Download Valvular heart disease

Acquired heart disease and
pregnancy
Dr Sherief
Contents
• Introduction
• General principles
• Valvular heart disease
• Infective endocarditis
• ACS in pregnancy
• Peripartum cardiomyopathy
• Prosthetic valves in pregnancy
• Post cardiac transplantation patients
Introduction
• Developed countries
– Women with heart disease : ̴ 1 % of the obstetric population
• Many women are postponing childbearing until the fourth
and fifth decades of life
– Advancing maternal age
– HTN, DM, DLP become more common
• Valvular heart disease, prosthetic valves, ACS, PPCM
Heart disease in pregnancy - General principles
Assessing risk
Predictors of cardiac events
• Severity of valve lesions
• Degree of ventricular dysfunction
Cardiac evaluation: The history, physical examination, echocardiogram
and ECG form the foundation of in all patients
Siu SC et al. Risk and predictors for pregnancy-related complications in
women with heart disease. Circulation 1997
– Retrospective study
– Analyzed outcomes of 221 women with heart disease who underwent
252 pregnancies (excluding miscarriages)
The findings were then applied in a prospective study
Siu SC et al. Prospective multicenter study of pregnancy outcomes in
women with heart disease. Circulation 2001
– 562 women with cardiac disease or arrhythmias who had 617
pregnancies
Heart disease in pregnancy - General principles
Results
There
excellent agreement
predicted and observed
The
fourwas
predictors
of cardiacbetween
events the
identified:
risk score class (NYHA class II to IV) or cyanosis
• rates
Poorbyfunctional
• Previous
cardiac event
(HF, TIA,
or arrhythmia
Risk score
Predicted
ratestroke)
(%) Observed
rate (%)
• Left heart
0 obstruction (MVA
5 <2 cm2, AVA <1.5
4 cm2, peak LVOT
gradient >30 mmHg)
1
27
• LV systolic
>1 dysfunction (LVEF
75 <40 %)
26
62
One point was assigned for each finding
• The actual rate of primary cardiac events (pulmonary edema,
arrhythmia, stroke, cardiac arrest or death) -- 13%
• 55% of events occurred antepartum
Heart disease in pregnancy - General principles
• Neonatal outcome also correlates with the maternal risk score
– Neonatal complications
• Risk score ≥1 : 33%
• Risk score 0 (no HD) : 11%
Siu SC et al. Adverse neonatal and cardiac outcomes are more common in
pregnant women with cardiac disease. Circulation 2002
• Risk scores of ≥1
– More frequent evaluations and close collaboration between the
patient's cardiologist and obstetrician
• Individuals at greatest risk should be referred to a maternalfetal medicine specialist (high-risk obstetrician) for management
of pregnancy
Heart disease in pregnancy - General principles
Management of labor and delivery
• Vaginal delivery – For almost all
• Induction of labor
– Prostaglandin analogues are absorbed into the systemic circulation and can
lower SVR, lower BP and increase HR
– These effects are more frequent with E2 than E1
• Cesarean delivery should be reserved for obstetric indications
• The concerns about cesarean delivery include:
– GA, if required, incurs the risk of hemodynamic instability associated with
intubation and the anesthetic agent
– Blood loss that is about twice as great as with vaginal delivery
– Increased risks of wound and uterine infection
– Postoperative thrombophlebitis is more common after cesarean delivery
– The risk of postoperative incisional bleeding is high in patients requiring
anticoagulants
Heart disease in pregnancy - General principles
Selection of mode of anaesthesia
Anesthesia/analgesia
Risk consideration
In labor
Example
Preferred
technique
• IM or IV opiates may be used to relieve pain and apprehension
Likelihood
of
requiring
DC
History
of arrhythmias
General
• Lumbar
epidural
anesthesia
is highly
effective
for hemodynamic
controlling
labor pain
Lateral
decubitus
position
to attenuate
the
cardioversion
– Lowers
pain-induced
elevations
ofmajor
sympathetic
activity
fluctuations
associated
with
uterine
contractions and the
– Reduces
urge of
to general
push
Negative
ionotropic
effect
Markedly impaired
Neuraxial
supinethe
position
– Provides
anesthesia for
operative
procedures
anesthetics
could excellent
be compromising
cardiac
contractility
– The epidural should be dosed slowly with local anesthetics since venous
Let itcan
come;
DON’Tbyletthe
her
push
return
be
reduced
anesthetic
Risk of acute PHT crisis from tracheal Pulmonary hypertension Neuraxial
– Single
shot spinal
 Rapid decrease in preload and afterload 
intubation,
coughing,
etc
Contraindicated in some cardiac lesions (MS, AS)
Undesirable circulatory effects of the Valsalva maneuver
Thromboembolic risk requiring
Mechanical valve
General
anticoagulation
timeforces
of neuraxial
Hemodynamic
Allowatmonitoring
the
of labor to descend the fetal head to the
– Systemic
arterial
pressure and
HR
perineum,
unassisted
by maternal
pushing
High likelihood
of postoperative
Immediate postpartum
General
– Pulse oximetry
controlled
ventilationECG
or further
– Continuous
monitoring cardiac procedure to be
Delivery
may
then be assisted
by low
forceps or vacuum extraction
invasive
performed
– treatment
A Swan-Ganz catheter for hemodynamic
monitoring should not be routinely
