Download Pregnancy in women with congenital heart disease

Pregnancy in women with heart
disease fetus point
Dr. M.Moshfeghi
OBS&GYN
fellowship of perinatology
Shariati.Hospital ,TUMS
Improved techniques of surgical repair
have resulted in
women with congenital heart disease
surviving to bear children
■ Preconceptional Counseling
Women with severe heart
disease will benefit from
counseling before undertaking
pregnancy,
significant worsening of NYHA class in
4.4 percent of pregnancies in which
the baseline class was
I or II.
The risk to
the woman
should be spelled out as clearly
as possible.
•
A woman may require a prosthetic
valve in the future.
should be advised to have her family
before
valve replacement
with its associated anticoagulant risk
One of the most important
questions is
whether the mother’s heart
disease is hereditary,
?
Congenital Heart Disease in Offspring
inherited as polygenic
Environmental factors
living at higher altitudes (> 3600 meters)
and was presumably
due to lower oxygen concentrations
Recurrence in the fetus IS
2.7percent
with concordance (recurrence of –
the same parental or sibling defect)
in approximately one-third
The risk of recurrence was greater if
the mother rather than the father
had congenital heart disease
(5.7 versus 2.2 percent)
cardiomyopathies, especially hypertrophic
inherited in a mendelian manner.
FAMILIAL dilated cardiomyopathy has also been
described.
Approximately
20% of idiopathic cardiomyopathy is inherited.
strong familial tendency in,
such as PDA and atrial septal defect (ASD)
the risks
to her fetus of drugs, other
?
therapies, and diagnostic tests
Echocardiography poses no
threat to the fetus,
but radiation incurred with radionuclide
angiography, cardiac catheterization with
contrast angiography,
or computed tomography pose a potential
hazard to the fetus.
CARDIOVASCULAR DRUGS
Some of the drugs commonly used in the
management of cardiovascular
disease have potentially harmful effects on the
developing
embryo and fetus
Warfarin embryopathy,
consisting of nasal hypoplasia,
optic atrophy, digital abnormalities, and mental
impairment,
occurs in a minority of cases.
A risk of 4% to 10%.
embryopathy is less likely if
the warfarin dosage is 5 mg/day or less
β-Adrenergic blocking agents,
for hypertension and tachyarrhythmia,
associated with
neonatal respiratory depression, bradycardia,
and
hypoglycemia when administered late in
pregnancy
The thiazide
harmful effects on the fetus
in the third trimester
impair
normal expansion of plasma volume.
Rarely, severe neonatal
electrolyte imbalance, jaundice,
thrombocytopenia, liver
damage, and even death have been reported.
angiotensin-converting
enzyme (ACE) inhibitors
profound and deleterious effect on fetal renal
Function
oligohydramnios,
neonatal renal failure.
absolutely
contraindicated during pregnancy
Hydralazine,
vasodilator and
oral antihypertensive agent, can be substituted
for ACE inhibitors
during pregnancy.
Amlodipine
is another alternative to
ACE inhibitors,
and it can be used with hydralazine if needed
Digoxin©
Maternal and fetal arrhythmias,
heart failure
No evidence for unfavorable side
effects on the fetus
PERIPARTUM MANAGEMENT
CONSIDERATIONS
In some, pregnancy termination may be
advisable
MAJOR MATERNAL&FETAL CARDIAC RISKS —
Pulmonary hypertension (pulmonary vascular
disease)
Maternal cyanosis
Poor maternal functional class
History of arrhythmia
Maternal anticoagulants
Pulmonary hypertension
Eisenmenger syndrome,
Preterm delivery and fetal growth retardation
at least 50 percent,
15 to 25 percent of pregnancies progressing to
term
Cyanosis —
The arterial oxygen saturation before pregnancy
important predictors of poor fetal and maternal
outcomes
The likelihood of a live birth was much lower in
women with a resting arterial oxygen
saturation below 85 percent
Oxygen administration —
The value of antepartum oxygen in cyanotic
women is unproven.
There is little convincing evidence that oxygen
benefits the mother, and there is no evidence
that a favorable effect is exerted on a growthretarded fetus,
Pregnancy is contraindicated in
women with
Eisenmenger syndrome
because of
high maternal mortality risk,
fetal risks,
risk of thromboembolism
CARPREG risk index
Four predictors of cardiac events were identified:
(NYHA class III or IV) or cyanosis
Previous cardiac events (eg, heart failure, transient
ischemic attack, stroke) or arrhythmia
Left heart obstruction (mitral valve <2 cm2, aortic
valve <1.5 cm2, or peak left ventricular outflow
gradient >30 mmHg)
Left ventricular systolic dysfunction (EF<40 %)
CARDIAC SURGERY DURING
PREGNANCY —
perform reparative cardiac surgery before
conception.
