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Cardiac Diseases in Pregnancy

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Title: Cardiac Diseases in Pregnancy


1
Cardiac Diseases in Pregnancy
February 18, 2005
  • Ibrahim Elias Fahdi, MD
  • University of Arkansas for Medical Sciences
  • Central Arkansas Veterans Healthcare System
  • Division of Cardiovascular Medicine

2
Objectives
  • Normal Physiology during pregnancy
  • Cardiac Testing
  • Common cardiac problems

3
Cardio-circulatory changes during normal pregnancy
parameter Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks)
parameter 5 12 20 24 32 38
HR ? ??? ??? ??? ???? ????
SBP ? ? ? ? ? ??
DBP ? ? ?? ? ? ??
SV ? ????? ?????? ?????? ????? ?????
CO ?? ?????? ??????? ??????? ??????? ???????
SVR ?? ????? ?????? ?????? ?????? ?????
LV EF ? ?? ?? ?? ? ?
? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40.
4
Our only hope is if we all write a letter to
Santa
The Wall Street Journal
5
Changes in plasma volume, erythrocyte volume, and
hematocrit during pregnancy
  • Plasma volume ? 50 (20-100).
  • Physiologic anemia of pregnancy.
  • Estrogen-mediated stimulation of the RAS.
  • Role of other hormones
  • deoxycorticosterone, prostaglandins, estrogen,
    prolactin, placental lactogen, GH, ACTH, ANP

From Pitkin RM, Nutritional support in obstetrics
and gynecology. Clin Obstet Gynecol 197619489.
6
Percent change in heart rate, stroke volume, and
cardiac output measured in the lateral position
throughout pregnancy compared with pregnancy
values
Modified from Robson SC, Hunter S, Boys RJ,
Dunlop W. Serial study of factors influencing
changes in cardiac output during human pregnancy.
Am J Physiol 1989256H1060-H1065
7
Cardio-circulatory changes during normal pregnancy
parameter Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks) Changes at various times (weeks)
parameter 5 12 20 24 32 38
HR ? ??? ??? ??? ???? ????
SBP ? ? ? ? ? ??
DBP ? ? ?? ? ? ??
SV ? ????? ?????? ?????? ????? ?????
CO ?? ?????? ??????? ??????? ??????? ???????
SVR ?? ????? ?????? ?????? ?????? ?????
LV EF ? ?? ?? ?? ? ?
? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40. ? 5 ?? 6-10 ??? 11-15 ???? 16-20 ????? 21-30 ?????? gt 30, ??????? gt 40.
8
Hemodynamic changes during labor and delivery
  • Anxiety, pain, uterine contraction.
  • Oxygen consumption ? threefold.
  • ? CO during labor (? SV and ? HR).
  • ? SBP DBP (especially 2nd stage)
  • Those changes are influenced by the form of
    anesthesia and analgesia.

9
Hemodynamic changes post partum
Blood shifting auto-transfusion (from the
contracting uterus to the systemic circulation)
Increase in venous return (relief of caval
compression)
-
Blood loss during delivery
Increase in effective blood volume
Substantial increase in LV filling pressure, SV
and CO
Clinical deterioration
  • HR and CO return to pre-labor values within 1
    hour. MAP and SV within 24 hours.
  • Hemodynamic adaptation persists post partum and
    return to pre-pregnancy values within
    12-24 weeks after delivery.

10
History Exercise capacity Current or past
evidence of HF Associated arrhythmias
Before conception
Physical exam
Cardiac Hemodynamics Severity of heart disease,
PA pressures Echo, MRI.
Exercise testing Useful if the history is
inadequate to allow assessment of functional
capacity
During pregnancy Evaluate once each trimester and
whenever there is change in symptoms
Multidisciplinary approach, Fetal Echo
During Labor Delivery Multidisciplinary
approach (Obstetrician, Cardiologist,
Anesthesiologist) Tailor management to specific
needs
Reimold, S. C. et al. N Engl J Med 200334952-59
11
High-risk pregnancy
  • Pulmonary HTN and Eisenmengers syndrome.
  • Symptomatic obstructive cardiac lesions
  • AS, PS, uncorrected coarctation of the aorta.
  • Marfans Syndrome with dilated aortic root.
  • Systemic ventricular dysfunction (LVEF lt 40).
  • Severe cyanotic heart disease.
  • Patients with prosthetic valves.
  • Significant uncorrected CHD.

12
Contraindications to Pregnancy
Lesion Maternal death rate ()
Severe Pulmonary Hypertension 50
Severe obstructive lesions AS,PS, HOCM, Coarctation. 17
Systemic Ventricular Dysfunction, NYHA class III or IV 7

13
Pregnancy Outcomes
  • The prevalence of clinically significant maternal
    heart disease is low (lt1)1.
  • Its presence increases the risk of adverse
    maternal, fetal, and neonatal outcomes2.
  1. Siu SC, Sermer M, Colman JM, et al. Prospective
    multicenter study of pregnancy outcomes in women
    with heart disease. Circulation 2001104515-521.
  2. Siu SC, Colman JM, Sorensen S, et al. Adverse
    neonatal and cardiac outcomes are more common in
    pregnant women with cardiac disease. Circulation
    20021052179-2184.

14
CARPREG
  • Cardiac disease in pregnancy prospectively
    enrolled 563 consecutive pregnant women with
    heart disease
  • Outcomes were determined in 599 pregnancies not
    ending with miscarriage

Siu SC, Sermer M, Colman JM, et al. Prospective
multicenter study of pregnancy outcomes in women
with heart disease. Circulation 2001104515-521.
15
Adverse maternal cardiac events
  • Primary cardiac events
  • Pulmonary edema.
  • Sustained brady- or tachy- arhythmias
    requiring therapy.
  • Stroke.
  • Cardiac arrest.
  • Death
  • Secondary adverse cardiac events
  • Worsening of NYHA class by gt 2 classes.
  • Need for urgent invasive cardiac procedure
    (percutaneous cardiac valvuloplasty, permanent
    pacing).

62
27
4
Predictors of primary cardiac events Odds ratio (95 CI) p
1. Prior cardiac event (HF, TIA or stroke) or arrhythmia. 6 (3-14) lt0.001
2. Baseline NYHA class gt II or cyanosis. 6 (2-22) 0,009
3. Left heart obstruction (MVA lt 2cm2, AVA lt 1.5 cm2, or peak LVOT gradient gt 30 mmHg). 6 (3-14) lt0.001
4. Reduced systemic ventricular systolic function (EF lt 40) 11 (4-34) lt0.001
N.B. There was no association between the type
of delivery and peripartum cardiac event rate (3
vs. 4, P0.46).
Siu SC, Sermer M, Colman JM, et al. Prospective
multicenter study of pregnancy outcomes in women
with heart disease. Circulation 2001104515-521.
16
Adverse neonatal events
  • Neonatal events
  • Premature birth
  • Small-for-gestational-age birth weight.
  • Respiratory distress.
  • Inter-ventricular hemorrhage.
  • And death.

Predictors of primary cardiac events Odds ratio (95 CI) P
1. Abnormal functional capacity (NYHA class II or cyanosis) 3 (1.1-6.1) 0.035
2. Use of anticoagulant drugs throughout pregnancy. 3 (1.4-8.2) 0,0093
3. Smoking during pregnancy. 2 (1.3-13.9 0.0045
4. Multiple gestation. 22 (6-85) lt0.001
5. Left heart obstruction 2 (1.01-2.9) 0.044
6. Women gt 35 years old or lt 20 years old. - -
N.B.in the 6 pregnancies in which the mother
received warfarin during all (n2) or part of
pregnancy (n4), embryopathy was not observed in
this small series.
Siu SC, Sermer M, Colman JM, et al. Prospective
multicenter study of pregnancy outcomes in women
with heart disease. Circulation 2001104515-521.
17
Cardiac Tests Performed 1
  • Doppler echocardiography
  • Stress testing
  • Radiation of the embryo
  • Age o to 10 days no effect or resorption
  • Age 10 to 50 days teratogenic effects
  • Age 50 to delivery
  • Intrauterine growth retardation
  • Central nervous system abnormalities
  • Increased incidence of childhood cancer or
    leukemia

18
Cardiac Tests Performed 2
  • Routine chest radiography delivers 20 m.rads
  • Standard fluoroscopy delivers 1-2 rads/min
  • Current recommendation
  • gt5 rads very low risk
  • 5-10 rads counseling for low risk
  • 10-15 rads during 1st 6 weeks individual
  • gt15 rads termination pf pregnancy

Colletti PM, Lee K Cardiac Problem in
Pregnancy.3rd ed. New York, Wiley Liss, 1998, pp
33-36
19
Cardiac Tests Performed 3
  • Magnetic Resonance Imaging
  • Pulmonary Artery Catheterization Great help in
    managing high risk patient during pregnancy,
    labor and delivery
  • Cardiac Catheterization
  • Can be done

20
Pulmonary hypertension as a risk of adverse
outcome
Pulmonary hypertension (Eisenmenger Syndrome)
Increased rate of adverse maternal events Up to
30-40 (? PVR)
When systolic PAP gt 75 systemic pressure
? intravascular volume HF (CO limited by
Pulmonary vascular disease and Ventricular
dysfunction)
? SVR (after 1st trimester) ?R-L Shunt
Cyanosis
Exacerbated during labor and delivery
Bed rest (2nd trimester), O2 (if helpful), ?
Anticoagulation, Cesarian section, invasive
monitoring, early ambulation
21
Aortic stenosis
  • Severe AS is poorly tolerated.
  • AVA lt 0.7 cm2, Mean PG gt 50 mmHg.
  • Mortality up to 17.
  • Symptomatic patients or Mean gradient gt 50 mmHg
  • ? Delay conception until after surgical or
    interventional correction.
  • Consider balloon valvuloplasty, Ross procedure,
    tissue valve (no need for anticoagulation).
  • Symptomatic patients before end of 1st trimester
  • Terminate pregnancy.
  • ?-Blockade, Bed rest.
  • Palliative aortic balloon valvuloplasty or AVR.
  • Early Delivery.

Hameed A, et al. The effects of valvular heart
disease on maternal and fetal outcome of
pregnancy. J Am Coll Cardiol 200137893-9.
Reimold, S. C. et al. N Engl J Med 200334952-59
22
Prosthetic valves and pregnancy
  • Anticoagulation

23
Warfarin vs. Heparin
  • Heparin
  • Does not cross the placenta
  • No teratogenicity
  • No fetal bleeding
  • Twice daily SC injection
  • Risk of osteoporosis
  • lt2 symptomatic fractures.
  • but 30 decrease in bone density.
  • Risk for thrombocytopenia
  • ?? Risk of thrombosis
  • Warfarin
  • Crosses the placenta.
  • ?early abortion, prematurity, and embryopathy
    when used in 1st trimester (6th12th weeks).
  • CNS Eye abnormalities (2nd 3rd trimester).
  • Bleeding in the fetus (especially at delivery)
  • Should be stopped before delivery.

warfarin embryopathy Nasal hypoplasia, Bone
epiphysis, optic atrophy, blindness, seizures.
Overall risk around 5. Decreases with the use
of UFH in the first 3 months
24
Dose-dependent Fetal Complications of warfarin in
pregnant women with Mechanical Heart
Valves Outcome of pregnancies
WARFARIN DOSE (MG) Healthy fetuses Fetal complications Total
5 28 27 FT 1 PR 5/33 (15) 4 SA 1 GR 0 WE (0) 33
gt 5 3 FT 22/25 (88) 2 WE (9) 18 SA 1 SB 1 VSD 25
Total 31 27 58
FT full term, GR growth retardation PR preterm SA spontaneous abortion SB still birth WE warfarin embryopathy FT full term, GR growth retardation PR preterm SA spontaneous abortion SB still birth WE warfarin embryopathy FT full term, GR growth retardation PR preterm SA spontaneous abortion SB still birth WE warfarin embryopathy FT full term, GR growth retardation PR preterm SA spontaneous abortion SB still birth WE warfarin embryopathy
Vitale N, et al. J Am Coll Cardiol
1999331637-41.
25
Unfractionated Heparin
  • 4X higher incidence of Thrombo-embolism during
    pregnancy than oral anticoagulants1.
  • Hanania G, et al. pregnancy in patients with
    valvular prosthesis-retrospective cooperative
    study in France (155 Cases). J Arch Mal Coeur
    Vaiss 199487429-437.
  • Failure of adjusted dose SC heparin to prevent
    thrombo-embolic phenomena in pregnant women (n
    40) with mechanical valve prosthesis.
  • Adjusted doses of SC heparin does not improve
    fetal outcome and increases maternal mortality2.
  1. Salazare E, et al. Filure of adjusted dose
    heparin to prevent thromboembolisc phenomena in
    pregnant patients with mechanical cardiac valve
    prosthesis. J Am Coll Cardiol 19961698-1703.

26
Frequency of fetal and maternal complications
according to the anticoagulation regimen used
during pregnancy in women with mechanical heart
valve prosthesis. Adapted from Chen et al. (976
women, 1234 pregnancies)
Anticoagulation regimen Embryopathy () Embryopathy () Spontaneous abortion () Thrombo-embolic complications () Maternal death ()
Vitamin K antagonist throughout pregnancy Vitamin K antagonist throughout pregnancy 6.4 25 31/788 (3.9) 10/561 (1.8)
Heparin throughout pregnancy Heparin throughout pregnancy 0 24 7/21 (33) 3/20 (15)
Low dose Low dose 0 20 60 40
Adjusted dose Adjusted dose 0 25 25 6.7
Heparin during first trimester, then vitamin K antagonists (with or without heparin before delivery) Heparin during first trimester, then vitamin K antagonists (with or without heparin before delivery) 3.4 25 21/229 (9.2) 7/167 (4.2)
Chan WS. What is the optimal management of
pregnant women with valvular heart disease in
pregnancy? Haemostasis 1999,29 suppl S1105-6
27
Low-dose ASA
  • The additional use of low-dose aspirin should be
    considered, particularly in
  • Women with high-risk valves.
  • Patients with cyanosis.
  • Patients with intra-cardiac shunts.
  • Women with previous TIAs and/or strokes.
  • And women with atrial fibrillation.

Chan WS. What is the optimal management of
pregnant women with valvular heart disease in
pregnancy? Haemostasis 1999,29 suppl S1105-6
28
LMWH
  • Do not cross the placenta.
  • Do not require frequent PTT monitoring
  • and have a longer half-life than UFH.
  • The data to support the use of LMWH, however, is
    not yet available.
  • A successful use of LMWH was reported in small
    number of patients and more information is
    required before LMWH can be recommended for
    anticoagulation in a patient with a prosthetic
    valve during pregnancy1.
  • Recently, two cases of LMWH treatment failure
    resulting in thrombosed prosthetic heart valves
    were reported in 20002.
  • LMWH should not be recommended at the present
    time in patients with heart valve prostheses
    during pregnancy.
  1. Elkayam U. Pregnancy through a prosthetic heart
    valve. J Am Coll Cardiol 1999331642-5.
  2. Lev Rano, Kamer A, Gurevitch J, Shapira, Mohr R.
    Low-molecular weight heparin for prosthetic heart
    valves treatment failure. Ann Thoracic Surg
    2000 69 264-5.

29
Mechanical Valves and Anticoagulation during
Pregnancy
  • Heparin may not prevent valve thrombosis ?how
    much ?route.
  • Adequate anticoagulation difficult.
  • Heparin can produce osteoporosis.
  • Little data regarding LMWH.
  • Warfarin can cause embryopathy.
  • Baby ASA safe probably beneficial.
  • 1-4 mortality in pregnant women with mechanical
    valve prosthesis, Whatever the anticoagulation
    regimen.

No Ideal Solution
30
Suggested algorithm for the management of
anticoagulation in patients with mechanical
prosthetic heart valves during pregnancy
Pregnancy in patients with prosthetic heart valves
Lower risk Second-generation prosthesis (e.g., St
Jude Medical, Medtronic Hall) And any mechanical
prosthesis in the aortic position
Higher risk First-generation prosthesis (e.g
Starr-Edwards, Bjork- Shiley) In the mitral
position
Coumadin to INR 3.0-4.5 for 36 weeks followed by
IV heparin to aPTT of gt 2.5-3.5
SC or IV (better) heparin-(aPTT 2.5-3.5) for 12
weeks Coumadin (INR 3.0-4.5) to 36th week IV
heparin (aPTT gt 2.5)
SC Heparin (aPTT 2.0-3.0) for 12 weeks Coumadin
(INR 2.5-3.0) to 36th week SC Heparin (aPTT
2.0-3.0)
SC heparin (aPTT 2.0-3.0) Throughout pregnancy
1-4 mortality in pregnant women with mechanical
valve prosthesis, Whatever the anticoagulation
regimen.
Braunwald textbook of cardiovascular medicine,
6th edition
31
Mode of delivery
  • Vaginal delivery
  • With facilitated second stage is preferred safe
  • Invasive hemodynamic monitoring only in
  • Severe valve stenosis
  • Recent heart failure.
  • Severe cyanotic heart disease
  • Pulmonary HTN.
  • Cesarean section
  • Avoids physical stress of labor
  • but not free from hemodynamic consequences.
  • Indications in CHD only for
  • Obstetric reasons.
  • Therapeutic anticoagulation with coumadin at
    onset pf labor.
  • Pulmonary hypertension.
  • Unstable aortic lesion with risk of dissection.
  • Severe obstructive lesions
  • Breast-feeding
  • Can be encouraged in women taking anticoagulants.
  • Heparin is not secreted in breast milk
  • and the amount of warfarin is low.
  1. Hameed A et al. J Am Coll Cardiol 2001378939.
  2. Elkayam U, et al. New Engl J Med
    2001344156771.
  3. Bozkurt B, et al. J Am Coll Cardiol
    19993417780.

32
Endocarditis prophylaxis
  • Antibiotic prophylaxis at the time of delivery is
    not recommended for patients expected to have
    uncomplicated vaginal delivery or cesarian
    section, unless clinically overt infection is
    present 1,2
  • Patients at high risk for endocarditis may
    receive antibiotics at the discretion of their
    physician2
  • Those with prosthetic heart valves.
  • Previous IE.

Antibiotics for prophylaxis against endocarditis Antibiotics for prophylaxis against endocarditis Antibiotics for prophylaxis against endocarditis Antibiotics for prophylaxis against endocarditis Antibiotics for prophylaxis against endocarditis
Ampicillin No major adverse effects Given along with gentamicin to high-risk patients to prevent IE B 2 gr IV or IM within 30 min before delivery. And 1 gr PO, IV or IM 6 hrs later.
Vancomycine No major adverse effects Given along with gentamicin to high-risk patients to prevent IE Cm I gr IV over 1-2 hours, given 30 min before delivery.
Gentamicin No major adverse effects Given along with Ampicilline or Gentamicin to high-risk patients to prevent IE C 1.5 mg/kg within 30 min before delivery (max 120 mg)
1 Sugrue D, Troy P, McDonald D. Antibiotic
prophylaxis against infective endocarditis after
normal delivery -- is it necessary? Br Heart J
198044499-502. 2 Dajani AS, Taubert KA, Wilson
W, et al. Prevention of bacterial endocarditis
recommendations by the American Heart
Association. JAMA 19972771794-1801.
33
Pregnancy and CHD Conclusions
  • Most women with heart disease can have a
    pregnancy proper care.
  • Pre-pregnancy evaluation mandatory.
  • High-risk cases benefit from combined high-risk
    OB and cardiac care in the same center.

34
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