Mom and Baby: The Heart of

the Matter

Eveleen R. Randall, MD

Department of Medicine, Division of Cardiology

Megan M. Schellinger, DO, MS

Department of OB/GYN, Division of Maternal-Fetal-Medicine

Objectives

• Briefly review CV physiology during pregnancy

• Hypertension spectrum in pregnancy

• Valvular heart disease during pregnancy– Native valve disease

– Prosthetic valves

• Aortopathies and pregnancy

• Pulmonary hypertension and pregnancy

• Congenital heart disease & the pregnant woman

Maternal Physiology Review(Compliments Dr. Shroff)

- ↑CO due to ↑HR, ↑SV & ↓PVR

- Ute/Ov blood flow 450-650ml/min

- ↓FRC/RV due to ↑ diaphragm

- No change in RR;↑TV and min ventilation

- Chronic mild resp alkalosis

- ↑Coagfactors/ fib

- 45% ↑ blood volume

- ↑vascular comp ↑ venous stasis

- ↓ motility

- ↓ LES tone + delayed gastric emptying GERD

4 Significant Hemodynamic

Changes in Pregnancy

• Plasma Volume Expansion

– 40-50% increase in plasma volume

• Increase normal cardiac output (30-50%)

– Increase Stroke Volume

– Increase Heart Rate

• Systemic Vascular Resistance Falls

• Procoagulant’s increase

– (I, VII, VIII, IX, X and Fibrinogen)

CV Physiology in Pregnancy

• Physiologic Changes noted per trimester

– First trimester HypotensiveNormotensive

• Meds +/-

• Early as 7 weeks

• Nadirs at 24-32 weeks

– Second trimester/Third Trimester (24-32 weeks)

• Pre-pregnancy blood pressures and higher noted

• Medications +

Maternal CV Risk – Risk

Stratification Scores

Hypertensive Disorders in

Pregnancy

Chronic (pre-existing) hypertension

BP >/= 140/90 before 20th week of pregnancy or persists longer than 12 weeks postpartum

Gestational hypertension Elevated BP 1st detected after 20 weeks in absence of proteinuria or other features of preeclampsia

Hypertensive Disorders in

Pregnancy

Preeclampsia without severe features

• New onset HTN + proteinuria

Preeclampsia with severe features

• New onset HTN + end-organ dysfunction ± proteinuria

Chronic HTN with superimposed preeclampsia

♀ w/ chronic HTN develops worsening HTN w/ new onset proteinuria or other features of preeclampsia

Hypertensive Disorders in

Pregnancy

Eclampsia • ± new onset HTN ± proteinuria• ± new onset HTN + end-organ

dysfunction ± proteinuria• SEIZURE

Acute Fatty Liver TTP/HUS • ± new onset HTN ± proteinuria• ± new onset HTN + end-organ

dysfunction ± proteinuria• Lab Abnormalities

• History of preeclampsia

• Multifetal gestation

• Chronic Hypertension

• Diabetes Type 1 or type 2

• Renal Disease

• Autoimmune (SLE, RA)

“ACOG supports the recommendation to consider the use of low-dose aspirin (81 mg/day), initiated between 12 and 28 weeks of gestation, for the prevention of preeclampsia, and recommends using the high-risk factors as recommended by the USPSTF and listed above.”

Prevention: Aspirin Therapy

CV risk in ♀ with HTN during

Pregnancy

• Twice as likely to develop HTN or pre-HTN in

12 months after delivery

• At least annual lifelong measurement of BP

• Recommend PCP to all patients with pre-

eclampsia

Supraventricular Arrhythmias

during Pregnancy

• Arrhythmias are the most common cardiac complication in pregnancy.– ♀ w/ established arrhythmias or structural heart disease at highest

risk

• Incidence of PSVT (AVNRT, AVRT) > a fib, a flutter

• Management of acute episodes: – Hemodynamic compromise: DCCV

– Vagal maneuvers, adenosine w/ acute episodes of PSVT

• Prophylaxis: digoxin, beta blockers, sotalol, flecainide

• Radiofrequency catheter ablation for malignant arrhythmias

Atrial fibrillation during

Pregnancy

• More common in ♀ w/ structural heart disease

– But, evaluate for other possible causes (ie

hyperthyroidism)

