Download Pregnancy and Heart Disease

Mehdi Mousavi M.D.
Interventional Cardiologist
Assistant Professor
Alborz University of Medical Sciences
[email protected]
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Approximately 2% of pregnancies involve
maternal cardiovascular disease
This poses an increased risk to both mother
and fetus
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Lightheadedness
Dizziness
Shortness of breath
Peripheral edema
Syncope
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Cardiac disease may sometimes be
manifested for the first time in pregnancy
because the hemodynamic changes may
compromise a limited cardiac reserve
The symptoms and signs of a normal
pregnancy may mimic the presence of cardiac
disease.
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The plasma volume ↑ in the sixth week of
pregnancy and by the 2d trimester
approaches 50% above baseline
Slightly lesser rise in red cell mass → relative
anemia of pregnancy
Heart rate ↑ about 20% above baseline
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The venous pressure in the lower extremities
↑ ⇨ 80% of healthy pregnant women
develop pedal edema.
Uterine blood flow ↑ ⇨ ↓ in peripheral
resistance ⇨ ↓ BP in the 1st trimester.
Cardiac output ↑ begins in 1st trimester and
by the end of the second trimester
approaches 30% to 50% above baseline.
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↑ volume load ⇨ compromise a patient who
has impaired ventricular function and limited
cardiac reserve
Stenotic valvular lesions (e.g., AS) are less
well tolerated than regurgitant lesions
because the ↓ in peripheral resistance ↑ the
gradient across the aortic valve.
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The tachycardia of pregnancy reduces the
time for diastolic filling in a patient with MS
⇨ ↑ in left atrial pressure.
With a lesion such as MR, the afterload
reduction helps offset the volume load on the
LV that gestation imposes.
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Lightheadedness, dizziness, shortness of
breath, peripheral edema, and even syncope
often occur in the course of a normal
pregnancy.
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With each uterine contraction, ∼500 mL of
blood is released into the circulation,
prompting a rapid ↑ in CO & BP
NVD ⇨ ∼400 mL of blood is lost.
CS ⇨ ∼ 800 mL of blood is lost.
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↑ in venous return, in part because of
autotransfusion from the uterus + the baby
no longer compresses the IVC.
24 to 72 hours after delivery, pulmonary
edema may occur.
(1) Prior cardiac event (e.g., heart failure,
transient ischemic attack, or stroke before
pregnancy) or arrhythmia
 (2) baseline NYHA class > II or cyanosis
 (3) left-sided heart obstruction (mitral valve area
smaller than 2 cm2, aortic valve area less than
1.5 cm2, or peak left ventricular outflow tract
gradient more than 30 mm Hg by
echocardiography)
 (4) reduced systemic ventricular systolic function
(EF < 40%).
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Estimated risk of a cardiac event in
pregnancies:
0 = 5%
1 = 27%
>1 = 75%
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In general, patients who cannot achieve more
than 70% of their predicted functional aerobic
capacity are unlikely to tolerate a pregnancy
safely.
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The maternal risk of pregnancy is very high
The patient should be counseled to avoid
pregnancy
Sometimes even to consider termination of
pregnancy if it occurs
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Pulmonary hypertension: Systolic PAP > 60%
to 70% of the systemic pressure
HF (DCM), LVEF < 40%
Significant stenotic cardiac lesions: AS, MS,
PS, Coarctation of aoera
Cyanotic lesions
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Mechanical prosthetic valves
Dilated aortic root > 40 mm (particularly
Marfan syndrome) are vulnerable to
progressive aortic dilation, dissection, and
rupture during pregnancy (not only increased
stroke volume but also the gestational
hormonal changes)
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Male and female ⇨ The decision to use a
barrier method therefore depends on how
critical it is for the woman to avoid pregnancy
and on compliance and the ability to use a
condom correctly.
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A vasovagal response occurring in a patient
with idiopathic PAH or secondary PH, such as
Eisenmenger syndrome, could be lifethreatening, and many physicians therefore
avoid use of an IUD in such patients.
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For the woman with heart disease, however,
concern exists because of increased risk of
venous thromboembolism, atherosclerosis,
HLP, HTN & IHD, particularly for those who
are > 40 years and for those who smoke.
