Heart Diz in Pregnancy2013O&Gperlis

7/27/2019 Heart Diz in Pregnancy2013O&Gperlis

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APPROACH TO HEART DISEASEIN PREGNANCY

Dr Abdul Hadi bin Jaafar

Head and Consultant Cardiology

Cardiology Department,Tengku Ampuan Afzan Hospital Kuantan


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Heart disease is present in 0.5-4% of pregnancies Common causes of heart disease in Malaysia:

Rheumatic Heart Disease 55%

Congenital Heart Disease 40%

Others: 5%

Commonest non obstetric cause of maternal mortalityaccounting for 10% of all deaths

Early detection and appropriate management improves

maternal and fetal outcomes

Introduction

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PHYSIOLOGICAL CHANGES IN THE

CARDIOVASCULAR SYSTEM IN

PREGNANCYParameter 1st

Trimester 2nd

Trimester 3rd

TrimesterBlood volume Cardiac output to toStroke volume orHeart rate toSystolic blood pressure Diastolic blood pressure Pulse pressure Systemic vascular

resistance


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Management Principles Preconceptual Counselling

Detection of Cardiac Disease in pregnancy Risk Stratification

Specialist Referral

General Principles of Management and

Follow Up

Labor and Delivery

Post Partum

Breast Feeding

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Preconceptual Counselling

Women with heart disease should be :

Encouraged to complete their family early

Discouraged from multiple pregnancies

High Risk patients should be advised on permanentcontraception, if the defect is not correctable

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Preconception Planning

1. Dilated cardiomyopathy 15-60% MMR

2. Primary pulmonary HTN 50% MMR3. Eisenmenger Syndrome 15-30% MMR

4. Marfan Syndrome with aortic root dilatation 25-50%MMR

5. Coarctation of aorta 5%6. Tetralogy of Fallot 12%

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Preconceptual CounsellingHigh Risk Patients:

Pregnancy should be strongly discouraged.If pregnant, consider for early T.O.P

Pulmonary Hypertension (PAP >75% of syst Pressures)

Eisenmengers Syndrome Cyanotic Heart Disease

Poor LV function ( LVEF 40mm

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Preconceptual CounsellingWherever possible, significant cardiac lesions shouldbe corrected before pregnancy

Congenital Defects

Mitral Stenosis ( MVA


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Detection of Cardiac Disease In Pregnancy History

Physical Examination Investigations

ECG

Echocardiogram

The echocardiogram is sometimes the only reliable methodof excluding a cardiac murmur as being non significant in

a pregnant patient.Thus the threshold fo r an echo cardiogram

shou ld be LOW

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Risk StratificationRisk Stratification of the mother and fetus depends on

the following cardiac conditions: New York Functional Class

Presence of Cyanosis

Left and Right Ventricular Function

Severity of Pulmonary Hypertension Presence of valve/conduit stenosis

Presence of conduction defects

Presence of arrhythmias

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Risk Stratification

Low Risk generally tolerate pregnancy well

Moderate Risk

High maternal and fetal Risk

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Risk Stratification LOW RISK Uncomplicated septal defects

Pulmonary stenosis

Aortic and mitral regurgitation

Hypertrophic Cardiomyopathy Acyanotic Ebsteins Anomaly

Corrected transposition without other defects

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Risk Stratification MODERATE RISK

Coarctation of the Aorta

Univentricular circulation after Fontan Operation

Prosthetic Valves on anti-coagulants

Severe Mitral Regurgitation with NYHA class 1

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Risk Stratification HIGH RISKPulmonary Hypertension ( PAP >75% of systemic Pressures)

Eisenmengers Syndrome

Uncorrected Cyanotic Heart DiseaseSevere Aortic Stenosis

Severe mitral stenosis

Poor LV function ( LVEF40mm)

Pregnancy in patients with heart disease also imposes

a high risk to the fetus esp: impaired maternal functional

class and presence of cyanosis

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Specialist Referral

Low Risk patientscan be managed by Primary CareDoctors

Moderate Risk Patientscan be managed in hospitals

where Specialists are available

High Risk Patients should ideally be managed in

tertiary Hospitals with a multi disciplinary team

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Specialist Referral

The following patients should be considered for early

specialist referral:

Known heart disease who have not been

assessed or risk stratified prior to pregnancy

Moderate and at High Risk Worsening symptoms due to heart disease

Suspected to have heart disease - confirm or refute the diagnosis

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General Principles Of Management

and Follow Up

At the First Visit :

Assessment of maternal and fetal health

Assessment of Maternal NYHA Functional Class

Confirmation of clinical diagnosis

Establishment of baseline hemodynamics

High Risk Patients should be considered for

T.O.P.

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and Follow Up

At Follow Up :

routine antenatal care (mother and fetus)

correct anemia

treat infections

Identify and treat complications of heart disease

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and Follow Up

Heart Failure: - diuretics, digoxin, nitrates and/or hydrallazine Worsening Right to Left Shunt: nasal oxygen, adequate

volume replacement

Thromboembolism

Arrhythmias

Patients with these complications,should be admitted

and kept in hospital till delivery.

All High Risk Patients should be hospitalized in the third

trimester

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SAFETY PROFILE OF CVS

DRUGS IN PREGNANCYDRUG PROFILE ADVERSE EFFECTS

Digoxin Safe Low Birth Weight

Diuretics Safe Impairment of uterine blood flow,

hyponatremia, thrombocytopenia,

jaundice, bradycardia

ACE I Use judiciously Skull ossification, IUGR, low birth

weight, oligohydramnios, neonatal

renal failure, limb contractures

Nitrates Unsafe

Calcium Antagonists Use judiciously Fetal Bradycardia

Sodium Nitrprusside Use judiciously Fetal Distress due to maternal

hypotension


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DRUGS PROFILE ADVERSE EFFECTS

Beta Blockers Safe IUGR, bradycardia, apnea at birth,

hypoglycaemia, hyperbilirubinaemia;may initiate uterine contraction

Adenosine Safe None reported

Propafenone Safe None reported

Lignocaine Safe High blood levels may cause fetal

acidosis and CNS depression

Amiodarone Unsafe IUGR, prematurity, hypothyroidsm

Procainamide Safe None reported

Quinidine Safe Toxic dose may induce premature

labor and damage to 8th cranial

nerve


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Labour and Delivery

The timing and mode of Delivery Hemodynamic Monitoring

Analgesia

Antibiotic Prophylaxis

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Labour and Delivery

1) Timing and Mode of Delivery

This should be individualised

High Risk patients should be delivered at a tertiary

center

Spontaneous Labor is preferred to induction The second stage of labor should not be allowed to

be prolonged

Vaginal delivery vs. caesarian section

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Labour and Delivery

3) Analgesia

This is important to control the stress of labor

An epidural is the technique of choice

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Labour and Delivery

4) Antibiotic Prophylaxis

Routine antibiotic prophylaxis in all susceptiblepatients

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Antibiotic Prophylaxis for Labour and Delivery

Standard Regimen:

Ampicillin/Amoxycillin IV or IM 2.0 gm +

Gentamycin IV or IM 1.5 mg/kg ( not to exceed

80mg) 30 mins before procedure

Followed By,

Ampicillin/Amoxycillin 1.5 gm orally 6 hours after initial

dose or repeat parenteral dose

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Penicillin Allergy:

Vancomycin IV or IM 1.0 gm over 1 hr +

Gentamycin IV or IM 1.5 mg/kg (not to exceed 80mg)

30 mins before procedure

Followed By,

repeat parenteral dose of Vancomycin

and gentamycin

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Alternative Low Risk Regime:

Amoxycillin oral 3gm 1 hour before procedure

Followed By,1.5gm amoxycillin 6 hours later

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Post Partum Most patients have an uncomplicate delivery and peurperium

Increase in venous return following delivery may

result in worsening heart failure in patients with stenoticvalves and impaired LV function

Patients with Eisenmengers syndrome decompensate

in the early post partum period due to increase right to leftshunting

These patients should be monitored for about 48-72 hours

and remain in hospital for about a week.

