Pregnancy & The Heart

Pregnancy And The Heart Adel Shabana, MD, MRCP

Thanks to: prof. Dr. Wael Kilany

Physiology Of Pregnancy

Physiology Of Pregnancy By The 32nd Wk, maternal COP is approximately 40% above the pre-pregnancy level and stays at this level till birth.During Delivery additional increase in HR and BP lead to further increase in COP to as much as 80% above the pre pregnancy level.

First stress test the woman has in her life.

Pre-Pregnancy Evaluation. CARPREG Index

Pre-Pregnancy Evaluation. CARPREG Index

Pre-Pregnancy Evaluation. CARPREG Index

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Pre-Pregnancy Evaluation. Cont.Women with severe Pulmonary Hypertension (PAP two thirds of the systemic pressure) have estimated maternal mortality between 30-50%.

Female with EF 40% with NYHA class III or IV have a high risk of maternal & fetal mortality. So considered a Contraindication for pregnancy.

Mode of delivery How to decide? Vaginal or caesarean delivery

The preferred mode of delivery is vaginal, with an individualized delivery plan. Why?less blood loss Less infection risk Less risk of venous thrombosis and thrombo-embolism.There is no consensus regarding absolute contraindications to vaginal delivery as this is very much dependent on maternal status at the time of delivery and the anticipated cardiopulmonary tolerance of the patient. Better to use lateral decubitus position to attenuate the haemodynamic impact of uterine contractions and avoid valsalva

In general, caesarean delivery is reserved for obstetric indications. Caesarean delivery should be considered for:Patient on oral anticoagulants in pre-term labour- Patients with Marfan syndrome and an aortic diameter >45 mm (Cesarean delivery may be considered in Marfan patients with an aortic diameter 4045 mm).Patients with acute or chronic aortic dissectionPatients in acute intractable heart failure.

Anesthesia???Lumbar epidural analgesia is often recommendable because it:reduces pain-related elevations of sympathetic activity, Reduces the urge to push, and provides anaesthesia for surgery. Continuous lumbar epidural analgesia with local anaesthetics or opiates, or continuous opioid spinal anaesthesia can be safely administered.Regional anaesthesia can, however, cause systemic hypotension and must be used with caution in patients with obstructive valve lesions.

What is the most common cardiac complication during pregnancy in women with and without structural heart disease?ArrhythmiasHypertension (1/4 of all antenatal admissions.)What is the most common medical problem in pregnancy?

Delivery is associated with important haemodynamic changes and fluid shifts, particularly in the first 1224 hr, which may precipitate heart failure in women with structural heart disease. Haemodynamic monitoring should therefore be continued for at least 24 h after delivery.

Management of Some cardiac problems with pregnancy

Case 21 Yrs, Pregnant female.32 Wks Gestational age.Severe occipital headacheLight flashes.BP 170/115LL edema up to the kneeUrine Dipstick +4 Protein.

Hypertension During Pregnancy

Hypertension During Pregnancy.(0.3 g/day in a 24 h urine collection or 30 mg/mmol urinary creatinine in a spot random urine sample)42 days post delivery

Risk factors before pregnancy for the development of hypertensive disorders:High maternal age, Elevated BP, Dyslipidaemia, Obesity, Positive family history, Antiphospholipid syndrome, Glucose intoleranceWomen who develop gestational hypertension or pre-eclampsiaare at increased risk of hypertension and stroke in later adult Life, as well as of ischaemic heart disease

Is it that serious????Hypertensive disorders in pregnancy remain a major cause of maternal, fetal, and neonatal morbidity and mortality in developing and in developed countries. Women at higher risk for severe complications such as abruptio placentae, CVA, organ failure, and DIC.Fetus at risk for IUGR, prematurity, and intrauterine death.

Summary of treatment optionsSBP 170 mmHg or DBP 110 mmHg in a pregnant woman is as an emergency, and hospitalization is indicated. Pharmacological treatment with i.v. labetalol, or oral methyldopa, or nifedipine should be initiated. I.v. hydralazine is no longer the drug of choice as its use is associated with more perinatal adverse effects than other drugs.The drug of choice in hypertensive crises is sodium nitroprusside infusion. But Prolonged treatment an increased risk of fetal cyanide poisoning The drug of choice in pre-eclampsia associated with pulmonary oedema is nitroglycerine infusion.For long term treatment of hypertension during pregnancy: Methyldopa is the drug of choice, Labetalol has efficacy comparable with methyldopa, CCBs e.g. nifedipine are drugs of 2nd choice

ACE I & ARBS Fetal Renal Affection. Diuretics decrease Placental Flow.

