How to manage the pregnant

woman with heart disease

Dr Fiona Walker, The Heart Hospital,UCLH, London

Dr Sara Thorne, University Hospital Birmingham

Dr Cathy Head, The Heart Hospital, UCLH, London

Dr Kate English, The Yorkshire Heart Centre, Leeds

Why you need to know

Dr Fiona Walker

Consultant Cardiologist

The Heart Hospital, UCLH NHS Trust, London

No conflict of interest

Prevalence maternal heart disease ~ 1-3%

Author / Year Country No Preg Prev of Rh HD Congenital HD Other HD Maternal

with HD Maternal HD Mort

Etheridge

1950-75 Australia 764 0.5% 83% 13% 4% 1.3%

Sugrue

1969-7 Ireland 387 0.5% 84 13 3 0.5

Mc Faul N.Ireland 519 1.3% 60 31 9 0.6

1970-83

Bitsch Denmark 87 0.3% 8 81 11 2.3

1977-86

Maternal heart disease

UCL High-Risk Obstetric service 2001-2004

14

131

Acquired heart disease

Congenital heart disease

Impact of Infant Heart SurgeryImpact of Infant Heart Surgery

0

50

100

0

1 mnth 1 y

r5 y

rs15 yrs

% alive

Surgery GOS 1955 - 95

Natural history

new population

1980

Adult CHD patientsPaediatric CHD patients

2010

Adult CHD patients

Paediatric CHD patients

North East Regional Database

O’Sullivan, Wren BCS 2000

1 year16 years

251Birth

Infants >Infants

72

Follow-up

91/year

+ =

1877 new cases per year

require LTFU in UK

~ 16000 - 20000 patients in UK

GUCH PopulationGUCH Population

�More adults than children with

Fallot’s Tetralogy!

�Almost no children with Mustard or

Senning

28 weeks9%↓SBP

↓DBP

Term30-50%↑CO

Term10-30%↑SV

term20-30%↑HR

34weeks34%↓PVR

24 weeks20%↓SVR

32 weeks45-50%↑↑Plasma

volume

Term20%↑Oxygen

consumption

Circulatory changes in pregnancy

The haemodynamic changes of pregnancy

Labour & delivery puerperiumpregnancy

Baseline CO

Peripheral vascular resistance COPVR

0

5

10

15

20

25

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002

mortality per 100,000 m

atern

ities

maternal mortality

direct mortality

indirect mortality

cardiac

Maternal mortality

Indirect maternal mortality (deaths per 100,000 maternities) 1967-2002

0

2

4

6

8

10

12

1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002

all indirect

cardiac

suicide

cancer

other indirect

Data from “Why mothers die – 2000-2002” www.CEMACH.org

0

5

10

15

20

25Rate per million

maternities

Thromboembolism

HT

Haemorrhage

AFE

Sepsis

Trauma

Anaesthetic

Cardiac

Psychiatric

Maternal mortality UK

Deaths from heart disease

1952-60 & 1985-93

0

50

100

150

200

250

Rheumatic SBE Coronary Other

1952-60

1985-93

Maternal Cardiac deaths 1993-99

cardiomyopathy

aneurysm

MI

PHT

other

CHD 20%

Substandard care in 40%

CEMACH 2000-2002 - 44 deaths from heart disease

Lesion specific pregnancy outcome data

943.30960Tissue valve

8313 (c)2.978240Mechanical

Valve

87291.04996Cy + / no PHT

845.73553PHT

865.4221074Marfan (a)

1006.101832Fontan

9200215Mustard

1008.101462Repaired TOF

1004.80221Repaired CoA

94696.3016Severe AS

68011938AS (a)

161.50408MS

Live births %Maternal

CVS comp %

Maternal

mortality %

No abhortionNo

pregnancies

Maternal

lesion

U. Thilen, SB Olsson. Eur J Obs & Gynae and Reproductive biology 75(1997) 43-50

Toronto prospective multicentre study of pregnancy

outcomes in women with heart disease

562 women, 599 pregnancies, 13 centres

Review at <28/40, 28-37/40, peripartum,6/52 postpartum, 6/12 post

CHD (445) 74%, acquired (127) 24%, arrhythmia (27) 4%, PHT

(25) 4%

Baseline: 21 (4%) NYHA III, Cy+ 4

13% pregnancies complicated by pulmonary oedema, arrhythmia

or stroke

0% mortality

(Sui et al ; Circulation;104:July 2002)

The 4 predictors of maternal cardiac events are ;

• Prior episode of heart failure, TIA, CVA, or arrhythmia

• NYHA ≥ II or cyanosis

• Left heart obstruction (MVA < 2 cm2, AVA < 1.5 cm2,

Peak LVOTO > 30 mmHg on echo)

• Reduced LV function (EF < 40%)

0 predictors - risk of a cardiac event is 5%

1 predictor - risk of cardiac event 27%

(Sui et al, Circulation;104:July 2002)

> 1- risk of cardiac event is 75%

Obstetric Problems which increase

Maternal risk

> Twins

Pre-eclampsia

Haemorrhage

Premature Labour

Hydramnios

Motto; 6P’s

Prior planning,

prevents

poor performance (outcome)

Pre-Pregnancy counselling ;

1. The complexity of the heart lesion

2. Appreciate impact of normal haemodynamic changes on lesion

3. Detailed knowledge of prior surgical correction(s)/interventions

4. Detailed knowledge of residua / sequelae

5. A discussion re ; long-term prognosis & risk of recurrence in

offspring ? 22q11

6. Optimisation of clinical status including drugs

7. Knowledge of other co-morbid medical problems

Pre - Pregnancy work-up

�Clinical review and examination

�Up to date TTE / stress echo

�ETT or CPEX

�Optimise and change Meds

�Communicate with obstetric team & local cardiologist

�Plan place & frequency of reviews

• Obstetric unit or cardiac unit

• Early or term

• Vaginal delivery v’s C-section

• Epidural / Spinal/ Natural

• Haemodynamic monitoring - invasive / non-invasive

• CVS drugs

• Endocarditis prophylaxis

• Duration of monitoring / observation post-partum

Labour & delivery planning

“If single do not allow marriage,

If fertile do not allow pregnancy

If pregnant do not allow delivery(!?)

If delivered do not allow breast feeding”

XIX century Obstetric aphorism referring to

women with heart disease

Neonatologist

Haematologist

Anaesthesia

GUCH cardiologist Obstetrician

Foetal medicine

Intensive careSpecialist nurse

Obstetric physician

Manpower for the high risk cardiac obstetric service

Thankyou!

Fiona.walker@uclh.org