Cardiac Diseases in Pregnancy

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Cardiac Diseases in Pregnancy

• Dr.Uma Gupta MD,FICMCH
• Dr.N.K.Gupta MS,MCh
• umankgupta_at_yahoo.com
• drnkgupta2000_at_yahoo.com

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The incidence and changing pattern of heart
disease

• It ranges from 0.1 to 4.
• Hospital statistics - industrialized countries
  have shown a decrease in the incidence from 0.9
  to 0.3

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• Incidence of heart disease

Sharp decline in the incidence of chronic
rheumatic heart disorders. Advances in the
medical and surgical treatment of patients with
congenital heart defects has resulted in an
increased survival to reproductive age.
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Maternal mortality from heart disease

• Statistics have demonstrated a decline in
  maternal mortality from cardiac disease since
  1950 from 5.6 to 0.3 per 100 000 births.
• Bs of improved medical care of the pregnant
  cardiac patient and a sharp decrease in the
  incidence of rheumatic heart disease.

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Maternal mortality from heart disease

• Confidential enquiry of latest report on
  maternal deaths in the United Kingdom, has shown
  that cardiac disease accounted for the greatest
  number of maternal deaths
• accounting for 35 (16.5) of all maternal deaths
  over the period 199799
• (37 of 323) in the 1991 to 1993 triennium
• (18) -1988 to 1990 trienniums
• (23) -1985 to 1987
• de Swiet M. Cardiac disease. In Lewis G,
  Drife J, eds. Why Mothers Die 19971999. The
  Confidential Enquiries into Maternal Deaths in
  the United Kingdom. London Royal College of
  Obstetricians and Gynaecologists, 2001 15364

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Maternal mortality from heart disease
Cardiac diseases is also the leading cause of
indirect maternal death. Of the cardiac deaths
reported to the Confidential enquiry between
2000-2002, 40 were noted to have substandard
care. Deans CL, Uebing A, Steer PJ. Cardiac
disease in pregnancy. In Progress in
Obstetrics and Gynaecology, Vol 17, Edi Studd J,
Tan S L, Chervenak FA.Churchill Livingstone 2007,
164-182.

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Cardiovascular Physiology of Pregnancy

• Normal pregnancy is associated with an increase
  of 30 to 50 percent in blood volume
• Blood volume increases, starting at the sixth
  week and rising rapidly until mid pregnancy the
  levels peak by 20 to 24 weeks of pregnancy and
  then are either sustained until term or decrease
  An estrogen-mediated stimulation of the
  renin-angiotensin system results in sodium and
  water retention appears to be the mechanism
  underlying the blood volume increase.

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Cardiovascular Physiology of Pregnancy

• Increase in cardiac output is most significant
  change during pregnancy.
• It begins to rise in first trimester and steadily
  rises to peak at 32 weeks by 30 to 50.
• Cardiac output is normally 4.2 L/min., is 6.5
  L/min. at 8-10 weeks of pregnancy and remains so
  till near term.
• Increase in cardiac output is achieved by rise in
  stroke volume (in early pregnancy) and Heart Rate
  (in latter part of pregnancy) adjusting together
  

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Cardiovascular Physiology of Pregnancy

• Due to rise in endogenous circulating
  catecholamine, there is positive inotropic and
  chronotropic myocardial response.
• Later in pregnancy, the rise is related to an
  acceleration of heart rate (25), since stroke
  volume decreases as a result of vena caval
  compression.

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• Blood Pressure remains almost to prepregnant
  levels except a tendency to fall during
  pregnancy (particularly during midtrimester) as
  the systemic vascular/peripheral resistance falls
  
• (due to large arteriovenous shunts at
  placental bed and physiologic vasodilation
  secondary to endothelial prostacyclin and
  circulating progesterone)

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• Colloid oncotic pressure is another important
  variable
• Both plasma and interstitial colloid oncotic
  pressure decrease throughout pregnancy
• There is accompanying increase in capillary
  hydrostatic pressure.
• An increase in hydrostatic pressure or a decrease
  in colloid oncotic pressure may overcome the
  delicate balance that favors oedema formation

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Colloid oncotic pressure

• After delivery, decrease in plasma colloid
  oncotic pressure takes place reaching a peak
  between 6 to 16 hours and returns towards
  intrapartum level after 24 hours.
• These changes can lead to dependant oedema
  complicating diagnosis of cardiac decompensation.

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Simulating cardiac disease

• Owing to these normal changes, many
• healthy pregnant women have symptoms
• mimicking those of cardiac disease,
• Including
• fatigue, dyspnea, and light-headedness,
• number of abnormal findings on physical
• examination, electrocardiography, and
  echocardiography

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Table 1. Normal physiological changes of
pregnancy that mimic symptoms and signs of
cardiac disease Symptoms Tiredness Dyspnoea Orthop
noea Syncope Light-headedness Physical
signs Peripheral oedema Hyperventilation Distended
neck veins with prominent A and V waves Brisk,
diffuse, and displaced left ventricular impulse Pa
lpable right ventricular impulse Increased S1
intensity Persistent splitting of S2 Early
ejection systolic murmurs at lower left sternal
edge or pulmonary area Cervical venous
hum Mammary souffle
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Contd.. Table 1. Normal physiological changes of
pregnancy that mimic symptoms and signs of
cardiac disease Electrocardiogram Left axis
deviation ST segment and T wave changes Small Q,
inverted P or T wave in lead III Increased R wave
amplitude in lead V2 Atrial or ventricular
ectopics Chest X-ray Straightened left upper
cardiac border Horizontal heart
position Increased lung markings Echocardiogram In
creased left/right ventricular dimensions Mild
increase in left/right atrial size Slightly
improved left ventricular systolic
function Functional tricuspid/pulmonary
insufficiency Small pericardial effusion
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Management areas

• Areas be considered in the clinical approach to
  the woman with heart disease who is pregnant or
  considering pregnancy
• Risk stratification, Pre-conceptional
• Antepartum management,
• Peripartum management,
• 4) Recurrence of congenital lesion in the
  neonate,
• 5) Site of antepartum and peripartum care.

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Pre-conceptional counselling

• This is an important aspect of management or
  the cardiac patient planning a pregnancy.
• Ideally, the obstetrician and cardiologist should
  work together to help the patient make an
  informed decision.
• Prevent an unwanted pregnancy and avoid the risks
  associated with pregnancy continuation or
  termination.

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Risk assessment

• Poor functional status (NYHA class III or
• IV) or cyanosis
• Left ventricular systolic dysfunction (ejection
• fraction lt 0.40)
• Left heart obstruction (mitral valve area
• lt2.0 cm2, aortic valve area lt 1.5 cm2, or
• peak left ventricular outflow tract gradient
• gt 30 mm Hg)

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Risk assessment
A cardiac event (arrhythmia, stroke, transient
ischemic attack, or pulmonary edema) before
pregnancy but since a prior cardiac surgical
procedure.
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Risk assessment

• Siu developed a risk index incorporating
• these factors.
• In a woman with heart disease and no other risk
  factors, the likelihood of a cardiac event during
  pregnancy is about 5, increasing to 25 with one
  risk factor 75 with more than one risk factor.
• Siu SC, Sermer M, Colman JM, et al. Prospective
  multicenter
• study of pregnancy outcomes in women with heart
  disease.
• Circulation 2001 104515521.

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Table 2. Maternal mortality risk and cardiac
disease Group Cardiac disease
Associated mortality risk I Atrial septal
defect lt1 Ventricular septal
defect Patent ductus arteriosus Pulmonary/tric
uspid valve disease Corrected tetralogy of
Fallot Bioprosthetic valve Mitral stenosis,
NYHA Class I, II II Coarctation of aorta
without valvular involvement 5 -
15 Uncorrected tetralogy of Fallot Marfans
syndrome with normal aorta Mechanical prosthetic
valve Mitral stenosis with atrial fibrillation
or NYHA Class III, IV Aortic stenosis Previous
myocardial infarction III Pulmonary
hypertensionprimary or secondary 25 -
50 Coarctation of aorta with valvular
involvement Marfans syndrome with aortic
involvement Peripartum cardiomyopathy Uncomplica
ted
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• A careful history is obtained to identify
  previous cardiac complications.
• The patients functional status as per The New
  York Heart Association(NYHA) is defined

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Table 3.NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION OF CARDIAC DISEASE CLASS I
No functional limitation of activity.
No symptoms of cardiac
decompensation with activity. CLASS II
Mild amount of functional limitation.
Patients are asymptomatic at
rest. Ordinary physical activity
results in symptoms. CLASS III
Limitation of most physical activity.
Asymptomatic at rest
Minimal physical activity
results in symptoms. CLASS IV Severe
limitation of physical activity results in
symptoms. Patients
may be symptomatic at rest/heart failure
at any point of
pregnancy. CLASS V If patient is on
ionotropic support, ventilator, Assisted
circulation or having comprised renal or
pulmonary function necessitating dialysis/EMCO
to maintain vital
signs. The criteria committee of the New York
Heart Association, Nomenclature and criteria for
diagnosis of diseases of heart and great vessels,
Edi 8, New York Association,1979.
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Antepartum Care

• The chief aim of management of the patient in
  pregnancy is to keep patient within her cardiac
  reserve.
• It is preferable to have detailed baseline
  information prior of pregnancy.

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Antepartum care

• Limiting activity is helpful in severely
• affected women with ventricular dysfunction,
• left heart obstruction, or class III or IV
  symptoms.
• Hospital admission by mid-second
• trimester may be advisable for some.

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Antepartum care

• Problems should be identified early and treated
  aggressively, especially pregnancy induced
  hypertension, hyperthyroidism, infection, and
  anemia.

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Antepartum care
Beta-blockers rather than digoxin should be used
to control the heart rate for patients with
functionally significant mitral
stenosis. Empiric therapy with beta-blockers is
offered to patients with coarctation, Marfan
syndrome, and ascending aortopathy for other
reasons (eg, a bicuspid aortic valve).
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Arrhythmias should be treated if warranted

• Premature atrial or ventricular beats are common
  in normal pregnancy, and in patients with
  preexisting arrhythmias,
• Pregnancy may exacerbate their frequency and
  hemodynamic severity.
• These usually are not treated.

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Antepartum care

• Sustained tachyarrhythmias, such as
• atrial flutter or atrial fibrillation, should be
• treated promptly.
• If possible, all antiarrhythmic drugs should
• be avoided during the first trimester, and those
• known to be teratogenic should be avoided
• throughout pregnancy.
• Because of their safety profiles, preferred drugs
  include digoxin, beta-blockers and adenosine.

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Antepartum care

• Anticoagulation therapy. No current
• strategy is equally safe for both mother and
  fetus.

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Anticoagulation therapy

• Oral therapy with warfarin is effective and
• logistically easy.
• However, it can affect embryonic organ
  development, although some evidence shows that a
  dosage of 5 mg per day may not be teratogenic.
• Fetal intracranial bleeding is a risk throughout
  pregnancy, particularly during vaginal delivery,
  unless warfarin is stopped before labor.

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Anticoagulation therapy

• Heparin in adjusted subcutaneous doses
• does not cross the placenta and so has no
  teratogenic effects.
• However, it may cause maternal
• thrombocytopenia and osteoporosis and is
• less effective in preventing thrombosis in
• patients with prosthetic valves.

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Anticoagulation therapy

• More recent guidelines recommend either
• (1) adjusted-dose heparin during the entire
  pregnancy or
• (2) adjusted-dose heparin until the 13th week of
  gestation,
• warfarin from the 14th week to the middle of the
  third
• trimester, and then restart adjusted-dose
  heparin.
• Low-molecular-weight heparin in adjusted
• doses is easier to administer and has been
• suggested as an alternative to adjusted-dose
• unfractionated heparin.
• Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of
  antithrombotic agents during pregnancy. Chest
  2004 126627S644S.

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Anticoagulation therapy

• At week 36
• Discontinue warfarin
• Change to UFH titrated to a therapeutic aPTT or
  anti-factor Xa level.
• At Delivery
• Restart heparin therapy 4 to 6 hr after delivery
  if no contraindications
• Resume warfarin therapy the night after delivery
  if no bleeding complications
• if labor begins while the woman is receiving
  warfarin, anticoagulation should be reversed and
  caesarean delivery performed
• Ginsberg JS, Greer I, Hirsh J. Use of
  antithrombotic agents during pregnancy. Chest
  2001119Suppl122S-131S

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Anticoagulation therapy

• Monitoring
• With LMWH administered sc. twice daily maintain
  anti-Xa level between 0.7 and
• 1.2 U/ml 4 hours after admn.
• With dose adjusted UFH, the aPTT should be at
  least twice control.
• those on warfarin, the INR goal should be
  3.0(range 2.5 to 3.5)
• Chan WS, Anand S, Ginsberg JS. Anticoagulation
  of pregnant women with mechanical heart valves a
  systematic review of the literature. Arch Intern
  Med 2000160191-196

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Peripartum management

• Cesarean section is indicated only for the
• following conditions
• Aortic dissection
• Marfan syndrome with dilated aortic root
• Taking warfarin within 2 weeks of labor.

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Peripartum care
Preterm induction is uncommon. However, once
fetal lung maturity is assured, a planned
induction and delivery may be warranted for
high-risk patients to ensure that appropriate
staff and equipment are available.
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Peripartum care

• Antibiotic prophylaxis for endocarditis is
• not routine. AHA guidelines do not recommend
  routine endocarditis prophylaxis for cesarean
  section delivery or for uncomplicated vaginal
  delivery without infection.37
• However, some centers do administer
• endocarditis prophylaxis for vaginal delivery
• in women with structural heart disease, as an
• uncomplicated delivery cannot always be
• anticipated.

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Peripartum care
Positioning the patient on her left side lessens
the hemodynamic fluctuations associated with
contractions when the patient is supine.
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Peripartum care

• Forceps or vacuum extraction should be
• considered at the end of the second stage of
  labor to shorten and ease delivery.

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Peripartum care

• Postpartum monitoring
• Because hemodynamics do not return to
  baseline for many days after delivery, patients
  at intermediate or high risk may require
  monitoring for at least 72 hours postpartum.

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Peripartum care

• Lactation should be encouraged unless patient is
  in failure.
• Cardiac output is not compromised during
  lactation.
• Lactation is a pathway for fluid excretion and
  diuretic requirement may actually fall.

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Contraception

• Barrier methods unreliable.
• COC contraindicated.
• Progesterone only pill have better side effect
  profile long acting slow releasing as Mirena
  intrauterine system have improved efficacy.
• Sterilization where family completed.
  (Laparoscopic clip sterilization carries risk).
• Deans CL, Uebing A, Steer PJ. Cardiac disease in
  pregnancy. In Progress in Obstetrics and
  Gynaecology, Vol 17, Edi Studd J, Tan S L,
  Chervenak FA.Churchill Livingstone 2007, 164-182.

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Conclusion

• Pregnancy causes significant haemodynamic changes
  and imposes an additional burden on the cardiac
  patient, especially around the time of labour and
  in the immediate puerperium.
• To achieve a successful pregnancy outcome, a
  clear understanding of these haemodynamic
  adaptations as well as meticulous maternal and
  foetal surveillance for risk factors and
  complications throughout the pregnancy is
  essential.

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Conclusion

• Appropriate contraceptive and family planning
  advice as well as pre-conceptional counselling
  are also important.
• The concerted efforts of a team consisting of the
• obstetrician, cardiologist, anaesthetist,
  cardiothoracic surgeon, neonatologist, and
  paediatric cardiologist are mandatory to ensure
  optimal results.

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THANK YOU