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There is a paucity of data about adverse
effects of progesterone agents on the
cardiovascular system, but these are probably
safe for most women with heart disease.
Are less reliable than combined preparations
Injectable progesterone: Cardiovascular
contraindications are otherwise the same as
those for progesterone
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Impaired ventricular function from any cause
(EF < 40%) ⇨ AVOID Estrogen
History of any prior thromboembolic event ⇨
AVOID Estrogen
Patients with congenital heart disease who
have cyanosis, atrial fibrillation or flutter,
mechanical prosthetic heart valves, or a
Fontan circulation probably should avoid
estrogen-containing preparations.
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Not obtained routinely in any pregnant
patient because of concern about radiation to
the fetus
Considered in any patient when there are
concerns about her cardiac status and new
onset of dyspnea or failure.
The chest radiograph in a normal healthy
patient may show slight prominence of the
PA, and as pregnancy advances, elevation of
the diaphragm may suggest an ↑ in the
cardiothoracic ratio (CTR).
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Cornerstone of cardiac evaluation in
pregnancy
Facilitates differentiation of the features of
cardiac disease from those of a normal
pregnancy
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Seldom performed during pregnancy
Can be performed safely, although careful
monitoring of maternal oxygen saturation is
necessary if midazolam is used for sedation
May be necessary in valvular disease, the
presence or absence of a shunt, intracardiac
thrombus, presence or absence of valvular
vegetation or perivalvular abscesse
(endocarditis)
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Imaging of the fetal heart can usually be
obtained by 20 weeks’ gestation
Typically, the heart should be smaller than
one third of the size of the fetal thorax.
Congenital
 Rheumatic heart
disease
 Cardiomyopathies:
dilated
hypertrophic
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Valvular disease:
bicuspid aortic valve
mitral valve prolapse
 Pulmonary
hypertension
 Coronary artery diseas
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Secundum atrial septal defect is the most
common congenital heart defects
Patients with even a large secundum atrial
septal defect usually tolerate pregnancy
without complication unless there is
coexistent PH or AF
DVT could precipitate a paradoxical embolus
and stroke
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VSD: Patients with small defects usually
tolerate pregnancy without difficulty
PDA: Small ducts with normal or near-normal
pressures usually cause no hemodynamic
perturbations during pregnancy.
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Those with severe aortic stenosis (valve area
smaller than 1 cm2) or a mean gradient
greater than 50 mm Hg should be counseled
not to have a pregnancy
Pregnancy is usually considered to be
contraindicated if the aortic dimension is
larger than 4.5 cm
↓ in peripheral resistance during pregnancy ⇨
↑ the aortic gradient and may precipitate
symptoms.
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Epidural analgesia needs to be carefully and
slowly administered, and spinal block should
be avoided because of the potential for
hypotension.
Several small reports have reviewed
percutaneous aortic balloon valvuloplasty
during pregnancy
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Women with coarctation may present for the
first time during pregnancy because of
systemic hypertension.
Because of the associated aortopathy, the
entire aorta is vulnerable to dilation,
aneurysm, and dissection.
Therapeutic options include antihypertensive
therapies, percutaneous balloon or stenting
of the coarctation, or surgical intervention.
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Pulmonary stenosis is usually well tolerated
during pregnancy, particularly if the right
ventricular pressure is < 70% of systemic
pressure and sinus rhythm is maintained
If necessary, balloon pulmonary valvuloplasty
can be performed, with shielding of the fetus
from radiation.
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Cyanosis poses risks for both mother and
fetus
↑ in peripheral resistance that accompanies
pregnancy augments the right-to-left shunt
and may exaggerate the maternal cyanosis.
Because of the erythrocytosis that
accompanies cyanosis and the propensity to
thrombosis, women who develop venous
thrombosis are at risk of paradoxical embolus
and stroke.
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In the setting of severe pulmonary vascular
disease (Eisenmenger syndrome), maternal
mortality may approach 50%.
The volume load of pregnancy may
compromise the poorly functioning right
ventricle and precipitate heart failure.
The fall in peripheral resistance augments
right-to-left shunting and may precipitate
more cyanosis.
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The highest incidence of maternal death is
during parturition and the puerperium.
There may be an abrupt decrease in afterload
as the baby is delivered, and hypovolemia
from blood loss can cause hypoxia, syncope,
and sudden death.