employed
Heart disease in pregnancy - General principles
Fetal monitoring
• The growth restricted fetus is especially vulnerable to hypoxia during labor
• Continuous electronic FHR monitoring is recommended
Postpartum care
• After expulsion of the placenta, bleeding is reduced by uterine massage
and iv oxytocin administration
• Oxytocin should be infused slowly (< 2 units/min) to avoid hypotensive
effects
• Prostaglandin F analogues (for PPH) -- Increase in PA pressure
• Methylergonovine should be avoided because of the high rate (>10 %) of
vasoconstriction and elevation of systemic pressure
• Hemodynamic monitoring of the mother is warranted for 12 to 24 hours
after delivery
• DVT prophylaxis -- meticulous leg care, elastic support stockings and early
ambulation
Valvular heart disease in pregnancy
Valvular heart disease
• Study of pregnancy complicated by RHD (519 patients)
– MS : 61%
– MR : 33%
– AR : 6%
McFaul PB et al. Pregnancy complicated by maternal heart disease. A review of 519
women. Br J Obstet Gynaecol 1988
Valvular heart disease in pregnancy
Risk
according
to valve
lesion
Settings
associated
with
low maternal and/or fetal risk:
ACC/AHA 2006 valvular guidelines (2008 focused update) and the
Asymptomatic AS with an LVEF >50% and a mean gradient < 25 mmHg
2007 ESC guidelines
Settings
with
high maternal
and/or
AR / MRassociated
with no or mild
symptoms
(NYHA class
I to II)fetal risk:
•
•
•
•
Severe
ASmild
withtoormoderate
without symptoms
MVP
with
MR with an LVEF >50 %
Symptomatic MS (NYHA class II to IV)
2 and a mean gradient < 5 mmHg) without severe
Mild
MSMR
(MVA
cmclass
AR or
with>1.5
NYHA
III to IV symptoms
PAH (PAP >75% of systemic pressure)
Aortic and/or mitral valve disease with severe LV dysfunction (LVEF < 40%) or
severe PAH (PAP >75% of systemic pressure)
Mild to moderate PS
• Marfan syndrome with or without AR
• Mechanical prosthetic valve requiring anticoagulation
Valvular heart disease in pregnancy
Cardiac surgery
Clinical course and management of valve disease
• Cardiac surgery should be avoided, if possible, during pregnancy
• Delay surgery (if possible) until the fetus is viable
– Maternal risks : Same as in nonpregnant women
– Cardiopulmonary bypass  Significant risk for the fetus
• Cesarean delivery as part of a combined procedure
• Early pregnancy with one of the high risk valve lesions  Termination of
• Best time for surgery -- Second trimester
pregnancy  Corrective surgery (before another attempt at pregnancy) is
Potential risks of teratogenicity from medication
recommended
Low
X-ray exposure
Premature delivery
• If the mother declines termination  Medical management (as per
ACC/AHA guidelines)  Intervention (only for refractory NYHA class III or
IV symptoms)
Mitral stenosis in pregnancy
• MS in women of childbearing age is nearly always rheumatic
in origin
• Women with RHD (MS being most common) : <25% of the pregnant
women with heart disease (US and Canada)
• MS is a common condition in pregnant women where RHD is
prevalent
• Report of 1194 pregnancies in women with heart disease in
three studies (Brazil, Turkey and Senegal) -- RHD was the
underlying cause in 56-88% of women
Avila WS et al. Pregnancy in patients with heart disease: experience with 1,000 cases. Clin Cardiol 2003
Diao M et al. Pregnancy in women with heart disease in sub-Saharan Africa. Arch Cardiovasc Dis 2011
Impact of cardiovascular changes in pregnancy
in women with MS
ANTEPARTUM
Physiologic
hypervolemia
LABOUR
Uterine contraction
Increased atrial
irritability and
hypercoagulability
Autotransfusion of venous
return from the lower
extremities
Atrial fibrillation
LA clot
↑HR during pregnancy
↑ transmitral gradient
and LAP
↑ risk of pulmonary
congestion or
pulmonary edema
Relationship between severity of MS and impact of pregnancy
• Severity of MS – Directly related to the risk of maternal and fetal
complications
• There is an incremental increase in the frequency of maternal
and fetal complications with increasing severity of MS
• Risk factors for maternal cardiac complications
– H/o cardiac complications
• pulmonary edema, arrhythmias, TIA or stroke prior to pregnancy
• poor baseline maternal functional class
• Pregnancy has any subsequent effect on the progression of
disease or symptoms in women with MS? No contemporary
studies
Summary of pregnancy outcomes in women with mitral stenosis
Severity
of MS
No. of
CHF or
Arrhythmia Preterm SGA
pregnancies pulmonary
delivery or
edema
IUGR
Still birth or
fetoneonatal
death
Mild
61
20
8
11
8
2
Moderate
47
45
15
27
19
2
Severe
18
67
33
39
17
11
Overall
126
36
14
21
13
3
References:
Hameed A et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy.
J Am Coll Cardiol 2001; 37:89
Silversides CK et al. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol
2003; 91:1382.
Nature and frequency of adverse pregnancy outcomes
Maternal outcomes
• In the four largest contemporary series from North America and Europe
300 pregnant women with MS - No maternal deaths
1 Study
strokeof 46 pregnant women with MS from sub-saharan Africa
Madazli R et al.
Pregnancy outcomes
in women
Arch Gynecol Obstet 2010
Maternal
mortality
rate with
washeart
32 disease.