, eliminates the fetal risk
Cardiac surgery during pregnancy
The maternal risks are about the same as those
in nonpregnant women
but cardiopulmonary bypass during pregnancy
incurs risk for the fetus
Fetal risks
nonpulsatile blood flow
reduced uteroplacental flow during
cardiopulmonary bypass,
deep hypothermia
preterm labor and delivery
If cardiopulmonary bypass is needed, high blood
flow (2.5 L/min per m2) and mean arterial
blood pressure greater than 70
SO If a woman presents early in pregnancy with
one of the high risk valve lesions,
we recommend
termination of pregnancy
followed by reparative surgery
before another attempt at pregnancy.
If the mother declines termination,
we manage the patient medically
and operate only for refractory NYHA class III or
IV symptoms
It is preferable to delay surgery, if possible, until
the fetus is viable;
a cesarean delivery can then be performed as
part of a combined procedure
During surgery, foam wedges should be placed
The fetal heart rate should be monitored
continuously.
Fetal bradycardia often responds to an increase
in pump flow rate.
In viable fetuses, prolonged bradycardia (less
than 80 beats per minute) that is
unresponsive to increased pump flow rates is
an indication for cesarean delivery if the fetus
is at a viable gestational age
Cesarean delivery has been successfully performed
while the mother was on cardiopulmonary
bypass
the catastrophe of sudden maternal death,
immediate postmortem caesarean delivery is an
important option.
an infant survival of approximately 15 percent
, cesarean delivery should be performed within four
minutes of maternal cardiac arrest
The resulting decompression of the gravid uterus
aids maternal resuscitation
Fetal heart rate monitoring —
FHR should be documented pre- and postoperatively at all gestational ages.
Maternal hemodynamic stability does not
guarantee that placental perfusion and
fetal oxygenation are optimal.
Intraoperatively, fetal heart rate monitoring
can be a more sensitive assessment of
maternal cardiorespiratory status than
maternal vital signs.
We suggest continuously monitoring all viable
fetuses (greater than 23 to 24 weeks of
gestation) throughout surgery, if technically
possible.
.
For abdominal operations, some centers use
transvaginal ultrasound to monitor fetal heart
rate.
reduced variability with induction of general
anesthesia,
. Baseline FHR may also decrease, but within the
normal range.
Vasoactive and chronotropic-modifying agents cross
the placenta and can produce changes in the fetal
heart rate
If bradycardia, tachycardia, or repetitive
decelerations occur, the anesthesiologist should
optimize uteroplacental oxygen delivery and
blood flow by ensuring there is no aortocaval
compression;
FETAL RISK —
functional class of the mother,
maternal cyanosis
maternal medications
……………expose the fetus to IUGR.
Overall fetal outcomes :
miscarriage in 15 percent
Fetal mortality was 1.7 percent
perinatal mortality was 2.3 percent (compared
to an expectation of less than 0.5 percent in
the general population),
adverse neonatal outcomes in 28 percent of
pregnancies
preterm (21 percent),
SGA (8 percent),
IUFD(3 percent),
IVH and neonatal death (1.4 percent each).
An adverse neonatal outcome was
independently predicted by a basal left
ventricular outflow gradient >30 mmHg
Maternal cyanosis
IUGR
37% prematurity
fetal wastage
a live birth 43%
The mean birth weight of full term 2575 g
compared to a normal term 3500 g.
.
We suggest that
antepartum fetal monitoring begin
at 28 weeks of gestation
ultrasound examinations at 28 and 34 weeks of
gestation to screen for fetal growth
retardation,
with additional assessment if growth delay is
diagnosed
Cyanotic congenital heart disease
A successful pregnancy was unlikely
if hemoglobin ≥ 20 g/dL
(live birth rate of 8 percent)
maternal arterial oxygen saturation was ≤ 85%
(live birth rate of 12 percent).
Complete heart block
congenital or acquired.
The congenital form called the neonatal lupus
syndrome
trans-placental passage of maternal anti-Ro/SSA
and anti-La/SSB antibodies.
Congenital third degree (complete)
atrioventricular block
present with fetal bradycardia between 18 and
28 weeks of gestation
(95 percent) are due to neonatal lupus
,
PREGNANCY — Approximately 50 percent of
patients with congenital complete heart block
are female
survival into childbearing age is anticipated
most of these patients will have indications for
pacemaker insertion
syncopal episodes occasionally first occur during
gestation
and the heart and circulation may not respond
adequately to the acute circulatory demands
of labor and delivery
Management of congenital CHB in
utero and in the perinatal period
steroid therapy if associated with anti-Ro/SSA
and anti-La/SSB antibodies,
and isoproterenol and/or pacemaker insertion
immediately after birth.
warfarin
potentially teratogenic.
Embryopathy
sixth to ninth weeks of
toxicity after this period is still possible
Fetal hemorrhage
, increases the risk of hemorrhagic fetal death
during vaginal delivery.
To minimize this risk, warfarin should be
discontinued after 34 to 36 weeks of gestation
and/or cesarean delivery should be
considered
, infusion of fresh frozen plasma into the mother
does not reliably reverse fetal anticoagulation.