Vagal responses to pain may also be lifethreatening.
Death may also occur from pulmonary
embolism or in situ pulmonary infarction
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Current recommendations are still that
termination of pregnancy is the safer option
The mode of delivery needs to be discussed
carefully.
Cesarean section delivery is probably
preferable[19] with cardiac anesthesia
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MS tends to worsen during pregnancy
because of ↑ CO coupled ↑ HR
The cornerstone of therapy for the
symptomatic patient is beta blockade.
Cardioselective beta blocker may prevent
deleterious effects of epinephrine blockade
on myometrial tissue.
The judicious use of diuretics is appropriate if
there is pulmonary edemaBed rest may also
be helpful to slow the heart rate and to
minimize cardiac demands.
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Anticoagulants should probably be given if
the patient is on bed rest and should certainly
be administered in the setting of atrial
fibrillation.
In unusual circumstances, when the mother is
refractory to medical therapy, balloon
valvuloplasty may be performed if the valve
anatomy is favorable and there is no
concomitant mitral regurgitation
Rarer still, surgical valvotomy may be
performed
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MR & AR are fairly well tolerated in
pregnancy, provided the regurgitation is no
more than moderate, the mother is symptom
free before pregnancy, and ventricular
function is well preserved.
MR & AR can usually be managed medically
with diuretics and vasodilator therapy.
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Surgery during pregnancy should be
contemplated only for control of refractory
symptoms
If surgery is required for MR, repair is always
preferred
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Can she become pregnant?
Is there a risk for mother or fetus?
If so what to do with Warfarin?
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Pregnancy ⇨ Maternal blood is highly
thrombogenic because there is an increased
concentration of clotting factors and
increased platelet adhesiveness combined
with decreased fibrinolysis.
The risk of valve thrombosis and
thromboembolism significant.
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Poses risks for mother and baby
Mechanical prostheses, have a greater
longevity but require anticoagulation, and
whichever anticoagulant strategy is chosen
during pregnancy, there is a higher chance of
fetal loss, placental hemorrhage, and
prosthetic valve thrombosis.
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Serial echocardiograms particularly useful
The valve area calculation& pressure halftime determination, more helpful than a
simple measurement of valve gradient
Valve gradient may ↑ as pregnancy advances
because the circulation becomes more
hyperkinetic and cardiac output increases.
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For patients in sinus rhythm, they confer the
advantage that warfarin is not required
Many patients take a daily baby aspirin (81
mg)
Vulnerable to structural degeneration and
calcification, which occurs more rapidly in
younger patients
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Mitral prostheses tend to degenerate faster
than those in the aortic position
There is some evidence that pregnancy may
accelerate valve degeneration
In some retrospective series, a second valve
replacement was necessary in approximately
one third of patients within 2 years of delivery
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Large molecule that does not cross the
placenta and does not cause developmental
abnormalities in the fetus.
UFH has been used subcutaneously and
intravenously and is often begun in the first
trimester, as soon as pregnancy is diagnosed,
to minimize fetal exposure to warfarin at the
critical time of fetal embryogenesis.
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Some physicians continue heparin throughout
pregnancy to avoid any fetal exposure to
warfarin, but unfractionated heparin has been
shown to be a poor anticoagulant in
pregnancy
Heparin early in the first trimester virtually
eliminates the risk of fetal embryopathy but
at the expense of maternal valve thrombosis,
which occurred with a frequency of 9%.
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If warfarin is discontinued between weeks 6
and 12 of gestation, replace with continuous
intravenous UFH, dose-adjusted UFH, or
dose-adjusted subcutaneous LMWH (Class I:
ACC/AHA).
The aPTT ratio should be maintained at a
level of at least 2 (Class I: ACC/AHA)
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LMWH is an attractive alternative to
unfractionated heparin because of its ease of
use and superior bioavailability
Deaths have been reported with its use,
however, usually associated with maternal
valve thrombosis.
The use of low-molecular-weight heparin
remains controversial
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If dose-adjusted LMWH is used, the LMWH
should be administered twice daily
subcutaneously to maintain the anti-Xa level
between 0.7 and 1.2 unit/mL 4 hours after
administration (Class I: ACC/AHA).