• Management:

– DCCV if hemodynamically unstable

– Rhythm control preferred to rate control

– If an episode of a fib > 48 hours TEE + DCCV,

anticoagulation 3 weeks then DCCV

– Digoxin, beta blocker, non-dihydropyridine CCB for

rate control

– Thromboembolism prophylaxis- ASA vs. anticoagulant

Native Valvular Heart Disease

and Pregnancy

Mitral Stenosis in Pregnancy

• MS is tolerated poorly because of: ↑ blood volume, ↑ cardiac

output, ↑ heart rate

• Pregnant women at risk for pulmonary edema, atrial

arrhythmias (1º A. Fib), ↓ functional NYHA class

• Women at highest risk of maternal cardiac complications:

– moderate to severe MS (valve area < 1.5 cm2)

– baseline NYHA Class III or IV

– h/o cardiac complications prior to pregnancy

– central cyanosis

– LV systolic dysfunction

Mitral Stenosis-

Preconception intervention

Symptomatic w/ moderate or severe

MS

ASx w/ moderate or severe MS

Percutaneous mitralvalvuloplasty

Percutaneous mitral

valvuloplasty *

* If a woman has normal PA pressures, exercise testing 1st to eval

for exercise-induced PA HTN • If excellent exercise capacity do NOT routinely intervene

Antepartum Care in Woman w/

Mitral Stenosis

• Multi-disciplinary approach involving OB, cardiology,

perinatology

• F/u frequency determined by risk level:

– Moderate or severe MS: monthly or bimonthly

– Mild MS: every trimester

• Medical management

• Echo assessment: 1st antepartum visit and again during 3rd

trimester, clinical ∆

Management of MS during

Pregnancy

Medical Management

• Small doses of furosemide

• Restriction of activities

• Beta blockers (avoid Atenolol- a/w

low birthweight)

• Digoxin (↑ renal clearance)

• Anticoagulation (VKA, UFH, LMWH)

♀ w/ mild,

moderate, or

severe MS

If despite medical management, a ♀ has severe Sx or HF: • Percutaneous mitral valvotomy (using abdominal shielding)• Timing: > 20 weeks BUT prior to mid-late 3rd trimester

Prosthetic Heart Valves in

Pregnancy

• Most common life-threatening complication =

valve thrombosis

• All forms of anticoagulation increase risk of

spontaneous abortion, retroplacental bleeding,

stillbirth, and fetal death

Bioprosthetic Heart Valves

Mechanical Heart Valves

Continue low-dose aspirin (75-100mg/day)

• Low-dose aspirin (75-100mg/day)

• Vitamin K antagonist or LMWH

Anticoagulation Options for

Mechanical Valves

• Without RF for valve thrombosis

1st Trimester 2nd/3rd Trimester

• Warfarin dose </= 5mg/d: Cont warfarin vs. dose-adjusted BID SC LMWH

• Warfarin dose > 5mg/d: dose-adjusted BID SC LMWH

• Majority: warfarin until 36 weeks (high value on reducing maternal risk)

• If mom chooses to avoid fetal risk assoc w/ VKA, therapeutic SC LMWH is reasonable alternative

Anticoagulation Options for

Mechanical Valves

• Peripartum management:

– A plan for anticoagulation should be agreed to by

OB, anesthesia, and cardiology

– At 36 weeks: VKA dose-adjusted BID SC

LMWH

– Continue low-dose ASA up until planned delivery

– Prior to induction of labor or C-section:

Women with SC LMWH can be switched to dose-

adjusted IV UFH or receive PPX doses of LMWH

Heart Failure and Pregnancy

Heart Failure and

Pre- Pregnancy Counseling

• Ideally, counseling should occur prior to pregnancy

• Risk of maternal mortality is very high during

pregnancy for ♀ w/ dilated CMY w/ LVEF < 20%

– Avoidance of pregnancy is advised

– If a ♀ becomes pregnant, termination of pregnancy

should be discussed

Medical Management of HFrEF

in Pregnancy

Drugs to use:

• Diuretic

• β blockers

• Hydralazine +

isosorbide dinitrate -vasodilator therapy in ♀ w/

Sx of HF

• If persistent Sx, add

digoxin

Drugs/drug classes to

avoid:

• Angiotensin inhibition (ACEi, ARBs, AR-neprilysin

inhibitor)- ↑ risk

embryopathy

• Ivarbardine – lack of

evidence of safety during

pregnancy

• Aldosterone

antagonists

Delivery in Setting of HFrEF

• Multi-disciplinary approach involving OB,

Anesthesia, and Cardiology

• Highlights

– Push or pull ? vs CD

– ICU

– Maternal telemetry

– Recovery in ICU

– Echocardiogram (24-48 hours after delivery)

Peripartum Cardiomyopathy

(PPCM)

• Diagnostic Criteria

– LVEF < 45%

– In absence of previous heart disease

– Occurs in last month of pregnancy OR during first 5

months after delivery

Peripartum Cardiomyopathy

(PPCM)- Etiology

• Pathophysiology unknown

– Is pregnancy the original insult?

– Is pregnancy the aggravating factor in ♀

susceptible to cardiomyopathy?

– Active myocarditis?

– Stress of pregnancy unmasks or unveils a

process that would have occurred later in

life?

Risk Factors of PPCM

• Advanced Maternal Age

• African-American

• History of multiple pregnancies

• Hypertension

• Genetics- initial manifestation or de novo

familial dilated CMY

Peripartum

Cardiomyopathy Management

• Co-management with cardiology

–Medical Management

–Echocardiogram

• Follow-up with MFM and Cardiology Postpartum

• BIRTH-CONTROL

• Genetic Counseling/Genetic Testing

• Subsequent pre-conceptual counseling with

MFM/Cardiology

Counseling in PPCM

Recovery in LVEF

Persistent LV dysfunction (LVEF < 50%) or LVEF ≤ 25%

At risk for recurrence in subsequent pregnancies

Avoid pregnancy- due to risk of HF

progression & death

Marfan Syndrome (MFS) and

Pregnancy

Counseling (ideally prior to conception)

• risk of Aortic dissection/rupture and aortic regurgitation screening TTE, CTA/MRA multidisciplinary approach: MFM, cardiology, geneticist risk is difficult to quantify- limited data

- Ao root diameter </= 40mm: 1% risk- Ao root diameter > 40 mm or rapidly ↑ Ao root size:

‘increased risk’

Management of MFS during

Pregnancy

Monitoring

• Serial TTEs• q4-8 weeks if Ao

root > 40mm (ESC, ACC/AHA/AATAS)

Medical Therapy

• β-Blockers- ↓ Aodilation and ↓

risk of Aodissection

• Strict BP control

Interventionduring Pregnancy

• Ao diameter ≥ 50mm + ↑

rapidly

Postpartum Marfan’s Syndrome

• ↑ risk of Ao dissection postpartum

• Expert consensus:

– ‘monitoring ♀ with MFS for complications during the

first 4-6 weeks postpartum.’

– Monitoring is individualized and determined by ♀’s

risk of dissection

Acute MI in Pregnancy

• Manage patient aggressively to save patient and

pregnancy

• Mortality 7% - due to reluctance to Tx patients

aggressively

• RF: h/o chronic HTN, DM, ↑ maternal age, eclampsia/pre-

eclampsia

• Initial Tx: Heparin, ASA, β blocker, nitrates

• BMS preferred over DES*; thrombolysis if LHC/PCI not

available

– *do not have great data on use of P2Y12 inhibitors in

pregnancy

Pulmonary Hypertension

One of the LEAST well-tolerated conditions in pregnancy

At the time of diagnosis of PAH

• STRONGLY counsel against pregnancy

• Initiate & provide appropriate contraceptive measure

If a patient were to become pregnant

Honest discussion about therapeutic termination of

pregnancy

Congenital Heart Disease and

Pregnancy

• Multi-disciplinary approach:– OB

– Cardiology

– Maternal Fetal Medicine (aka perinatology)

– Anesthesia Consultation

• Regular follow-up in clinic

• Serial echocardiograms over pregnancy

• Level II Ultrasound– Serial Fetal Ultrasounds for growth

– Antenatal testing at 34 weeks

• Fetal Echocardiogram at 20-24 weeks

• Delivery planning and timing – Clinical stable vs. “functionally significant CHD”

Delivery Timing

Late Preterm Steroids

Counseling

“You said I can’t get pregnant,

not that I shouldn’t get pregnant.”