A cesarean delivery may prevent hemorrhagic
fetal death, and fresh frozen plasma should be
administered to the neonate
For women who are taking long-term vitamin •
K antagonists and are attempting to become
pregnant, the 2012 ACCP Guidelines have
made a weak suggestion in favor of
performing frequent pregnancy tests and
substituting treatment with LMW heparin as
soon as pregnancy is achieved, rather than
switching to a LMW heparin preparation while
attempting pregnancy
We believe that this is a reasonable option for a woman
who meets all of the following criteria:
She has regular monthly menstrual cycles.
She agrees to have a blood pregnancy test within the first
seven days of the missed first day of expected menses.
She can be switched to a LMW heparin preparation
promptly if the pregnancy test is positive, and will have
a second blood pregnancy test if the first test is
negative and menses have not begun within 10 days of
the missed first day of expected menses.
She understands the baseline risk of birth defects (3
percent) in the population and the further increased
risk and types of embryopathy if she continues to take
her long-term vitamin K antagonist during or after the
sixth week of pregnancy (ie, ≥14 days after the missed
first day of expected menses).
Antepartum management
Serial ultrasound
fetal growth,
fetal behavior (FPP),
amniotic fluid,
blood flow
. The frequency is based upon the severity of
findings and whether the examinations are
being done to monitor fetal well-being (one to
seven times per week) or fetal growth (every
two to four weeks).
Doppler velocimetry of the umbilical artery is
recommended
for monitoring pregnancies in which growth
restriction is diagnosed
Timing of delivery
Remote from term,
normal umbilical artery flow by Doppler
velocimetry is reassuring
We would immediately deliver any pregnancy
≥32 weeks with reversed flow,
under 34 weeks with absent flow
Delivery of
the late preterm (34 to 36 6/7ths weeks)
or early term (37 0/7ths to 37 6/7ths weeks) IUGR
fetus is recommended
if there are additional risk factors for adverse
outcome, such as maternal
medical/obstetrical disorders, arrest of growth
over a three- to four-week interval, and/or
absence or reversal of Doppler flow in the
umbilical artery
For pregnancies with mild growth restriction at
34 to 37 weeks, normal umbilical artery
Doppler flow, and no additional maternal/fetal
risk factors,
delivery can be delayed until 38 to 39 6/7ths
weeks, when pulmonary maturity is likely
Delivery at 37 to 38 weeks is reasonable if
umbilical artery flow is decreased.
INTRAPARTUM MANAGEMENT
—
perform continuous intrapartum fetal
monitoring to detect nonreassuring fetal heart
rate patterns
. Umbilical cord blood analysis should be
considered as a component of establishing
baseline neonatal status.
INDICATIONS FOR FETAL
ECHOCARDIOGRAPHY
Familial risk factors
Maternal risk factors
Fetal risk factors
Familial risk factors
First or second degree relatives with congenital
heart disease
(eg, the fetus’ siblings, parents, and
grandparents)
Syndromes including congenital heart disease
(eg, Noonan, tuberous sclerosis, Holt-Oram,
velocardiofacial [DiGeorge] syndrome)
Maternal risk factors
Maternal congenital heart disease
Cardiac teratogen exposure (eg, lithium , folate
antagonists, organic solvents thalidomide ,
anticonvulsants, isotretinoin , paroxetine ,
warfarin )
Maternal medical illness (eg, diabetes,
phenylketonuria, anti Ro/SSA or anti La/SSB
antibodies)
Exposure to prostaglandin synthetase inhibitors (can
cause premature closure of the ductus arteriosus
in the third trimester)
Rubella infection in the first trimester
In vitro fertilization
Fetal risk factors
Suspected cardiac anomaly during basic sonogram
Extracardiac anomaly
Aneuploidy
Nonimmune hydrops
Arrhythmia
Abnormal fetal situs
Increased nuchal translucency at 11 to 14 weeks of
gestation
Chromosomal abnormality
Monochorionic twins, with or without twin-twin
transfusion syndrome
Fetal karyotype, with screening for deletion in •
22q11.2 when conotruncal anomalies are
present
Simpson (2012) recommends cesarean
delivery for women with the following:
(1) dilated aortic root >4 cm or aortic aneurysm
(2) acute severe congestive heart failure;
(3) recent myocardial infarction;
(4) severe symptomatic
aortic stenosis;
(5) warfarin administration within 2 weeks of
delivery;
(6) need for emergency valve replacement
immediately
after delivery
Indications for Fetal Echocardiography •
Fetal
Arrhythmias
Extracardiac anomalies
Hydrops
Hydramnios
Growth restriction
Chromosomal defects
Increased nuchal translucency thickness at 11 + 0 - 13 + 6 weeks'
gestation
Trucuspid regurgitation at 11 + 0 - 13 + 6 weeks' gestation
Retrograde flow in the ductus venosus at 11 + 0 - 13 + 6 weeks'
gestation
Abnormal heart at 18-20 weeks routine scan (usually abnormal
four-chamber view)