After delivery All antihypertensive agents taken by the nursing mother are excreted into breast milk at very low concentrations, but higher for propranolol and nifedipine.Post-partum hypertension is common. Hypertensive women during pregnancy may be normotensive after birth but then become hypertensive again in the first postnatal week. Methyldopa should be avoided post-partum because of the risk of post-natal depression.Women experiencing hypertension in their first pregnancy (especially early onset) are at increased risk in a subsequent pregnancy.

Case 36 Yrs Old Pregnant female 4 kids34 WksSOB, NYHA class IV, Orthopnia.PalpitationsLL edema up to the knee.BP 160/90, P 100 BPM regularS3 gallop

Peripartum Cardiomyopathy

Peri-Partum Cardiomyopathy Congestive heart failure identified toward the end of pregnancy or in the months following delivery in the absence of other identifiable cause or previous history of CHF.

PPCM is suspected to be the consequence of an unbalanced oxidative stress leading to proteolytic cleavage of prolactin into a potent angiostatic factor and into pro-apoptotic fragments

Risk Factors:Advanced age of mothers or teenageBlackMultiparousMultifetal pregnancyGestational hypertension, preeclampsia,Family history, smoking, DM,Prolonged use of b-agonists.Prognosis 50 % improvement within 6 months of delivery. (?devices)A subsequent pregnancy carries a recurrence risk for PPCM of 3050%.

PPCM treatment Medical therapy should be started promptly (-blockers, digoxin, hydralazine, nitrates, and diuretics) [metoprolol NOT atenolol [ Newborns should be supervised for 2448 h after delivery to exclude hypoglycaemia, bradycardia, and respiratory depression]ACE -I, ARBs, and aldosterone antagonists should be avoided until after delivery. (during breastfeeding benazepril, captopril, or enalapril are preferred).Anticoagulation post partum!Bromocriptine shown to improve LV EF and composite clinical outcome in patients with acute severe peripartum cardiomyopathy when added to heart failure therapy. (in addition to preventing lactation due to high metabolic demnd)

Delivery

Vaginal delivery is always preferable if the patient is haemodynamically stable and there are no obstetric indications for caesarean delivery. Close haemodynamic monitoring is required. Epidural analgesia is preferred. Urgent delivery irrespective of gestation duration should be considered in women with advanced heart failure and haemodynamic instability despite treatment. Caesarean section is recommended with combined spinal and epidural anaesthesia

HCMB-blockers/VerapamilCardioversion for AF

Delivery:Low risk cases may have a spontaneous labour and vaginal delivery.A planned delivery is recommended in all others. The severity of LVOTO will determine if regional anaesthesia is acceptable (Epidural anaesthesia causes systemic vasodilation and hypotension, and therefore must be used with caution in patients with severe LVOTO.) I.v. fluids must be given judiciously and volume overload must be avoided as it is poorly tolerated in the presence of diastolic dysfunction.Syntocinon may cause hypotension, arrhythmias, and tachycardia, and should only be given as a slow infusion.

Case 22 yrs female Marfan syndromeEcho: Normal internal dimensions, EF 65%, dilated aortic root 49 mm, mild AR, Normal RVSP.Came for cardiac consultation before pregnancy.What do you advise??

Aortic Diseases

MARFANBICUSPID AORTIC VALVEEhler-Danlos, Turner, annuloaortic ectasia

Risk factors for aortic pathology in the general population are hypertension and advanced maternal age.

Pregnancy is a high risk period for all patients with aortic pathology. Haemodynamic changes & hormonal changes lead to histological changes in the aorta, increasing the susceptibility to dissection.

Aortic Diseases

Dissection occurs in the last trimester of pregnancy [50%] or early postpartum [33%] of the cases.Consider aortic dissection in all pregnant females with chest pain.In women with Marfan syndrome + aortic root >45 mm pregnancy should be discouraged. Complete evaluation of aorta before pregnancy is recommended And if she gets pregnant she should deliver with CS.

Bicuspid AVApproximately 50% of the patients with a bicuspid aortic valve and AS have dilatation of the ascending aorta.Dilatation is often maximal in the distal part of the ascending aorta, which cannot be adequately visualized by echo; therefore, MRI or CT should be performed pre-pregnancy. Complete evaluation of aorta before pregnancy is recommended

In summary: (look for aortic diameter/aetiology)Pre pregnancy surgery: 45 in Marfan 50 in BAVSurgery during pregnancy (or after early CS) in any aetiology , 50 and increasing rapidly or if dissection occursB blockers and repeated echo/imagingMode of delivery:If < 40 vaginalIf 40-45 vaginal with epidural (Iia) or CS (IIb)If 45 CS

Case 23 Yrs old pregnant female.12 Wks Gestational age.SOB NYHA class II, No orthopnea, No PND.Known RHD, MR.Echo: LVEDD 64, LVESD 37, EF 65%, Severe rheumatic MR, RVSP 40 mmHg.BP 130/80HR 75 BPM

Case 25 Yrs Old pregnant femalePregnant 8 Wks.SOB, NYHA Class III.Echo: Normal dimensions, Normal EF%, MVA 0.9 cm, MPG 14 mm Hg, Favorable score for BMV, Mild MR, RVSP 60 mm Hg.BP 150/90, P 100 BPM, Mild LL edema.What To Do??

