Cardiac Disease and PregnancyCardiac Disease and Pregnancy

Catherine Nelson-Piercy

Guy’s & St Thomas’ Hospitals

& Queen Charlotte’s Hospital

London, UK

Physiological changes in pregnancy

• Cardiac Output (CO) increases by 40%

• Further increases peripartum

• Stroke Volume and Heart Rate increase

• Peripheral vasodilation and decrease SVR

• PCWP and CVP unaltered

• Colloid osmotic pressure reduced

• Supine position = 25% fall in CO

Early peak in HR (17%) SV (17%) CO (45%)

Plasma volume (40-50%)

Heart rate

Cardiac output &

Stroke volume

Non pregnant Post delivery weeks gestation

4 8 12 16 20 24 28 32 36 40

Physiological Changes in Pregnancy

Slide courtesy of Sara Thorne

Saving Mothers’ Lives 2006-2008, National launch - March 2011

Leading causes of maternal deaths

2006-08, UK

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Saving Mothers’ Lives 2006-2008, National launch - March 2011

Cardiac Deaths Rates per million maternities

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1985

-87

1988

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1991

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1994

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1997

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Saving Mothers’ Lives 2006-2008, National launch - March 2011

Cardiac deaths; UK 2000-2008

Type and cause of death 2000-02 2003-05 2006-08 Acquired

Aortic dissection 7 9 7

Myocardial infarction (MI) 8 12 6

Ischaemic heart disease (No MI) 0 4 5

Sudden Adult Death Syndrome (SADS) 4 3 10

Peripartum cardiomyopathy 4 0* 9**

Other Cardiomyopathy 4 1 4

Myocarditis or myocardial fibrosis 3 5 4

Mitral stenosis or valve disease 3 3 0

Thrombosed aortic or tricuspid valve 0 0 2

Infective endocarditis 1 2 2

Right or Left ventricular hypertrophy or

hypertensive heart disease 2 2 1

Congenital

Pulmonary hypertension (PHT) 4 3 2

Congenital heart disease (not PHT or

thrombosed aortic valve) 2 3 1

Other 2 0 0

Total 44 48*** 53

*12 Late cases reported in 2003-05

**2 late cases reported in 2006-08

***includes one women for whom little information on cause was available

Saving Mothers’ Lives 2006-2008, National launch - March 2011

MI / Ischaemic heart disease

(2003-8)

2003-2005 2006-2008 Total UKOSS*

MI 12 6 18 23 (14 angio)

Atheroma 8 3 11 (61%) 7 (50%)

Dissection 1 1 2 (11%) 3 (21%)

Embolus/thrombosis 1 1 2

Normal Coronaries 2

Undetermined 2 2 4

IHD without MI 4 5 9

Total IHD 12 8 20

Total MI / IHD 16 11** 27

*antenatal MI, 2005-2010

** 9 died postnatally

Risk factors for IHD

2003-5

• Aged 27-40 (av 35 years)

– 6 35 yrs old

• 11 parous

• 6 obese, (4 BMI > 40)

• 7 smoked

• 2 hypertension

• 1 FH +ve

• 2 type 2 diabetes

• 3 asian

2006-8

• Aged 28 to 46 (av 36 years)

– 8/11 ≥ 35 yrs old (5 ≥ 40)

• All were parous, (7 ≥ para 4)

• 3 were obese

• 6 smoked

• 4 hypertension

• 2 FH +ve

• 1 GDM

• 1 hypercholesterolaemia

• 1 sickle cell disease

Deaths in women in UK from Acute Myocardial

Infarction

0

10

20

30

40

50

60

70

15 -19 20 - 24 25 - 29 30 -34 35 - 39 40 - 44

AGE in years

2003

2004

2005

Age

15-24 25-34 35-44

2000-

02 0.11 0.44 2.43

2003-

05 0.05 0.38 1.98

Death rates per 100,000 population from myocardial

infarction among women of childbearing age, UK,

2000-05

ONS, General Register Office Scotland, General

Register Office, Northern Ireland

percentage of maternities in the Upercentage of maternities in the UKK

35-39 40

1997-

1999 12.3 2.1

2003-

2005 15.9 3.2

IHD in pregnancy: messages

• High index of suspicion in those with risk factors

• May not present with typical angina

– Myocardial infarction and acute coronary syndrome can present with atypical features in pregnancy such as abdominal or epigastric pain and vomiting or dizziness.

