Cardiovascular Disease in Pregnancy

1
Cardiovascular Disease in Pregnancy
Songsak Kiatchoosakun M.D. Cardiology,
Medicine Khon Kaen University
2
Introduction

• Pregnancy, labor and delivery are associated with
  burdens on the cardiovascular system
• The outcome of pregnancy is related to functional
  class and underlying heart disease

3
Hemodynamic Modifications during Pregnancy

• Blood volume starts to rise at 5th week
• Systemic vascular resistance and blood pressure
  are decreased
• Resting heart rate increases by 10-20 beats/min
• Cardiac output increases by 30-50

4
High Risk Pregnancy

• Advise avoidance of pregnancy
• Mitral stenosis with functional class II-IV
• Mitral and aortic regurgitation with functional
  class III, IV
• Severe pulmonary hypertension
• Left ventricular dysfunction
• Marfans syndrome with dilated aortic root
• (gt 40 mm)
• Cyanotic heart disease
• Severe obstructive lesion (aortic stenosis,
  pulmonary stenosis)

5
High Risk Pregnancy

• Close follow up required
• Prosthetic valve
• Mild to moderate valvular heart disease
• Marfans syndrome without aortic root dilatation

6
Signs and Symptoms in Normal Pregnancy

• History
• Dyspnea
• Orthopnea
• Palpitation
• Physical examination
• Edema
• Systolic murmur lt grade II/VI
• Increased of S1, P2

7
Suspicious Symptoms and Signs of Cardiac Disease
in Pregnancy

• Progressive dyspnea
• Syncope
• Chest pain
• Cyanosis
• Left parasternal heave
• A grade III/VI or greater systolic murmur
• Any diastolic murmurs
• S4 gallop
• Fixed split of S2
• Opening snap

8
Cardiovascular Disease in Pregnancy

• Valvular Heart disease
• Rheumatic heart disease
• Prosthetic heart valves
• Hypertension
• Congenital heart disease
• Peripartum cardiomyopathy
• Marfan syndrome and aortic regurgitation
• Arrhythmias

9
Valvular Heart Disease and Maternal Outcomes

Hameed A. J Am Coll Cardiol 200137893
10
Valvular Heart Disease and Fetal Outcomes

Hameed A. J Am Coll Cardiol 200137893
11
Mitral Stenosis

• Most common valve disease in pregnancy
• Valve area lt 1.5 cm2 increases risk of
• Pulmonary edema
• Heart failure
• Arrhythmias
• Intrauterine growth retardation
• Closed follow up is necessary
• Doppler echo at 3 and 5 month and monthly
  thereafter

12
Diagnostic Assessment

• Echocardiography
• Confirm diagnosis
• Determine the severity of stenosis
• Pulmonary artery pressure and RV function
• Mitral valve score to determine the success of
  percutaneous mitral balloon valvuloplasty

13
Medical Management

• Most pregnant woman with mitral stenosis can be
  managed medically
• Limit activity
• Restrict salt and fluid
• Diuretic if needed

14
Medical Management

• Digoxin is useful in atrial fibrillation
• Rheumatic prophylaxis
• Penicillin V 250 mg X 2
• Benzathine Penicillin IM q 3 weeks
• Betablocker

15
Beta-blocker in Pregnancy

• Beta-1 selective agents metoprolol and atenolol
  limits the risk interaction with uterine
  contraction
• Cross placenta and excrete in breast milk
• No serious adverse effects on neonates
• Fetal bradycardia and hypoglycemia have been
  reported

16
Percutaneous Balloon Mitral Valvuloplasty (PBMV)

• Should be considered after failure of aggressive
  medical treatment
• Radiation exposure and technical difficulties are
  major limitations
• Transesophageal echocardiography guidance may
  decrease the fluoroscopy time and maternal
  complications

