.
How common is cyanosis during pregnancy?
1 to 3 percent of pregnancies are complicated by some type of heart disease, including heart disease that produces cyanosis. Although maternal death is very rare during pregnancy, maternal heart disease is the reason for 10 to 15 percent of maternal deaths.
How is cyanosis during pregnancy diagnosed?
Since cyanosis is a clinical sign, not a disease, its not diagnosed, but rather detected as part of the evaluation of the patient. Physical examination reveals a bluish coloration to the skin and lips. In women who are cyanotic, one of the vital signs, called oxygen saturation (02 sat, the percentage of your blood hemoglobin that is saturated with oxygen molecules), which is measured with pulse oximetry, will be abnormally low, usually below 85 percent. This is compared with a normal pulse oximetry range of 95-100 percent, whereas any reading below 90 percent is considered low.
Does cyanosis cause problems during pregnancy?
As noted above, cyanosis in pregnancy is usually in the context of heart disease. The degree to which you will suffer problems depends greatly on how well your heart functions prior to pregnancy. Doctors grade your heart function into one of four severity levels based on the classification system of the New York Heart Association (NYHA).
In Class I, you have heart disease, but no symptoms that would limit your normal activity. In Class II, there are mild symptoms, such as dyspnea (breathing difficulty) or angina, chest pain that comes and goes. If you have Class III heart disease, you are comfortable only when you rest, so your activity is limited. In Class IV, you suffer symptoms, even when resting and so activity is extremely limited, and you must remain in bed. Additionally, the World Health Organization (WHO) rates risk during pregnancy from cardiovascular disease. Cyanosis also puts you at risk both for blood clots and hemorrhage.
If you are in the NYHA Class I or Class II category, the risk of problems isnt excessive as your pregnancy advances, though you may have to rest more than women who do not have heart disease, and you may become somewhat cyanotic. However, if you are Class III or IV, then pregnancy can threaten your life, meaning that you should seriously consider never getting pregnant.
Can cyanosis cause problems for the baby?
Yes. Cyanosis means that your hemoglobin is carrying less oxygen than it ought to be carrying in your blood. In the placenta, oxygen moves from the maternal blood to the fetal blood. This happens because fetal hemoglobin attracts oxygen better than adult hemoglobin does, so the fetus can receive oxygen if the mothers blood has some deficiency of oxygen. If the deficiency is severe, if you are very cyanotic, there won’t be enough oxygen for the fetus, creating a risk of fetal death or brain damage. The latter is more likely if you are Class III or IV. The fetus is also at risk for problems that include distress and poor growth.
In addition to the direct effects of the mothers disease, pregnant women with heart disease have an elevated risk (5 to 10 percent) that their children will have cardiac anomalies. Thus, if you have heart disease to the point of being cyanotic, your doctor will order echocardiography to examine the fetal heart and its function in detail.
What to consider about taking medications when you are pregnant or breastfeeding:
- The risks to yourself and your baby if you do not treat the cyanosis
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat cyanosis during pregnancy?
The medications that you will be given depend on your condition and the risks that it brings. If you are cyanotic, your doctor will put you on supplemental oxygen, either through a tube in your nostril or a mask. If you are at risk of suffering a clot, you are given medication to reduce this possibility. In many cases, this means low molecular weight heparin (LMWH), which is safe for the fetus. In some cases, doctors will put you on whats called unfractionated heparin, which also is fairly safe. One of the most powerful blood-thinning medications is warfarin, which cannot be taken during the first trimester because it causes birth defects, nor can it be taken during the final weeks of pregnancy because it can cause hemorrhage in the fetal brain. There are some cases in which a woman really needs warfarin or a similar drug, and she is shifted from LMWH to warfarin in mid-pregnancy and then shifted back to heparin in late pregnancy. Also, if your heart condition puts you at risk of a heart infection called infectious endocarditis, you will be given antibiotic medication. There are different options for antibiotics, including regimens, that are considered to be very safe in pregnancy.
Who should NOT stop taking medication for cyanosis during pregnancy?
Cyanosis is a sign of a very serious underlying disease. This means that if you are on med
ication for your condition, all medication changes must be made as part of a decision with your doctor. Usually, this means a team of doctors that includes a cardiologist, an obstetrician who specializes in high-risk pregnancies, and other specialists.
What should I know about choosing a medication for my cyanosis during pregnancy?
It is important to stay in communication with your health care provider as the release of new studies over time can change the outlook on the role of specific medications during pregnancy.
You may find Pregistrys expert reports about the medications to treat this condition here. Additional information can also be found in the sources listed below.
What should I know about taking a medication for cyanosis when I am breastfeeding?
Supplemental oxygen, LMWH, and warfarin are all considered safe for nursing mothers. If you require antibiotics, some regimens can be selected that are safe for nursing mothers as well.
What alternative therapies besides medications can I use to treat my cyanosis during pregnancy?
Cyanosis is a sign of a serious underlying condition, which often requires medications. However, your doctor is also likely to recommend rest, so that you will not be as active as other pregnant women.
What can I do for myself and my baby when I have cyanosis during pregnancy?
It is very important to follow the instructions of your doctors.
Resources for cyanosis in pregnancy:
For more information about cyanosis during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or contact the following organizations: