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Risk Stratification and Management of Pregnancy in Women

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Title: Risk Stratification and Management of Pregnancy in Women


1
Risk Stratification and Management of Pregnancy
in Women with Congenital Heart Disease 18th
International Symposium on ACHD Toronto 2008
  • Samuel Siu MD SM
  • Gunton Professor and Chair of Cardiology,
    Schulich School of Medicine and Dentistry,
    University of Western Ontario
  • Adjunct Professor of Medicine, Obstetrics,
    Gynecology, University of Toronto

2
Disclosure
  • Conflict of interest None
  • Unlabeled or investigational use None

3
Acknowledgement
  • Co-investigators
  • Jack Colman, Mathew Sermer, Candice Silversides,
    Rachel Wald
  • Members of CACH Network
  • Research Coordinator
  • Jennifer Mason
  • Infrastructure support
  • Mrs. Josephine Rogers
  • Gary Webb
  • Division of Cardiology, UHN/MSH

4
Peer Reviewed Grants
  • PSI 1994-1995
  • MRC 1995-1998
  • CIHR 2002-2006
  • CIHR 2006-2009
  • HSF 2005-2007
  • HSF 2007-2009
  • HSF 2006-2008

5
Females with CHD should have age-appropriate
preconception counseling beginning in adolescence
  • Risk to the mother
  • Risk to the fetus
  • Recurrence risk of CHD in offspring
  • Site of obstetrical care
  • Antepartum and peripartum management
  • /-
  • Contraception options if applicable

6
Assessing Maternal Risk Low Maternal
Mortality CARPREG 617 Pregnancies, 68 with CHD
Maternal FetoNeonatal Obstetric Cardiac
Siu, Circ 2001
7
Assessing Maternal Cardiac Risk
  • Risk stratification
  • Lesion specific
  • Risk index
  • Combination of Lesion specific and Risk index
  • History, physical exam, 12 lead ECG,
    transthoracic echo

8
Recent Lesion Specific Studies (gt10 pregnancies)
9
High Risk Cong Heart Lesions
  • Marfan syndrome with aortopathy
  • Eisenmenger
  • Mechanical valve
  • Peripartum cardiomyopathy with residual LV
    dysfunction

10
Pregnancy Marfan
  • High risk patients with dilated aorta or
    coarctation
  • Overall mortality 1 Maternal, 22 Fetal
  • Lower risk aortic diameter lt40 mm (Pyeritz, AJ
    Med 81)
  • Prospective series of 45 preg in 21 women
  • 3/8 pts with dilated root/prior root surgery had
    dissection(2) or rapid root dilatation
    (1) (Rossiter, AJ Ob Gyn 95)
  • Prospective series 47 preg in 23 women root lt 45
    mm (Meijboom, Heart 2004)
  • 1 type B dissection in women with repaired Type A
  • Increased growth of aortic root in the 9 women
    with initial aortic root gt 40 mm
  • Risk of continual aortic dilatation during
    pregnancy
  • Dissection can occur with normal AO diameter or
  • distal to repair
  • ?? Risk level of aortopathy in BAV

11
Mortality in Pregnant Women with Eisenmenger
Weiss, JACC 1998 Avila, Clin Card 2003
SVRgtshunt increasegtHypoxemiagtmaternal and fetal
deterioration Extremely sensitive to volume
depletion and hypotension Risk of death up to 30
days after delivery Increase in prematurity rate,
IUGR, perinatal mortality
12
Assessing Maternal Cardiac Risk
  • Risk stratification
  • Lesion specific
  • Risk index
  • Combination of Lesion specific and Risk index
  • History, physical exam, 12 lead ECG,
    transthoracic echo

13
Canadian Multi-Centre Prospective Study of 599
Pregnancies Risk of Cardiac Complication (CHF,
ARR, Stroke, or Death)
Frequency Events ( Pregnancies)

Number of Predictors
Siu, Circ 2001
14
Antepartum Predictors of Cardiac Events
  • Arrhythmia, TIA, CVA, or CHF prior to pregnancy
  • NYHAgt2 or cyanosis
  • Left heart obstruction (MVA lt2 cm2, AVAlt1.5 cm2,
    LVOT gradient gt30 mmHg by echo)
  • Systemic ventricular EFlt40 by echo

Cardiac Point Score Total number of predictors
(presence 1, absence 0) Cardiac Point
Score Lowest 0 Highest 4
Siu, Circ 2001
15
Boston Retrospective Study of 90 Pregnancies In
Women with CHD
Frequency Events ( Pregnancies)

Number of Predictors
Khairy, Circ 2006
16
Boston Retrospective Study of 90 Pregnancies In
Women with CHD
Frequency Events ( Pregnancies)