17
Surgical Intervention

• Indicated in patients who failed medical
  treatment
• Should be performed between 24-28 weeks
  gestation
• Maternal mortality rate 1.5-5
• Fetal mortality rate 20-30 in open heart
  surgery
• Closed mitral valvotomy is preferable
• safe for mother
• fetal mortality of 2-12

18
Regurgitation Valve Disease

• Pregnancy is generally well tolerated even in
  severe valve regurgitation
• The decrease in vascular resistance and
  tachycardia during pregnancy reduces the
  regurgitation fraction
• Medical therapy in patients with heart failure
• Nitrate
• Dihydropyridine calcium blockers
• ACE inhibitors and ARB are contraindicated

19
Pregnancy with Heart Valve Prostheses

• Problems
• Hypercoagulable state during pregnancy
• Use of oral warfarin is associated with fetal
  anomalies (nasal hypoplasia, epiphysis stippling,
  CNS anomalies)
• Overall risk is 5
• Dose related low risk if daily dose lt 5 mg

20
Regimens of Anticoagulant

• Regimen 1-Warfarin sodium through out pregnancy
  with unfractionated heparin sodium near term
• Regimen 2-Substitution or warfarin with
  unfractionated heparin between 6-12 weeks and
  near term
• Regimen 3-Unfractionated heparin through
  pregnancy

21
Fetal Complications
Chan WS. Arch Intern Med 2000160191
22
Maternal Complications
Chan WS. Arch Intern Med 2000160191
23
Conclusions

• Risk of embryopathy (4-6) when warfarin is used
  during 6-12 week of gestation
• Subcutaneous heparin does not provide adequate
  anticoagulation
• No advantage in the use of heparin during 6-12
  week of gestation to prevent fetal wastage
• Heparin in first trimester is associated with
  high incidence of thromboembolism

24
Recommendations

• Warfarin therapy throughout pregnancy is the
  safest therapeutic option for the mother
• Patients who choose not to take warfarin should
  receive unfractionated heparin or low molecular
  weight heparin (aPTT 2-3 time control, predose
  anti Xa 0.7)
• Warfarin should be replaced by heparin at the
  36th week to avoid neonatal intracranial
  hemorrhage

25
Hypertension in Pregnancy

• Complicates 6-8 of all pregnancies
• Complications
• Cerebral hemorrhage
• Hepatic failure
• Acute renal failure
• Abrutio placenta
• Pregnancy outcomes relate with underlying causes
  of HT

26
Pharmacological Treatment

• Methydopa first line agent 750 mg-4 g
• Betablocker
• Calcium channel blocker
• Hydralazine
• Diuretics
• Contraindicated in preeclampsia
• May reduce uteroplacental flow
• ACEI and ARB blocker renal agenesis

27
Cardiovascular Drugs in Pregnancy

• Drug Use in pregnancy Safety
• Digoxin HF, arrhythmia Safe
• Beta-blocker HT,MS, IHD Safe
• Nifedipine HT Safe
• Hydralazine HT, HF Safe
• Nitrate IHD Limited data
• Diuretics HF,HT /-
• ACEI HT, HF Unsafe
• Amiodarone Arrhythmias Unsafe

28
(No Transcript)
29
Cardiovascular Evaluation in Pregnancy

• History
• Physical examination
• Investigations
• ECG
• Echocardiography

30
Management

• Low risk patients
• HT stage I without end organ damage
• Control of HT before conception
• Frequent supervision is essential
• High risk patients
• Severe HT with end organ damage and co-morbidity
  condition
• Need frequent assessment

31
Hypertensive Disorder

• Classification and definition
• Chronic HT HT prior or before 20 wks of
  gestation
• Preeclampsia-eclampsia proteinuria with new
  HTafter 20 wks of pregnancy
• Pre-eclampsia superimposed on chronic HT
  increased BP (30/15) change in proteinuria or
  target organ damage
• Gestational HT new HT after 20 wks of pregnancy
  without proteinuria
• Transient HT elevated HT during or after
  pregnancy without sings of preeclampsia