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Fetal exposure to warfarin in the first
trimester may be associated with fetal
embryopathy
The reported fetal risk of embryopathy varies
widely but probably averages 6%
Warfarin also appears to increase the risk of
fetal loss and spontaneous abortion.
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For the woman with an older generation or
tilting disc mitral prosthesis, particularly if
she is in atrial fibrillation, the safer approach
may be to treat her with warfarin for the first
34 to 35 weeks of pregnancy, particularly if
her dose is less than 5 mg/day.
If warfarin is used, the INR goal should be 3.0
(range, 2.5 to 3.5) (Class I: ACC/AHA).
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For those patients at lesser risk, heparin
therapy (with the provisos noted earlier) may
be selected as soon as pregnancy is
diagnosed, warfarin substituted at 13 to 14
weeks, and heparin restarted at
approximately 35 weeks in anticipation of
delivery.
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It is reasonable to give low-dose aspirin (75
to 100 mg/day) in the second and third
trimesters of pregnancy in addition to
anticoagulation with warfarin or heparin
(Class IIa: ACC/AHA)
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Concern in the third trimester about labor
and delivery because the immature fetal liver
does not metabolize warfarin as rapidly as
the mother's liver
Reversal of anticoagulation in the fetus may
take up to 1 week because of the immature
fetal liver.
Vaginal delivery when the fetus is
anticoagulated is contraindicated because of
the risk of fetal hemorrhage.
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Warfarin should be discontinued starting 2 to
3 weeks before planned delivery and
continuous intravenous UFH given instead
Class I: ACC/AHA)
It is reasonable to resume UFH 4 to 6 hours
after delivery and begin oral warfarin in the
absence of significant bleeding (Class IIa:
ACC/AHA).
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LMWH should be discontinued at least 24
hours before delivery if epidural analgesia is
to be used because it has a prolonged effect
and there is risk of spinal hematoma.
UFH can be substituted for LMWH peridelivery
because it can be started and stopped
abruptly.
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Pregnancy is usually contraindicated if the
ascending aorta is larger than 40 mm in
diameter
Many patients are receiving long-term
treatment with beta-adrenergic blockers to
slow the progression of aortic regurgitation.
Beta blockers should be continued during
pregnancy if there is any aortic dilation.
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Echocardiography every 6 to 8 weeks is
recommended to monitor the mother's aortic
root size
Any chest pain should be promptly evaluated
to rule out dissection.
During labor and delivery, pushing should be
avoided, with an assisted second stage if
necessary.
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NYHA Class I or II may need to limit
strenuous exercise and to have adequate rest
Supplementation of iron and vitamins to
minimize the anemia of pregnancy
Low-salt diet if there is concern about
ventricular dysfunction
Regular cardiac and obstetric evaluations
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Patients who are NYHA Class III or IV may
need hospital admission for bed rest and
close monitoring and may require early
delivery if there is maternal hemodynamic
compromise.
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Cardiac surgery is seldom necessary during
pregnancy and should be avoided whenever
possible.
In the first trimester ⇨ Higher risk of fetal
malformation and loss if cardiopulmonary
bypass is performed
In the last trimester ⇨ Higher likelihood of
precipitating premature labor
The “optimal time” appears to be between 20
and 28 weeks of gestation
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For most patients with cardiac disease, a
vaginal delivery is feasible and preferable; a
cesarean section is indicated only for
obstetric reasons.
If vaginal delivery is elected, fetal and
maternal electrocardiographic monitoring
should be performed.
The second stage should be assisted, if
necessary (e.g., forceps or vacuum
extraction), to avoid a long labor.
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Patient anticoagulated with warfarin because
the baby is also anticoagulated, and vaginal
delivery carries an increased risk to the fetus
of ICH
Patients who have a dilated unstable aorta
(e.g., Marfan syndrome)
Severe pulmonary hypertension
Severe obstructive lesion such as AS
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Patients who are most vulnerable to the
deleterious effects of endocarditis are those
with cyanotic heart disease and prosthetic
valves or a prior history of endocarditis
Antibiotics are considered optional
Many institutions routinely give antibiotics
because of the documented bacteremia. This
can occur even during an uncomplicated
delivery
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Hypertension in pregnancy is an important
cause of maternal morbidity and mortality
∼ 50% of patients will develop preeclampsia
Hypertension is just one feature of the diffuse
endothelial dysfunction, which is associated
with vasospasm, reduced end-organ
perfusion, and activation of the coagulation
cascade
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Hypertension (blood pressure ≥140 mm Hg
systolic or ≥90 mm Hg diastolic) present
before pregnancy or that is diagnosed before
the 20th week of gestation
Preeclampsia develops in approximately 25%
of patients with chronic hypertension
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New hypertension with a blood pressure of
140/90 mm Hg on two separate occasions
A rise in pressure of 30/15 mm Hg or more
Arising de novo after the 20th week of
pregnancy
Blood pressure normalizes by 12 weeks post
partum.