Number of Predictors
Khairy, Circ 2006
17
Predictors of maternal cardiac complications
(newly identified predictors in bold)
LVOTLeft ventricular outflow tract
Drenthen W et al. European Society of Cardiology
Congress 2007
18
Putting It Together Assessment of Maternal
Cardiac Risk into Low, Intermediate, or High Risk
  • Global assessment using risk index (mild,
    intermediate, high)
  • Known CHD lesion-specific risk factors
    (intermediate, high)
  • Eisenmenger, Marfan with aortic involvement,
    mechanical valves, etc
  • Assume intermediate risk if incomplete or absent
    data
  • Discordance between global and lesion specific
    assessment
  • Use the higher risk category for management and
    counseling

19
Neonatal Events in Completed Pregnancies



plt0.005 HD vs Controls
Odds Ratio for any neonatal event HD vs
controls Unadjusted 2.8 (1.7-4.5) Adjusted
2.6 (1.5-4.6)
Siu, Circ 2002
20
Risk to the Fetus or Neonate Canadian
Multi-Centre Study Independent Predictors of
Fetoneonatal Events
  • NYHAgt2 or cyanosis
  • Left heart obstruction
  • Maternal smoking
  • Multiple gestation
  • Anticoagulation during pregnancy

Siu, Circ 2001
21
Interactions between Cardiac and Obstetric Risk
Factors
Fetoneonatal event rate

Age 20-35 No OB Risk Factor
Age lt20 or gt35 or OB Risk Factors
Siu, Circ 2002
22
Predictors of neonatal complications (newly
identified predictors in bold)
Drenthen W et al. European Society of Cardiology
Congress 2007 September 1-5, 2007 Vienna,
Austria.
23
CARPREG Risk Factors for Obstetrical
Complications
  • Pregnancy Induced Hypertension
  • Nulliparity
  • Coarctation of the Aorta
  • Postpartum Hemorrhage
  • Peripartum anticoagulation
  • Maternal cyanosis

Siu, Circ 2001
24
Maternal Antepartum Events Impacts on
Obstetrical and FetoNeonatal Outcomes
Pregnancies
Preterm FetoNeonatal Labor
Complications
Cardiac Arrhythmia Events
Recurrence
Siu, 1997
Silversides, 2006
25
Recurrence risk of congenital heart disease
  • Background rate of 0.5 per 100 livebirths in
    general population
  • Parent with CHD, risk increase to at least 5-10
  • Higher recurrence rates in patients with
    autosomal dominant (Marfan, HCM, Catch 22) or
    familial disorders
  • Family history crucial
  • Genetic consultation invaluable

26
Management Interventions to Reduce Risk
  • Correction of cyanosis
  • Treatment of severe obstructive lesion ? Role for
    preventative therapy of severe AS and MS
  • Smoking sensation
  • Preconception vitamins

27
Antepartum Management
  • Multi-disciplinary approach
  • Maternal Cardiac Clinic for all
  • Patient care conference for high risk group
  • Serial cardiac assessments
  • As early in pregnancy
  • 28-32 weeks gestation
  • Fetal echo for mothers with CHD
  • Medications for selected groups
  • Beta blockers
  • Anticoagulation

28
Peripartum Management Issues
  • Where to deliver
  • Induction vs spontaneous labor
  • Vaginal vs C section
  • Anesthesia/analgesia
  • Cardiac monitoring
  • Prevention of paradoxical embolism
  • Endocarditis prophylaxis

29
Postpartum Management
  • Repeat maternal cardiac assessment at 6 wks 6
    months postpartum
  • Reassess cardiac medications
  • Reestablish baseline and risk stratify for future
  • Arrange for follow up
  • Pediatric cardiac exam of newborns after 6 weeks
    of age

30
Incremental Diagnostic Yield of Pediatric Cardiac
Assessment After Fetal Echocardiography in 276
Offspring of Women with Congenital Heart Disease
(Thangaroopan, Pediatrics 2008)
Presence of congenital heart disease confirmed
on pediatric echocardiography in all Presence
of congenital heart disease confirmed in 18/35
infants (7) by pediatric echocardiography
31
Females with CHD should have age-appropriate
preconception counseling beginning in adolescence
  • Risk to the mother
  • Risk to the fetus
  • Recurrence risk of CHD in offspring
  • Site of obstetrical care
  • Antepartum and peripartum management
  • /-
  • Contraception options if applicable

32
Risk Stratification and Management of Pregnancy
in Women with Congenital Heart Disease 18th
International Symposium on ACHD Toronto 2008
  • Samuel Siu MD SM
  • Gunton Professor and Chair of Cardiology,
    Schulich School of Medicine and Dentistry,
    University of Western Ontario
  • Adjunct Professor of Medicine, Obstetrics,
    Gynecology, University of Toronto
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