%
Hameed A et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am
Coll Cardiol 2001
Diao M et al. Pregnancy in women with heart disease in sub-Saharan Africa.
Leśniak-Sobelga A et al. Clinical and echocardiographic assessment of pregnant women with valvular
heart
fetal outcome. Int J Cardiol 2004
Archdiseases--maternal
Cardiovasc Disand
2011
Silversides CK et al. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003
•
448 pregnant patients with RHD
(88 patients with MS ; 54 had moderate to severe MS)
8 deaths - 1.4% mortality (HF due to severe native mitral disease)
8 episodes of thromboembolism
Avila WS et al. Pregnancy in patients with heart disease: experience with 1,000 cases. Clin
Cardiol 2003
Nature and frequency of adverse pregnancy outcomes
• AF is the most common arrhythmia
Fetal outcomes
• 20% of the pulmonary edema episodes occurred in the setting of
atrial tachyarrhythmias
Perinatal
complications
premature labor
lowpeak
fetal
weight
• The
period
of maternal cardiac complications is during the second
perinatal
death
and
third trimester
Silversides CK et al. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003
• In the two largest North American series (total of 126 pregnancies)
More frequent with increasing severity of MS and in the presence
Deterioration of one NYHA class - 74%
of complications Two NYHA classes - 40%
Silversides CK et al. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003
Hameed A et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am
Coll Cardiol 2001
Mitral stenosis in pregnancy - Evaluation
Risk stratification
• Highest risk of maternal cardiac complications
– Moderate or severe MS (MVA <1.5 cm2)
– Baseline maternal NYHA class III or IV
– H/o cardiac complications prior to pregnancy
• Pulmonary edema
• Arrhythmias
• TIA or stroke
– Central cyanosis
– LV dysfunction
• PAH (PASP >60 mmHg) -- ? additional risk factor
(Findings not uniform in contemporary studies)
Mitral stenosis in pregnancy - Evaluation
Frequency of cardiac follow-up
No specific recommendations for echocardiographic
• Determined by the risk level
assessments
• The
2011
ESC guidelines
At the
minimum
2 ECHO studies
First antepartum
visit follow-up for moderate to severe MS (MVA < 1.5 cm2)
– Monthly
or bimonthly
Third
trimester
visit
– At
every
trimester
and prior to pregnancy for mild MS
Transmitral gradient will increase as pregnancy progresses
PHT and planimetry : Less preload dependent methods to
measure MVA
PASP may also increase
Mitral stenosis in pregnancy - Management
•Postpartum
Functional
deterioration - treated by
Peripartum
Oral
contraceptives
The
preferred
time
for PMBV
is in the
22augmented
to 26 weekcardiac output
Elevated
HR
is
crucial
to
maintain
the
–
Restriction
of
activities
and
beta
blockers
(avoid
atenolol)
to reduce
Most
women
with
MS
can
undergo
pregnancy
without
the need
Minimizes
the
radiation
risks
to
the
developing
fetus
Intensive
monitoring
in
later
pregnancy
tachycardia
and improve
LV filling the spikes in CO during labor
forFetal
invasive
interventions
Regional
anesthesia
Estrogen-based
OCPifAttenuate
survival
is unlikely
emergent delivery
is precipitated
Goal
ofdose
ventricular
rate control
: 70-90 bpm
–
Small
ofrequired)
furosemide
Anticoagulation
(if
can
bedelivery
resumed
once
there
isrisk
nosecond
evidence
Almost
all
can
undergo
with
assisted
stage
Except
for
those
increased
Maternal
and
fetal
riskwith
is vaginal
substantial
ifthromboembolic
PMBV
isandelayed
in
severe
MSof early
: Severe
symptoms
or HFIVdespite maximal medical therapy
orBMV
late PPH
Severe
MS, PHT, NYHA
• Electrical
Digoxin
<cardioversion
BB (renal
clearance
of digoxin
is associated
increased during
pregnancy)
Progesterone
based
preparations
are
not
with
thromboembolic
No
specific
guidelines
on the
timing
postpartum
assessments
Caesarian
: Reserved
for
obstetric
indications
and in whom
Abdominal
shielding
should
beofemployed
Efficacy
of
PMBV
Poor
response
to
rate
control
risk
anticoagulation
cannot
be
reversed
Study
of
45
pregnant
women
underwent
PMBV
or
assessment
at
4-6
weeks
•Cardiac
Sustained
or
frequent
palpitations
–Needs
prompt
investigation
Hemodynamic
instability
The procedure is best donepostpartum
past thewho
period
of
organogenesis
Screen
for postpartum
deterioration
surgical
mitral
valve
commissurotomy
forafter
severe
heart
failure
(>20
weeks)
CV
changes
of
pregnancy
fully
resolves
the
sixth
postpartum
Adjust
cardiac
medications
• Refractory
AF and other
SVT
for
deleterious
effect
on
uteroplacental
HF requiring
intubation
and
ventilation
-- Only
Antiarrhythmic
agent
maintenance
of
sinus
rhythm
-- The
month
Discuss
contraception
choices
Procedural
success
rate
of
PMBV
95%
Prior
toindication
mid to late
third trimester
perfusion
cardiac
for
Repeat
clinical
assessment
with ECHO (after 6m)  Baseline for future
fetal
safety
profile
to CS
be considered
Improvement
in can
symptoms
- same
in both groups
Gravid
uterus
interfere
with
catheter
access
and hemostasis
–
Prompt
initiation
of
anticoagulation
(potential
teratogenicity
andwith the
Most
cardiac
medications
are