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Proteinuria (>0.3 g during 24 hours or ++ in
two urine samples) in addition to new
hypertension. Edema is no longer included in
the diagnosis because of poor specificity.
When proteinuria is absent, suspect the
disease when increased blood pressure is
associated with headache, blurred vision,
abdominal pain, low platelets, or abnormal
liver enzymes.
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Preeclampsia tends to occur more commonly
Primiparous women
Twin pregnancies
Young age
Older age
Multiple gestations
Concomitant heart disease
Concomitant renal disease
Chronic hypertension
Young
(<20 years)
Primigravida
After 20 weeks of
pregnancy
Weight gain and
edema: sudden
Funduscopy: Spasm,
edema
Preeclampsia
Older
(>30 years)
Multigravida
Before 20 weeks of
pregnancy
Weight gain and
edema: gradual
Funduscopy:
Arteriovenous nicking,
exudates
Chronic Hypertension
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SBP <160 mm Hg
LVH: Rare
Proteinuria: Present
Plasma uric acid level ↑
BP after delivery: NL
Preeclampsia
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SBP >160 mm Hg
LVH: More common
Proteinuria: Absent
Plasma uric acid level→
BP after delivery: ↑
Chronic Hypertension
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the only other effective strategy to prevent
preeclampsia is the use of low doses of
aspirin.
The only cure for preeclampsia is delivery
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Although antihypertensive medications are
effective in treating chronic hypertension that
has worsened during pregnancy, they are not
effective in preventing preeclampsia
Drug treatment of maternal BP does not
improve perinatal outcome and may be
associated with fetal growth retardation
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Nonpharmacologic treatment (including close
supervision and restriction of activities)
should be considered with SBP 140-149 mm
Hg or DBP 90-95 mm Hg (ACC/AHA).
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In the presence of gestational hypertension
(with or without proteinuria), drug treatment
is indicated at blood pressure ≥140/90 mm
Hg (ACC?AHA)
SBP levels ≥170 or DBP >110 mm Hg should
be considered an emergency requiring
hospitalization.
Most authorities recommend antihypertensive
drugs only if DBP > 100 mm Hg.
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Oral methyldopa, labetalol, calcium
antagonists, and (less frequently) beta
blockers are drugs of choice
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Nitroglycerin is the drug of choice
Diuretic therapy is inappropriate because
plasma volume is reduced
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IV labetalol
Oral methyldopa
Oral nifedipine
IV hydralazine is no longer the drug of choice
because of excess perinatal adverse effects.
IV infusion of sodium nitroprusside is useful
in hypertensive crises, but prolonged
administration should be avoided.
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If pregnancy begins while a woman is
receiving antihypertensive drug therapy,
medications including diuretics but excluding
ACEIs and ARBs are usually continued
The mother should be protected and that the
fetus will not suffer from any sudden
hemodynamic shifts that occur when therapy
is first begun.
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Methyldopa ⇨ Safe; considered by some to be
the drug of choice for hypertension in
pregnancy
Calcium channel blockers ⇨ Relatively safe;
few data; concern regarding uterine tone at
the time of delivery
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Hydralazine ⇨ Safe; no major adverse effects
As emergency, IV hydralazine is no longer the
drug of choice because of excess perinatal
adverse effects (ACC/AHA).
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Beta blockers ⇨ particularly labetalol have
been used with good effect
Beta-blocking agents should not be taken in
the first trimester, if possible (ACC/AHA)
Cardioselective beta blocker may prevent
deleterious effects of epinephrine blockade
on myometrial tissue.