• ECG and troponin unchanged by pregnancy

– single normal ECG does not exclude ischaemia, especially if performed when the woman is pain-free.

• Get them to the catheter lab quickly

• Thrombolysis safe

• Use bare metal stents

• Aspirin and Clopidogrel are safe

Heart Failure Association of the European Society of

cardiology Working Group on PPCM 2010

PPCM is an idiopathic cardiomyopathy presenting

with heart failure secondary to LV systolic

dysfunction toward the end of pregnancy or in the

months following delivery, where no other cause of

heart failure is found. It is a diagnosis of exclusion.

The left ventricle may not be dilated but the ejection

fraction is nearly always reduced below 45%.

Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Eur J Heart Fail 2010;12:767-78.

Peripartum CardiomyopathyPeripartum Cardiomyopathy

Risk factors

Multiple pregnancy

Pregnancy complicated by hypertension (pre-existing or pre-eclampsia)

Multiparity

Advanced maternal age

Afro-Carribean race

Diagnosis

Echocardiography. Diagnostic criteria

• Left ventricular ejection fraction < 45% (LVEF at presentation 26-31%)

• Heart enlarged with global dilation of all four chambers and markedly reduced left ventricular function

The STAT3–oxidative stress–cathepsin D–16 kDa cascade.

Yamac H et al. Heart 2010;96:1352-1357

©2010 by BMJ Publishing Group Ltd and British Cardiovascular Society

Management

• Elective delivery if antenatal.

• Thromboprophylaxis.

• Conventional treatment for heart failure

– diuretics, vasodilators (hydrallazine and/or nitrates), digoxin, inotropes

– Selective beta blockers (bisoprolol), carvedilol (vasodilator)

– ACE inhibitors (after delivery)

• Inotropes

• Intraaortic balloon pump

• Left ventricular assist device

• Cardiac transplantation.

Mortality

• Recent series from South Africa, US quote

mortality rates of 11-13%

• US data – 0- 19%

• Predictors of death / poor outcome

– Increased age, African, multiparous

– Reduced LVEF at presentation (<30%)

– increased LV size

– NYHA class

– Postpartum presentation

Blauwet L & Sliwa K. Obstetric Medicine 2011.

Cardiac Events predicted by:

• Prior cardiac event or arrhythmia

• NYHA classification > II or cyanosis

• LV Ejection fraction < 40%

• Left heart obstruction

– Mitral valve area < 2 cm2

– Aortic valve area < 1.5 cm2

– Aortic valve gradient > 30mmHg

Siu et al Circulation 2001;104:515

Predictors of cardiac events in pregnancy:

Toronto study

Predictors of cardiac events in pregnancy:

Toronto study

Score 1 for each risk factor

Score 0: Event risk 5%

Score 1: Event risk 27%

Score>1: Event risk 75%

Drug treatment and method of delivery

were not independent risk factors

Siu et al Circulation 2001;104:515

Congenital Heart

Disease

Modified WHO classification

gives best risk estimation

model for cardiac risk in

pregnancy

Page 22

Balci A, Sollie-Szarynska KM, van der

Bijl AGL, et al.

Heart 2014;100:1373–1381.