excreted
in
breast
milk
follow-up
Fetal
complications
were less frequent
femoral
approach
fetopathic
effects
of warfarin)
Small amounts
Endocarditis
prophylaxis
is were
not routinely
Fetal
and neonatal
mortality
lower with recommended
PMBV (5 Vs 38% ) for
is generally
safeto prevent
Elective
cardiovascular
invasive
procedures
should
be delayed
after
–Use
Rhythm
control
thromboembolic
episodes
and theuntil
risk of
uncomplicated
vaginal
or
cesarean
delivery
An
exception
isedema
Amiodarone
: Breastfeeding
is contraindicated
during maternal use of
the
postpartum
month
avoid
unnecessary
pulmonary
de Souza
JA sixth
et al. PBMV
in comparison
withto
OMV
commissurotomy
forthromboembolic
MS during pregnancy.risk
J Am
Amiodarone
Coll Cardiol
2001
MVP/MR in pregnancy
Effect of pregnancy
• MVP is well tolerated during pregnancy even when there is
MR
–
–
–
–
Hypervolemia  Increase in cardiac volume  Reduce valvular regurgitation
Decrease in SVR  Decrease in the regurgitant volume
Tachycardia increases forward stroke volume
Improve function of the prolapsed valve and obscure the physical findings of
MVP
• MVP with mild or moderate MR (During pregnancy and delivery)
– Remain asymptomatic
– Do not experience cardiac complications
• Pregnancy tends to increase the frequency of atrial and
ventricular premature beats - Beta blockers may be required
MVP/MR in pregnancy
• MVP with severe MR
– Dyspnea, in particular after the second trimester (corresponds with the
increase in CO)
– CHF is rare
– Occurrence of dyspnea/CHF does not carry a poor prognosis (Unlike in
stenotic lesions)
– Diuretics -- Chronic MR with pulmonary congestion
– Preeclampsia (Increase in SVR and the decline in renal function) 
Increases the risk of pulmonary congestion
• Severe MR can be poorly tolerated during pregnancy only in three
instances:
– Acute MR resulting from chordal rupture
– If AF occurs with a FVR
– Long-standing severe MR complicated by severe LV dysfunction (prognosis
being comparable to that of cardiomyopathy)
MVP/MR in pregnancy
• High risk candidates
–
–
–
–
NYHA class III to IV
LVEF < 40%
Severe PAH (PAP >75% of systemic pressure)
Should undergo mitral valve surgery/repair prior to pregnancy
• Chronic MR with LAE  AF and atrial thrombi  Need for
anticoagulation ; Attendant risks
• Vaginal delivery can be performed in most women
• Valve repair is the preferred procedure
Other valvular lesions
Aortic stenosis
• BAV -- In developed countries
• RHD
Aortic regurgitation
• Well tolerated during pregnancy
• Normal fall in SVR improves the CO unless the regurgitation is severe
Tricuspid regurgitation
• Isolated acquired TR (endocarditis or carcinoid syndrome) -- well tolerated
during pregnancy
• The risk of diuretic-induced hypoperfusion may be increased
Infective
endocarditis
Infective
endocarditis
prophylaxis
–
Rareorand
life-threatening
of pregnancy
Vaginal
cesarean
delivery infection
In
patients
withpotentially
established
that couldcomplication
cause bacteremia
(chorioamnionitis
or pyelonephritis)
– Rates have not
been well defined
Not•anThe
indication
forinfection
routineshould
antibiotic
prophylaxis
underlying
be treated
in the usual fashion
– In• aTreatment
2003 review,
68 cases
were identified
should include
an iv regimen
effective for IE prophylaxis
Rate•of18
bacteremia
with(27%)
these occurred
procedurespostpartum
is low
of the cases
Reasonable to consider IE prophylaxis before vaginal delivery at the time of
• Underlying heart disease – 31%
Prophylaxis
is not indicated
vaginal
delivery
or cesarean
membrane rupture
in select for
patients
with
the highest
risk ofsection
adverse outcomes
• ACC/AHA
Recent
dental
work - 7%heart disease guidelines)
(2007
AHA
guidelines)
(2008
adult congenital
drug
in 4%
•• IV
Proof
of use
efficacy
of prophylaxis in this setting is not available
Antibiotic prophylaxis is not recommended for genitourinary procedures
• Maternal mortality rate – 22%
(2008 AHA/ACC guidelines)
If antibiotic
given
to prevent enterococcal
• Fetalprophylaxis
mortality is
rate
- 15%
endocarditis, amoxicillin, ampicillin and vancomycin are appropriate agents
IE of
prophylaxis
is notfrom
recommended
for vaginal
cesarean
delivery
in the
(Most
the data came
individual case
reportsorand
are subject
to publication
absence of infection (ACOG, Committee on Obstetic Practice)
bias)
Administered at the time of delivery
Campuzano K et al. Bacterial endocarditis complicating pregnancy: case report and
systematic review of the literature. Arch Gynecol Obstet 2003
Acute coronary syndromes in pregnancy
• Some studies have suggested an increased risk during pregnancy and in
the early postpartum period
IHD -- Most common cardiac cause of maternal death -- Study from UK
Is pregnancyJW,itself
a risk
factor
MI? in high risk cardiac conditions. Heart 2009
Roos-Hesselink
Duvekot
JJ,large
Thorne
SA.for
Pregnancy
Epidemiology
— Two
epidemiologic
studies:
First-ever MI not related to pregnancy in women of child-bearing age -• 5.0
California
(1991 – 2000) --- Incidence of AMI: 2.8 per 100,000 deliveries
per 100,000
Ladner
HE et al.