Preconception Counseling

• CHD start as a teenager– LARCs

• Complex CHD preconception counseling

• Recommendations should be individualized– Multiple Medications

– Baseline Creatinine

– Baseline Cardiac Function

– Co-Morbidities

• Genetic Counseling-recurrence risk stratified by type of lesion

• Anesthesia consultation

Rates of Complications

According to Degree of Renal

Insufficiency (%)

Creatinine PTD Preeclampsia HTN FGR Perinatal mortality

Live birth Decline in renal function

< 1.4 20 11 25 24 9 >90 16

1.4-2.8 36-60 42 56 31-37 7 >90 50

2.8 73-86 42 56 43-57 36 N/A 40

Dialysis 48-84 86 100 50-80 60 40-50 N/A

Renal Transplant

52-75 20-37 47-63 20-99 7 74-80 14

QuestionA 30 year old female with a history of mitral stenosis status post mechanical mitral valve replacement presents to your clinic because she recently found out that she is pregnant. She is currently 8 weeks pregnant. She takes warfarin 4mg daily for anticoagulation, and her INR has been therapeutic on her current regimen.

Now that she is pregnant, how do you manage her anticoagulation for the remainder of the first trimester?

(a) Hospitalize the patient and start IV heparin

(b) Start apixaban 10mg BID for anticoagulation

(c) Continue only aspirin 81mg daily

(d) Continue her current regimen of warfarin 4mg daily,

maintaining INR 2.5-3.5

(e) Discontinue warfarin, start enoxaparin adjusting the

dose by following aPTT.

Heart Failure with Preserved Ejection

Fraction

• Β blockers• HR-limiting CCB • Digoxin is not

indicated to treat HFpEF

Aortic Stenosis in Pregnancy

• Most commonly due to congenital bicuspid AoV

• Maternal cardiac morbidity related to AS severity + Sx

• Complications a/w AS: HF and/or arrhythmias– In ASx ♀ w/ mild or moderate AS: Pregnancy is usually

well-tolerated

– ASx ♀ with severe AS may tolerate pregnancy- need close f/u

• Management: Multidisciplinary approach

• In w/ ♀ moderate to severe AS, need to f/u w/ cardiology post pregnancy

Anticoagulation Options for

Mechanical Valves

• With RF for prosthetic valve thrombosis:

– Reducing maternal risk:

• Continue VKA with close INR monitoring through pregnancy until 36 weeks

– Minimize fetal risk:

• BID subQ LMWH with monitoring of anti-Xa levels

Peripartum Cardiomyopathy

Elkayam U et al. N Engl J Med 2001;344:1567-1571.

Marfan Syndrome- Elective repair

prior to conception

• What do the guidelines say?

European Society of Cardiology (2011)

ACC/AHA/AATS (2010)

Ao root ≥ 45 mm (or > 27mm/m2)

Ao root > 40 mm

MFS and Delivery

AAo Diameter < 40 mm

AAo Diameter ≥ 40 mm, but ≤ 45 mm

AAo Diameter > 45 mm

• Vaginal delivery • Vaginal delivery using epidural

anesthesia • Expedited 2nd stage

or delayed pushing (minimize Valsalva)

• C-section

Pulmonary Hypertension

• One of the LEAST well-tolerated conditions in pregnancy– RV failure, worsening cyanosis/hypoxia, ↑ pulmonary arterial

resistance, thrombosis

• Maternal mortality is exceptionally high: 30-50%

• Rates of spontaneous abortions ~ 40-50%; fetus at risk for IUGR and preterm delivery

• Multidisciplinary approach for these patients- OB, pulmonary HTN specialist (cardiology &/or pulmonary), anesthesia – and close monitoring

• Goal of management: optimize RV preload & RV systolic function, and ↓ PVR