Advise against pregnancy

Pulmonary arterial hypertension

Systemic ventricular dysfunction

LVEF < 30%,

NYHA III/IV

Previous PPCM with any residual LV impairment

Severe mitral stenosis

Severe symptomatic aortic stenosis

Aorta > 45mm Marfan

Aorta > 50 mm bicuspid

Severe coarctation

Pulmonary hypertensionPulmonary hypertension

• Non-pregnant mean PAP > 25 mmHg rest, > 30 on exercise or PVR > 200dy/sec/cm or >2.5 Woods Units (nb. catheter not echo)

• Danger relates to fixed increased pulmonary vascular resistance

• Inability to increase pulmonary blood flow with refractory hypoxaemia

• Most deaths can be attributed to

– thromboembolism

– hypovolaemia

– pre-eclampsia.

Pulmonary Hypertension

Bedard, Dimopoulus, Gatzoulis Eur HJ 2009; 30:256

• Systematic review 1997-2007

• 73 pregnancies

• Idiopathic PAH (72% on advanced therapies)

• Congenital heart disease associated PAH (52%)

• Other PAH (47%)

• Overall mortality reduced

– 1978-1996 = 38% (Yentis et al. BJOG 1998; 105: 921-922)

– 1997-2007 = 25% Idiopathic PAH 17%

CHD PAH 28%

Other PAH 33%

• Phosphodiesterase inhibitors (sildenafil)

• Endothelin-receptor antagonists (bosentan)

• Inhaled nitric oxide

• Prostacyclin analogues

PAH targeted therapies

Page 26

• Current Literature (limited to case series)

• Reported mortalities 77--17%17%

• Risk probably does relate to degree and

vasoresponsiveness

• Individualized pre pregnancy counselling

is essential

• Thorough assessment in PH centre

Is Pulmonary Hypertension still a contraindication to

pregnancy?

Yes in most cases Yes in most cases

CONTRACEPTION

Aortic Dissection

• More common in pregnancy – 7-9 deaths every 3 yrs

• Risk factors Marfan’s / Ehlers Danlos syndrome (type IV) / Turner’s / bicuspid AoV / Coarctation

• Most are type A (ascending aorta)

• Most present late pregnancy/within a week post partum

• Chest pain often attributed to pulmonary embolism

– Severe and interscapular

• Associated hypertension

– Systolic hypertension ignored

Mitral stenosis

• Asymptomatic

• Sinus Rhythm

• No therapy

• MVA = 0.9cm2

Learning points – mitral stenosis

1. Severe mitral stenosis that is asymptomatic prior to and in

early pregnancy may decompensate later in pregnancy and is

potentially fatal

2. The fact that mitral stenosis is asymptomatic does not mean

that it is mild and that pregnancy will be tolerated

3. Pulmonary oedema may present with wheezing

4. Rheumatic valve disease should always be considered in

pregnant women from developing countries

5. Patients with mitral valve disease should be evaluated pre-

pregnancy when possible

Which Anticoagulant Regimes for

Mechanical Valves?

Which Anticoagulant Regimes for

Mechanical Valves?

• Warfarin throughout

• Heparin until 12/40,

Warfarin until 36/40

Heparin

• Heparin + aspirin throughout Large aortic

Bileaflet

Small mitral

Bjork Shiley

<5mg warfarin

LMWH vs Warfarin

• Aortic valve

• Newer valve

– Carbomedics

• Sinus rhythm

• Warfarin dose > 5mg

• Likely compliance with 2 injections / day

• Give adjunctive aspirin

• Mitral valve

• Older (smaller) valve

– Bjork shiley

• AF/ large LA

• Warfarin dose < 5mg

• > 1 mechanical valve

• Previous CVA / embolus

So… what are the anticoagulation options in pregnant

women with mechanical valves?

Any strategy carries risks

Women should participate in the choice of anticoagulation

Women should be fully informed of risks and benefits of all options

Decision should be individualized and ideally made pre pregnancy

Care should be multidisciplinary

Cyanotic congenital heart disease

• Main risks = fetal

• < 20% chance of live birth if oxygen saturation < 80-85%

• Increased risk of

– Miscarriage

– FGR

• Maternal thromboembolism