Acute myocardial
infarction
in pregnancy
the puerperium:
a population-based
Most
cases
occur
in the third
trimester
andand
six-week
postpartum
periodstudy.
(3.6
million
woman-years
of
observation)
Obstet Gynecol 2005
Roth
A et al. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996
Petitti DB et al. Incidence of stroke and myocardial infarction in women of reproductive age. Stroke 1997
• TheUSinfarction
(2000-2002) Nationwide Inpatient Sample of pregnancy discharges in
commonly involves the anterior wall
about
hospitals
--- Incidence
of 6.2 in 100,000
pregnancies
Härtel
D et1000
al. [Myocardial
infarction
and thromboembolism
during pregnancy].
Herz 2003
James AH et al. Acute myocardial infarction in pregnancy: a United States population-based study.
Circulation 2006
• The risk of MI was increased 3-4 times compared to nonpregnant women
ACS in pregnancy
Risk factors — Four major risk factors for acute MI
• Older maternal age (age >35 years)
• Hypertension
• Diabetes mellitus
• Obesity
US survey -- Multivariable regression model
RISK FACTOR
ODDS RATIO
HYPERTENSION
21.7
DIABETES MELLITUS
3.6
AGE
30 - 34
6.7
≥ 35
16
THROMBOPHILIA
25.6
SMOKING
8.4
PREGNANCY COMPLICATIONS – Blood transfusions, post partum infections
ACS in pregnancy
Coronary artery morphology
Coronary dissection
Diagnosis and management
Evaluation of coronary morphology in 96 cases (1995-2005) by
Hormonal
and hemodynamic
changes
 Structural changes in the intima and
Same principles
as autopsy
in the general
population
arteriography
or
media of the arterial wall
Coronary
artery
Troponins
arepathology
preferred to CK-MB and Frequency
troponin I may be the marker of
Dissection
can
occurwomen
inwith
the or
absence
factors
Coronary
atherosclerosis
withoutof risk
40 %
choice in
pregnant
thrombus
Hypertension
 Independently
the arterial
-- more in
frequent
US Survey
(2000-2002):
Cardiacdamage
catheterization
waswall
performed
45% and
Thrombus
in normal
coronaries
8%
dissections
(HRinfor
AMI 21)
PCI or CABG
37%
Dissection
27 %
Spasm
Spontaneous coronary artery dissection 2--%search for undiagnosed CTDs (such
as
EDS)
Emboli
2%
Normal
13 J%Heart Lung Transplant 1994
Mather PJ coronaries
et al. Postpartum multivessel coronary dissection.
Roth A et al. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol
2008
ACS in pregnancy
Unique considerations
Labor and delivery
ESC
guidelines
Induction
of labor
scheduled
cesarean
should
be delayed
• The
The
fetus
should
beorclosely
monitored
withdelivery
a plan for
delivery
if there is sudden
Anticoagulation
maternal
ornot
fetal
deterioration
(for atdoes
least
2-3cross
weeks)
Heparin
the placenta -- Does not affect the fetus directly
Outcome
–
In
the
event
of
maternal
cardiac
arrest,
the best(eg,
prognosis
for previa,
the fetus
occurs when
delivery
(No
prospectivel
clinical
trials
available)
complications
in
complicated
pregnancy
placenta
abruptio
placenta)
–
• Bleeding
ECG
and
troponin
level(s)
should
be
performed
in
pregnant
women
is within 4-5 minutes
Discontinue
if
bleeding
occurs
and during
labourefforts
– chest
Delivery
may
also aid
maternal
resuscitative
with
pain
• MIthe
in cardiac
late third
trimester
 Highest risk for maternal death
Minimize
workload
during delivery
PCI• Low
- Increased
demandsappears
duringtolabor
+ Incomplete
dose
aspirin (75cardiac
to 162 mg/day)
be safe
in pregnancy
Epidural
anesthesia
• BMS
Coronary
preferred angioplasty is the preferred reperfusion therapy for patients
Supplemental
oxygen
myocardial
SafetySTEMI
of DES
is unknownhealing  Cardiac decompensation
with
•
Clopidogrel
:
Left lateral position
– Safety in of
human
has not been established (Animal studies – no teratogenic effects)
HTNpregnancy
and tachycardia
NitratesTreatment
In-hospital
maternal
mortality
was
7.3%
(Canada)
–NSTEACS
Clopidogrel vaginal
+ Aspirin
: Might increase
bleedingbirth
at the(in
time
of delivery
••Maternal
Instrumental
delivery
or
cesarean
unstable
cases) and 5.1% (US)
hypotension should
be avoided
Without risk criteria -- conservative strategy
• Fibrinolytic
therapy
– Relative
contraindication
With risk criteria
-- invasive
strategy
Beta blockers
Prior MI
/PCI/CABG
– No controlled studies examining the efficacy and safety
Generally
safe
Little
– Noinformation
teratogenicityavailable
has not been reported
Avoid
atenolol
evaluation
of their
status,
particularly
LV function,
ongoing
– Risk ofon
maternal
hemorrhage
: cardiac
8%
ESCThorough
Guidelines
the management
of cardiovascular
diseases
during pregnancy:
the Task Force
on the
Labetalol
may
be
the
preferred
beta
blocker
– The risk
ofischemia
puerperaland
hemorrhage
is confined
toofwomen
treatedSociety
withinofeight
hours (ESC).
of delivery
Management
of Cardiovascular
Diseases
during
Pregnancy
the
European
Cardiology
myocardial
underlying
coronary
anatomy
(Stroke
andof
massive
pulmonary embolism
have been treated safely during this period)
EurCessation
Heart
J 2011
ACE
inhibitors
and
statins
ACE inhibitors, ARBs and statins --- Contraindicated
Cardiomyopathy in pregnancy
• Ventricular dysfunction in childbearing women
– Prior viral infection
– HIV infection
– Peripartum cardiomyopathy
– Drug-induced cardiomyopathy (eg, cocaine, doxorubicin)
• Women with LVEF < 40%
• HF
• Arrhythmias
• Stroke were more common
Siu SC et al. Risk and predictors for pregnancy-related complications in women with heart
disease. Circulation 1997
Cardiomyopathy in pregnancy
Impact of etiology of the cardiomyopathy on outcomes
• Study of 26 women from Brazil
– Cardiac complications
Idiopathic group >> PPCM with persistent LV dysfunction
Avila WS et al. Pregnancy and peripartum cardiomyopathy. A comparative and prospective
study. Arq Bras Cardiol 2002
• Study of 31 women from the US
– Adverse maternal outcomes
• Peripartum group >> Idiopathic group
Bernstein PS et al. Cardiomyopathy in pregnancy: a retrospective study. Am J Perinatol 2001
• Study of 99 women with peripartum cardiomyopathy from Haiti
– 15 had subsequent pregnancies
– 50% of these women experienced worsening HF and long-term systolic
dysfunction
Fett JD et al. Brief communication: Outcomes of subsequent pregnancy after peripartum
cardiomyopathy: a case series from Haiti. Ann Intern Med 2006
Cardiomyopathy in pregnancy
A study from Toronto evaluated rates of adverse maternal fetal and neonatal
events in 36 pregnancies in women with DCM
• 14/36 (39%) pregnancies were complicated by at least one maternal
cardiac
Patientsevent
with known or suspected LV dysfunction should have an
echocardiogram
before
conception,
soon as
possible
• All
maternal cardiac
events
occurredor
in as
women
with
either after
of
pregnancy
is confirmed,
to dysfunction
determine baseline
ventricular function
– Moderate
or severe LV
(LVEF <45%)
– NYHA III or IV
Pregnancy
shouldevent
be discouraged if EF <45%
– Prior cardiac
Any one of these three risk factors  64% risk of an adverse cardiac event
• The 16 month event-free survival
– 18 pregnant women with LVEF <45% – 28%
– 18 age and LVEF-matched nonpregnant women with DCM – 83%
• Adverse fetal and/or neonatal event - 20% pregnancies
Grewal J et al. Pregnancy outcomes in women with dilated cardiomyopathy. J Am
Coll Cardiol 2009
Peripartum
cardiomyopathy
Peripartum cardiomyopathy
Pregnancy-associated cardiomyopathy
Definition
• Epidemiology
Development
of HF in the last month of pregnancy or ≤5 months of
Time
of onset
delivery of cardiomyopathy earlier in pregnancy
Development
Wide geographical variation
• Absence
another
identifiable
for thein HF
1:2289 of
to 1:4000
live
births in thecause
US, 1:1000
SA, 1:300 in Haiti and
Characteristics of early-onset disease
1:100 inofNigeria
• Absence
recognizable
heart
disease prior
to the
last month of
Review
of 123 women
with a H/o
cardiomyopathy
during
pregnancy
pregnancy
100
- PPCM
Etiology
- Earlierdysfunction
presentation(LVEF
(mean
of 32orweeks)
• 23
LV systolic
< 45%
a reduced fractional shortening)
Still remains unknown and may be multifactorial
No differences
between
thetotwo
groups
last criterion
wasdisorder
added
prevent
the
inclusion of patients with disorders
NoThe
distinct
hormonal
has
been
identified
Age, race, associated conditions
that mimic systolic HF
LVEF (29 vsHTN,
27%),
the rate
and time
of recovery
– Accelerated
diastolic
dysfunction,
systemic
infection, pulmonary embolism, or
Inflammatory
cytokines
Maternal
outcomes
complications of late pregnancy itself (eg, preeclampsia or amniotic fluid embolus).
Elevated levels of TNF-alpha and IL-6
Fas/Apo-1
and CRP
more of
severe
disease
Early
presentation
mayare
beassociated
part of thewith
spectrum
PPCM
Pearson GD et al. Peripartum cardiomyopathy: NHLBI and Office of Rare Diseases (National Institutes of
Elkayam
U et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a
Health) workshop recommendations and review. JAMA 2000
comparison
early andcardiomyopathy:
late presentation.
Circulation
2005
Sliwa
K etbetween
Peripartum
inflammatory
as predictors
of
Hibbard
JUal.
et al.
A modified definition
for peripartum
cardiomyopathy markers
and prognosis
based on
echocardiography.
Obstet Gynecol 1999
outcome
in 100 prospectively
studied patients. Eur Heart J 2006
Peripartum
cardiomyopathy
- Etiology
Peripartum
cardiomyopathy
Myocarditis
Abnormal
immune
response
A retrospective
review
of 34 EMB specimens from PPCM patients
Clinical
presentation
Risk factors
A possible
cause
of PPCM? (9 %)
Incidence
of myocarditis
Role
of prolactinresponse to a fetal antigen
Maternal
immunologic
Sanderson
etcomplaint:
al. Peripartum
heart disease: An endomyocardial
Most
Dyspnea
Age >common
30 years
Comparable
to
that
inJ idiopathic
DCM
biopsy
study.
Brfound
Heart
1986 circulation
Fetal
cells may
escape
into
the
maternal
 Lodge in the cardiac tissue
Multiparity
Altered prolactin processing
– EMB
in 5/11
(45%)
pts with response
PPCM - Myocarditis
 Trigger
afrequent
pathologic
autoimmune
Other
symptoms:
African
descent
Rizeq –
MN6etmonths
al. Incidence
of
myocarditis
inmyocarditis
peripartum cardiomyopathy.
Am JHF
Cardiol 1994
f/u
:
those
with
had
persistent
Cough,
orthopnea,
PND
and
hemoptysis
with
multipleagainst
fetuses
High Pregnancy
titers
of with
autoantibodies
cardiac
tissue proteins
Mice
a knockout
in
the STAT3
develop
PPCM (including myosin)
–
No
or
sparse
evidence
of
myocarditis
had
improvement
fatigue,
chest2002)
discomfort
or abdominal
pain in HF
(AnsariH/o
AA Nonspecific
et
al. Clin Rev Allergy
Immunol
preeclampsia,
eclampsia
or
postpartum
HTN
symptoms
and/or LV size and function
Reasons
forcocaine
discrepancy
Maternal
abuse
Reduction
in levels
STAT3
serum
Increased
cleavage of prolactin
into
an
No difference
in the
of
immunoglobulins,
between
subjects
and
Systemic
Small
sample
and
pulmonary
size
emboli
are
more
common
Long-term
(>4 weeks)
tocolytic therapy
antiangiogenic
andoral
proapoptotic
isoformwith beta agonists such
controls
• Two
other
series:
Time
of biopsy
PPCM >> Other cardiomyopathies
Cénac as
A etterbutaline
al. Absence of humoral autoimmunity in peripartum cardiomyopathy. A comparative study
–
Myocarditis
in 28%
and
77%
of patients with
PPCM
variability
isdeficiency
exacerbated
among
patient
by
the
populations
hypercoagulable
state
induced by
in Niger.
IntRisk
J Cardiol
1990
Selenium
: Conflicting
data
–
Myocarditis
in only
9% in idiopathic
cardiomyopathy group
Limitations
pregnancy
of EMB
to diagnose
myocarditis
O'Connell
JB et al.error
Peripartum cardiomyopathy: clinical, hemodynamic, histologic
Familial
disease
Sampling
and prognostic characteristics. J Am Coll Cardiol 1986
Variability in histologic criteria
Evidence of familial clustering (Morales A et al Circulation 2010)
Interaction
between pregnancy
related
factors
(eg, late
pregnancy
oxidative
• Viral genomes
were noted
in 31%
of PPCM
with
myocarditis
stress) and a susceptible genetic background
Peripartum
cardiomyopathy
– Differential
diagnosis
Peripartum
cardiomyopathy
- Diagnosis
BNP
Cardiac
PPCM
ptscatheterization
typically
have elevated BNP or NT-proBNP levels
Electrocardiogram
Differential
diagnosis
Right heart catheterization is rarely needed
• Sinus tachycardia (rarely AF), nonspecific ST and T wave abnormalities and
-Assessment
of cardiac
pressures
can be made
with Doppler
Chestvoltage
x-ray
abnormalities
(low voltage
or criteria
for LVH)
PPCM -- Diagnosis
of exclusion
Cardiomegaly
pulmonarypresent
venous congestion
and/or
interstitialleads
edema (occasionally
• echocardiography
Q waveswith
are e/o
occasionally
in the anterior
precordial
DDs:
pleural
be QRS
helpful
in critically
ill patients
• May
PReffusions)
and
intervals
may
also
be prolonged
Pre-existing
idiopathic
DCM
unmasked
by pregnancy
Not necessary to diagnose PPCM (exposes the patient
to ionizing radiation)
Pre-existing familial DCM unmasked by pregnancy
Endomyocardial
biopsy
Echocardiography
HIV/AIDS
cardiomyopathy
Cardiac
magnetic
resonance
imaging
Role
remains
unclear
•
Global
reduction
in
contractility
and
LV enlargement
without hypertrophy
Limited
reports; role
is still being
Pre-existing
valvular
heartevaluated
disease
unmasked
by pregnancy
proportion
of pts have
evidence<30%
of myocarditis
• Variable
LVEF
<45%
and/or
fractional
shortening
PLUS
Case
reports
and small
series
: Variable
presence of
LGE in
patients with PPCM
Hypertensive
heart
disease
2
No
pathognomonic
findings
in
PPCM
• presence
LVESD > and
2.7 persistence
cm/m
The
of LGE
may be associated with poor recovery of cardiac
Pre-existing
unrecognized
CHD
Inherent
risk in
performing
a biopsyfor
ofidiopathic
a dilatedDCM;
RV Not precisely defined for PPCM)
(Based
upon a 1992
NHLBI
workshop definition
function
Pregnancy-associated MI
Improving LGE may be associated with cardiac recovery
Pulmonary
embolus
Other
possible
echocardiographic
Viral
and
studies
Lack
ofbacterial
LGE may
be associated withfindings
presence: or absence of cardiac recovery
• Role
Regional
heterogeneities of systolic wall thickening
is unclear