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Breast Feeding

Patients with heart disease and an uncomplicated

pregnancy should be encouraged to breast feed

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DRUGS IN LACTATIONDRUG PROFILE COMMENTS

Digoxin Safe Amount ingested far < the pediatric dose

Quinidine Safe Amount ingested far < the pediatric dose

Procainamide Safe Amount ingested far < the pediatric dose

Amiodarone Not safe Excreted in significant amounts in milk

Verapamil Safe Amount ingested far < the pediatric dose

Propanolol Safe No adverse effect

Metaprolol Safe Amount ingested far < the pediatric dose

Atenolol Safe No adverse effect

ACE-I Not safe


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1.4. Management of Specific Conditions

1.4.1 Valvular heart disease including prosthetic

Valves1.4.2 Congenital Heart Disease

1.4.3 Pulmonary Hypertension and Eisenmengers

Syndrome

1.4.4 Depressed LV function1.4.5 Hypertrophic Cardiomyopathy

1.4.6 Marfans Syndrome

1.4.7 Arrhythmias

1.4.8 Anticoagulation in pregnancy

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HEART DISEASE

IN

PREGNANCY

Specif icCondi t ions


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Valvular Heart Disease

Mitral stenosis Patients with mild to moderate

Mitral Stenosis (MVA>1.0 cm2)

usually tolerate pregnancy well

In severe Mitral stenosis

and/or pulmonary hypertension,

consider percutaneous mitralvalvotomy during 2nd trimester

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Aortic Stenosis

Patients with mild to moderate ASAVA>1.0 cm2, normal resting ECG

& absence of LVH on voltages,

good LV function &normal exercise

tolerance) usually tolerate pregnancy well

In severe Aortic stenosis use diuretics and/or digoxin

Failure of medical therapy may require termination of

pregnancy or palliative percutanous aortic valvuloplasty

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Pulmonary stenosis Generally well tolerated even in the presence of severely

elevated RV pressures

Prosthetic Valves Most patients with a normally functioning valve tolerate

pregnancy well.

Maternal Mortality 1-4% in those with mechanical heart

valves

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Pulmonary Hypertension

Pulmonary Hypertension is present when the systolic

pulmonary pressures are >30 mmHg and the mean pressure>20mmHg respectively

Pulmonary Hypertension may be due to:

Primary Pulmonary Hypertension

Eisenmengers Syndrome

Secondary Vascular Pulmonary hypertension

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Pulmonary Hypertension

Patients with PHT usually die at the time of delivery or

in the early post partum period This is due to shunt reversal with increased right to left

shunting and resultant hypoxia and acidosis

These patients should be admitted in the second trimester

and the following considered:

An t icoagulat ion t i l l term and ear ly post partum

Contin uous oxygen therapy, aiming at SaO2 > 90%

Adequate hydrat ion

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Anticoagulation in Pregnancy

Anticoagulants are indicated in the following situations:

Mechanical Heart valves

Deep venous thrombosis & thromboembolism

Atrial fibrillation associated with structural heart disease

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The anticoagulants available are:

Oral anticoagulants

Warfarin is associated with embryopathy in

4-10% of newborns

Unfract ionated Heparin

Low dose heparin is inadequate for thromboprophylaxisduring pregnancy

Its usage requires monitoring of the APTT

Low m olecular weight Hepar in

Does not require APTT monitoring

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Patients on long term anticoagulants must be counselled prior

to conception

3 options for anticoagulation:I. Combined heparin and oral anticoagulants

First trimester: unfractionated heparin/LMWH

Second trimester till 36 weeks: warfarin

From 36th week: unfractionated heparin/LMWHII. Full dose heparin throughout pregnancy

III. Continuous warfarin therapy:

First trimester till 36 weeks: warfarin

From 36th week: Unfractionated heparin/LMWH

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In High risk Patients with Mechanical Heart

valves we advocate Option III.