More concern exists with regard to Atenolol
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Lasix ⇨ Safe; caution regarding maternal
hypovolemia and reduced placental blood
flow
ACE inhibitors ⇨ Contraindicated; IUGR,
oligohydramnios, renal failure, abnormal
bone ossification; FDA class X
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When preeclampsia develops, bed rest is
usually initiated, with salt restriction and
close monitoring, and magnesium sulfate is
often administered in an effort to prevent
eclamptic seizures and to prolong the
pregnancy
Caution is needed to avoid volume overload
because pulmonary edema is the most
common cause of maternal mortality.
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A cardiomyopathy manifesting between the
last month of pregnancy and 6 months post
partum
Inflammatory factors are highly implicated
Women who recover are at increased risk of
recurrences with subsequent pregnancies
Peripartum cardiomyopathy Versus a chronic
cardiomyopathy exacerbated by the volume
load occurring during pregnancy
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Shortness of breath
Exertional Dyspnea
Orthopnea
Paroxysmal Nocturnal
Dyspnea (PND)
Cheyne-Stokes
Respiration
Acute Pulmonary
Edema
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Fatigue
Anorexia
Nausea
Early sataity
abdominal pain and
fullness
Congestion of the liver
Nocturia
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Pulmonary crackles
(Rales)
Pleural effusions
Cool peripheral
extremities
Cyanosis of the lips
and nail beds
S3 & S4
The murmurs MR or TR
Pulse pressure ↓
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JVP ↑
Abdomino-jugular
reflux⇨ +
Giant v waves in JVP ⇨
TR
Hepatomegaly
Ascites
Peripheral edema
Sinus tachycardia
Joundice
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ECG ⇨ LBBB, Q-Wave, LVH
CXR ⇨ PH, interstitial or pulmonary edema
Echocardiography ⇨ EF, Diastolic function,
LVH
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Most commonly furosemide, may be used to
treat CHF during pregnancy and sometimes
are used for the treatment of HTN.
Aggressive use of diuretics, however, may
cause reduction in placental blood flow and
have a detrimental effect on fetal growth.
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Particularly in the setting of diabetes and
tobacco abuse
AMI is rare, and when it occurs, pregnancy ↑
the maternal risk 3-4 fold
The most common cause is coronary artery
dissection
The treatment should be urgent coronary
angiography, with a consideration of PCI
The heart may be more vulnerable to
arrhythmias during pregnancy
- Increase in preload
- Increased heart rate
- Fluid and electrolyte shifts
- Changes in catecholamine levels
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The presenting symptom complex may be
difficult to separate from the normal
symptoms of pregnancy, including a
sensation of fast heartbeat and skipped
beats, which most commonly are
supraventricular ectopics.
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Laboratory tests, such as CBC, electrolyte
level measurement, and thyroid function test
If there is any doubt after the clinical
examination, a transthoracic echocardiogram
should be obtained
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Commonly used antiarrhythmic drugs cross
the placental barrier to some extent
Because of the potential problem of recurring
tachyarrhythmias during pregnancy, the
policy of withdrawing antiarrhythmic drugs
and resuming them later can be
recommended only as an alternative in
selected cases.
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Supraventricular and ventricular ectopic beats
(PAC, PVC) require no therapy
PAC (commonly observed during pregnancy),
are generally benign and well tolerated. In
patients with mild symptoms and structurally
normal hearts, no treatment other than
reassurance
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Class I: Vagal maneuver [C], Adenosine [C],
DC cardioversion [C]
Class IIa: Metoprolol,* propranolol* [C]
Class Iib: Verapamil [C]
Prophylactic therapy; Class I: Digoxin [C]
Metoprolol*
Prophylactic therapy; Class IIa: Propranolol*
[B], Sotalol,* flecainide[†] [C]
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They cross the placenta but are not
teratogenic
They have been demonstrated to cause fetal
growth retardation
Associated with neonatal bradycardia and
hypoglycemia
Beta-blocking agents should not be taken in
the first trimester, if possible
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Cardioselective beta blocker may prevent
deleterious effects of epinephrine blockade
on myometrial tissue.
Beta blockers have been used safely during
pregnancy, although it is recommended that
fetal growth be monitored more carefully
More concern exists with regard to Atenolol

Digoxin has been used during pregnancy for
many decades, and although it does cross the
placenta, no adverse effects with its use have
been reported.