There is an increasing number of women with congenital heart disease surviving to childbearing age, with more complex conditions. Women with adult congenital heart disease may tolerate the physiological changes of pregnancy poorly, and can deteriorate at any point, including postpartum. Such women should be counselled of the risks of pregnancy with their condition, and be managed by a specialist multidisciplinary team. Early epidural and a 'low cardiac output' approach allows many women to achieve a normal delivery, but others may require Caesarean section to prevent deterioration in labour. Caution is advised with the commonly used uterotonic drugs. Cardiac disease has remained the leading cause of maternal mortality since the 2000e2002 triennium. Between 2009 and 2014 the deaths of 189 women who died from heart disease associated with, or aggravated by, pregnancy were reported by MBRRACE-UK (Mothers and Babies: Reducing Risk through Physiological changes of pregnancy Pregnancy induces changes in the cardiovascular system to meet the increased metabolic demands of the mother and fetus 5,6 : (i) total blood volume increases by 45% on average; (ii) cardiac output (CO) increases by 30e50%, peaking in the second trimester; (iii) heart rate rises progressively, peaking in Luke Bishop MB ChB FRCA is an advanced trainee in obstetric anaesthesia.

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