If the patient chooses option I or II, sheshould be made aware of the higher risk

of valve thrombosis and thromboembolism

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The choice of anticoagulation regimen for mechanicalheart valves during pregnancy should be made by

balancing 2 risksmaternal morbidity and mortality

from thromboemboliccomplications versus fetal loss

and embryopathy

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Option I

Combined heparin

+ warfarin

Option IIHeparin throughout

Optio n IIIWarfarin throughout

Frequency of Fetal and Maternal Complications

With various Anticoagulation Options

Spontaneous

abortion

Congenital

anomalies

Thrombo-

embolism

Death

24.8% 3.4% 9.2% 4.2%

23.8% 0%-2.8% 33.3% 15%

24.7% 6.4% 3.9% 1.8%

Fetal

compl icat ions

Maternalcompl icat ions


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Higher Risk

1st generation PHV (e.g., Starr-Edwards,Bjork Shiley) in the mitral position,atrial fibrillation, history of TE onanticoagulation

Warfarin (INR 2.53.5) for 35 weeks,followed by UFH (mid-interval aPTT 2.5) or

LMWH (pre-dose anti-Xa 0.7) and

ASA 80

100 mg q.d.OR

UFH (aPTT 2.53.5) or

LMWH (pre-dose anti-Xa 0.7) for 12 weeks,followed by

warfarin (INR 2.53.5) to 35th week, then

UFH (aPTT 2.5) or

LMWH (pre-dose anti-Xa 0.7) and

ASA 80100 mg q.d.

Lower Risk2nd generation PHV (e.g., St. JudeMedical, Medtronic-Hall) anymechanical PHV in the aortic postion

SC UFH (mid-interval aPTT 2.03.0) or

LMWH (pre-dose anti-Xa 0.6) for 12weeks,

followed bywarfarin (INR 2.53.0) for 35 weeks, then


LMWH (pre-dose anti-Xa level 0.6)OR


LMWH (pre-dose anti-Xa 0.6) throughoutpregnancy

Elkayam U et al . Ant icoagulat ion in pregnant w omen wi th prosthet ic hear t

valve. J Cardiovasc Pharmacol Th er 2004;9:10715.


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Assessing the risk Based on a prospective study of pregnancy

outcomes in women with heart disease in

Canada* Overall rate of primary cardiac event

(pulmonary oedema, stroke, cardiac arrest,

arrhythmias and death) was 13%

*CARPREG Investigators . Circu lat ion

2001 Ju l 31; 104(5):515-521


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Predictors of cardiac events*1. Poor functional class (NYHA > II) or cyanosis

2. Previous cardiac event (eg; heart failure, TIA, stroke) or

arrhythmias

3. Left heart outflow obstruction

MVA < 2cm2

AVA < 1.5 cm2

Peak LVOT gradient > 30mmHg4. LV systolic dysfunction (EF < 40%)

*CARPREGInvest igators.Circulat io n 2001

Ju l 31;104(5):515-21


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The score

Score of 0 5% risk

Score of 1 27% risk

Score of >1 75% risk

Risk of developing primary cardiac event

Mode of delivery and outcome;

VD 3% vs. Caesarean 4% (p= 0.46)

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Summary

All women with heart disease should be counselled on

the maternal and fetal risks, should they become pregnant

Wherever indicated, significant cardiac lesions should

be corrected prior to pregnancy

Pregnant patients with heart disease should be riskstratified

Patients at low risk can be managed by their primary

care doctors

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Summary Patients at moderate risk may be managed in hospitals

with specialists

Patients at high risk should ideally be managed in

tertiary care centers

In addition to routine antenatal care, complications of

heart disease should be looked for and treated

accordingly

Patients requiring anticoagulants should be counseled

on the available options

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Summary

Labour and delivery in patients at moderate and high

risk is best managed by a multidisciplinary team

The timing and mode of delivery should be individualised

Adequate analgesia during labour is important

We recommend antibiotic prophylaxis during delivery

in all susceptible patients

HEART DISEASE IN

PREGNANCY

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Heart Diz in Pregnancy2013O&Gperlis

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