Vol.3, No.1, 37-38 (2011) Health
Copyright © 2011 SciRes. Openly accessible at htt p://www.sci rp.org/journal / H E A LTH/
A 29-year-old pregnant woman with a history of
anthracycline-induced clinical heart failure
Valentina Scheggi*, Fabio Mori
Department of Cardiology, Azienda Ospedaliero-Unive rsit a ria Careggi, Firenze, Italy;
*Corresponding Author: valentina.scheggi@libero.it
Received 11 November 2010; revised 2 November 2010; accepted 8 November 2011
The number of women with heart disease who
reach childbearing age in a good functional
state increases continuously as advances in
diagnosis and treatment improve overall health
and prognosis. The cardiologist’s role is to give
the woman an estimate of both maternal and
fetal risk to allow her to make an informed deci-
sion about embarking on a pregnancy, and to
provide appropriate antenatal care. There are
only a few data about the natural history of
anthracycline-induced cardiomyopathy during
preg- nancy; we report our experience of a
29-year- old pregnant woman with a history of
anthracycline-induced clinical heart f ai l ure.
Keywords: Anthracyclines; Heart Failure;
Pregnancy; Cardiomyopathy
Heart disease is present in 0.5-1% of all pregnancies
and accounts for about 10-15% of all maternal death.
Management of these patients requires teamwork of ob-
stetricians, neonato logists, cardiologists, anesthetists and
sometimes cardiac surgeons but there are only a few data
in the literature to guide clinicians in maternal and fetal
care. We report the case of a pregnant woman with anth-
racycline-induced cardiomyopathy and a review of the
We evaluated a 29-year-old woman in the 5th week of
pregnancy. During childhood she had osteosarcoma
treated with anthracyclines and at the age of 2 5 years she
presented anthracycline-induced NYHA class IV heart
failure with markedly reduced systolic left ventricular
function (EF 24%) and severe mitral regurgitation. She
was treated with ACE-inhibitors, beta-blockers and di-
uretics with good clinical result and improving systolic
left ventricular function with EF until 47% and trivial
mitral regurgitation.
At the time of evaluation the pulse was 83 bpm, blood
pressure was 90/60 mmHg, without signs of heart failure;
the electrocardiogram was normal and p-BPN was 600
The ACE-inhibitor was discontinued and she was
treated with bisoprolol and LMWH.
Her clinical conditions and left systolic ventricular
function continued to be stable and she vaginally deli-
vered a healthy child at 35 weeks of pregnancy.
The follow up after delivery was uneventful with sta-
ble EF.
Mortality among minimally symptomatic pregnant
women with cardiac disease is about 1%, as among the
healthy general population. In contrast, severely symp-
tomatic women have been reported to experience a mor-
tality risk up to 5-15%.
Just a small number of parameters allow dichotomic
classification into high-risk and low -risk patients.
In a prospective multicentre study enrolling 562
women, Siu et al. [1] identified poor functional NYHA
class or cyanosis, left ventricular systolic dysfunction
(EF < 50%), and left heart obstruction as major deter-
minants for mater nal cardiac complications.
Neonatal complications (20% of pregnancies) were
associated with poor functional class or cyanosis, left
heart obstruction, anticoagulation, smoking, and multiple
Vere na Stangl et al. [2] found that women at high-risk
(as defined above) had a 6.1-fold higher maternal com-
plication rate and a 6.1 times higher fetal/neonatal event
rate; 64.7% of the high-risk women delivered prema-
turely, compared to 16.4% in the low-ris k group.
V. Scheggi et al. / Ntural Science 3 (2011) 37-38
Copyright © 2011 SciRes. Openly accessible at http:/ /www.scir p.org/journal/HEA LTH/
In low-risk women, fetal complications were compa-
rable to those reported for the general population but
preterm birth rate was slightly higher.
Thorne et al. [3] showed that the risk of maternal
death is approximately 7% if the patient is in New York
Heart Association (NYHA) functional class III or IV.
Other adverse risk factors include ejection fraction <
20%, mitral regurgitation, right ventricular failure, atrial
fibrillation, and systemic hypotension.
The natural history of specific types of cardiomyopa-
thy during pregnancy is unknown and there are only a
few data about pregnant women with anthracycline-in-
duced cardiomyopathy.
Anthracycline-cardiotoxicity can become manifest as
either clinical heart failure or asymptomatic cardiac
dysfunction. Both can develop also years after the cessa-
tion of treatment, as happened in our patient.
Elvira C. van Dalen [4] evaluated the incidence of pe-
ripartum anthracycline-induced clinical heart failure in a
cohort of 53 women. This study demonstrates a low risk
in childhood cancer survivors.
It is worth noticing that 2 of the 53 women included in
this study developed heart failure shortly after the end of
anthracycline therapy and that neither of them developed
any peripartum cardiac problems.
About therapy, sodium and physical activity restric-
tions, in association with drugs like digoxin and furose-
mide, help control heart failure during pregnancy.
Hydralazine, with or w ithout nitrates, is an alternative
to angiotensin-converting enzyme inhibitors, that are
associated with side effects.
As anti-arrhythmics, amiodarone may be toxic but
beta-blockers c a n be us ed safel y.
Finally, patients with ventricular dysfunction must be
anticoagulated with heparin at prophylactic doses to
prevent thromboembolism.
In summary, pregnancy outcome in women who re-
ceived anthracyclines for malignancy in childhood is
generally favorable. Th ose with left ventricular dysfunc-
tion, as our patient, should be considered at increased
risk but probably the most important prognostic f actor is
the NYHA class.
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Mercier, L.-A., Morton, B.C., Kells, C.M., Bergin, M.L.,
Kiess, M.C., Marcotte, F., Taylor, D.A., Gordon, E.P.,
Spears, J.C., Tam, J.W., Amankwah, K.S., Smallhorn,
J.F., Farine, D. and Sorensen, S. (2001) Prospective
multicenter study of pregnancy outcomes in women with
heart disease. Circulation, 104, 515-521.
[2] Stangl, V., Schad, J., Gossing, G., Borge s, A., Baumann,
G., Stangl, K. (2008) Maternal heart disease and preg-
nancy outcome: A single-centre experience. European
Journal of Heart Failure, 10, 855-860.
[3] Thorne, S.A. (2004) Pregnancy in heart disease. Heart,
90, 450-456. doi:10.1136/hrt.2003.027888
[4] Dalen, E.C.V, Pal, H.J.H.V.D. , Bos, C.V. D. , Kok,
W.E.M., Caron, H.N. and Kremer, L.C.M.. Clinical heart
failure during pregnancy and delivery in a cohort of
female childhood cancer survivors treated with anthra-
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