Valvular Heart Disease

Valvular Heart Disease

Regurgitant lesions are better tolerated than stenotic lesions, Pre-pregnancy intervention is only indicated when severe regurgitation is accompanied by refractory heart failure.Moderate & severe MS is generally poorly tolerated during pregnancy and should be treated interventionally Pre-pregnancy.During pregnancy percutaneous commissurotomy should only be considered when symptoms persist despite medical therapy.In aortic stenosis intervention pre-pregnancy is indicated in case of :Symptoms, LV dysfunctionSymptoms during exercise testing.

- After 20 weeks gestation. Abdominal lead shielding Experienced team

CS in severe MS with P++ & in sveere AS- Percutaneous aortic valvuloplasty?????

Doctor.. I came today to ask you if I can get pregnant or not?-- Mdme You must have an exercise test first???Aysmptomatic severe MS or ASAsymptomatic moderate/severe MR/AR

Case 30 Yrs old female.Prosthetic AV.Missed period, pregnancy test +ve.INR 2 / Marevan 3 mg.What would u do???

30 Yrs old female.Prosthetic MV.Missed period.Pregnancy test +ve.INR 2.7 / Marevan 7 mg.What would u do???

Prosthetic valves

Mechanical valves carry the risk of valve thrombosis which is increased during pregnancy.

In a large review, this risk was: 3.9% with OACs throughout pregnancy (maternal death 2 %) 9.2% when UFH was used in the first trimester and OACs in the second and third trimester (maternal death 4 %)and 33% with UFH throughout pregnancy (maternal death 33%)

UFH throughout pregnancy is additionally associated with thrombocytopenia and osteoporosis.

The ESC Task Force does not recommend the addition of acetylsalicylic acid to this regimen because there are no data to prove its efficacy and safety in pregnant women.

OAC and embryopathy riskOACs cross the placenta and their use in the first trimester can result in embryopathy in 0.610% of cases.UFH and LMWH do not cross the placenta and embryopathy does not occur. Substitution of OACs with UFH in weeks 612 greatly decreases the risk. The incidence of embryopathy was low (2.6%) in a small series when the warfarin dose was < 5 mg and 8% when the warfarin dose was > 5 m daily.

The mother and her partner must understand that according to current evidence use of OACs is the most effective regimen to prevent valve thrombosis, and therefore is the safest regimen for her, and risks for the mother also jeopardize the baby.

What to do if Valve thrombosis occur ??AnticoagulationSurgeryFibrinolysis:Most fibrinolytic agents do not cross the placentaRisk of embolization (10%) and of subplacental bleedingShould be applied in critically ill patients when surgery is not immediately available. May be considered instead of surgery in non-critically ill patients when anticoagulation fails, because fetal loss is high with surgeryTherapy of choice in right-sided prosthetic valve thrombosis.

Summary ..OAC with VKA is the safest therapy to prevent valve thrombosis and is therapy of choice during the second and third trimester.During the first trimester continuationof OAC should be considered whenthe required daily dose is low (Warfarin 55% because intrinsic haemostatic defects increase the risk of excessive menstrual bleeding.

Tubal ligation is usually accomplished safely, even in relatively high risk women (hysteroscopic sterilization is better).

Cardiac arrest in a pregnant womanIn unstable pt. The patient should be placed in a full left lateral decubitus position to relieve aortocaval compressionDuring CPR: Continuous manual LUD should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation this is preferable to TILTING

Cardiac arrest in a pregnant woman

Anterolateral defibrillator pad placement is recommended as a reasonable default (Class IIa; Level of Evidence C). The lateral pad/paddle should be placed under the breast tissue, an important consideration in the pregnant patient.

In the setting of cardiac arrest, no medication should be withheld because of concerns about fetal teratogenicity (Class IIb; Level of Evidence C).Fetal assessment should not be performed duringresuscitation (Class I; Level of Evidence C).

PMCD Def: the birth of the fetus after maternal cardiac arrest, most commonly during resuscitation.Advantages: Relief of aortocaval compressionSave the baby

oxytocin should be used with cautionbecause it can precipitate rearrest