As mentioned
in 2010 European Society of Cardiology (ESC) working group
• Prognostic
LA
enlargement
value of CMR in PPCM has not been established
Resultsonnonspecific
statement
peripartum
cardiomyopathy
Marmursztejn
et al. Delayed-enhanced
cardiac magnetic
resonance imaging features in peripartum
• Limited
MR, TRJ prognostic
value in patients
with myocarditis
cardiomyopathy. Int J Cardiol 2009
• Small pericardial effusion
Peripartum cardiomyopathy – Evaluation
Measurement of BNP
• Serial BNP levels may predict HF in at risk patients during pregnancy
• BNP levels in healthy women increase two-fold during pregnancy
(lower than that observed in HF)
• A prospective study from Toronto evaluated BNP levels
– 66 women with pregnancy and HD and 12 healthy women
• Those with heart disease had significantly higher BNP levels (median 79 vs
35 pg/ml)
• A BNP >100 pg/ml was measured in all 8 women with an adverse maternal
cardiac event during pregnancy
• In seven of these women the BNP >100 pg/ml was obtained prior to or at
the time of decompensation
Tanous D et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll
Cardiol 2010
Peripartum cardiomyopathy - Treatment
Treatment
Immunosuppressive
agents
• Largely similar to that for other types of HF
Efficacy is unclear:
Occasionally
initiated
in patients with
and biopsy• Additional
therapeutic
issues include
anticoagulation
and PPCM
arrhythmia
proven myocarditis
management
Empiric immunosuppression
is notglobulin
recommended
• Immunosuppression
and immune
therapy
Significant
side effects
– Evaluated; Role is not established
Arrhythmia management
Intravenous immune globulin
• AF occurs occasionally in patients with PPCM
• Sustained
VT has rarely
been reported with PPCM
No clear evidence
of benefit
Bozkurt B et al. Intravenous immune globulin in the therapy of peripartum cardiomyopathy. J Am
Anticoagulation
Coll Cardiol 1999
• High
risk for thrombus
thromboembolism
Retrospective
study of formation
6 women and
treated
with IVIG and 11 controls treated
• Hypercoagulable state of pregnancy
conventionally
After•6m
follow-up
Stasis
of blood due to severe LV dysfunction
Absolute
increaseshould
in LVEFbe: IVIG
group >particularly
controls (26
Vs 13%)
• Use of
anticoagulants
considered
when
there is
severe LV dysfunction (LVEF <30 %)
Peripartum cardiomyopathy – Treatment
Bromocriptine
Heart transplantation
Bromocriptine
Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe
peripartum
cardiomyopathy:
a proof-of-concept
pilottherapy
study. Circulation
2010
The
only acceptable
treatment
if conventional
is not successful
Beneficial response: Several case reports and one small randomized study
Studies in
90s : (newly
Transplantation
was performed
in upS.Africa
to one-third of
24early
women
diagnosed
PPCM) from
Available data are insufficient to recommend routine use of bromocriptine
cases
treatment for PPCM
Transplantation was required
in only 4 - 7 % (2005) 10
10
The drug(Bromocriptine+standard
stops the production of
breast milk making
breastfeeding impossible
care)
(standard care alone)
Success rates
: Good
(2.5 mg BD 2wks f/b 2.5 mg OD 6wks)
Insufficient evidence to establish the safety and efficacy
At 6 months
Long-term survival and frequency of transplant-associated complications
• LVEF
27needed
to 58%
27 to 36%
Larger trials
(compared
to are
matched
idiopathic DCM) – Variable
•
•
Mortality
1
4
Composite of pregnancy has been cautiously undertaken after successful heart
Subsequent
– Death
1
8
transplantation
for PPCM
–
–
NYHA III or IV
LVEF <35%
Peripartum cardiomyopathy - management
Delivery
• Timing and mode of delivery: Limited data
– multidisciplinary approaches are often useful
• PPCM with advanced HF
– Prompt delivery for maternal cardiovascular indications
• Early delivery is not required if the maternal and fetal conditions are
stable (The 2010 ESC working group statement)
• Cesarean is generally reserved for obstetrical indications
– Critically ill patients in need of inotropic therapy or mechanical support
Breastfeeding
• No clear data showing adverse cardiac effects from breast feeding
• Breast feeding be avoided because of the potential effects of prolactin
subfragments (2010 ESC working group)
Peripartum cardiomyopathy - prognosis
Persistent
LV other
dysfunction
Findings
in
reports
Recovered
LV
function
Subtle
residual
dysfunction
matters?
Outcomes
in cardiomyopathy
is related to etiology
The
potential
risks
of
subsequent
pregnancy
is
substantial
Prognosis
Predictors
of persistent
dysfunction
Mortality
rate
: 6heart
%
at transplantation
5LV
years
(Felker GMat
N follow-up:
Engl J Med 2000)
Following
Obstetric
and
neonatal
outcome
Report
of
seven
women
with
h/o
PPCM who regained normal resting LV size
During
subsequent
pregnancies
Maternal
outcome
LVEF
≤30
%
Risk
of subsequent
are
more
limited
pregnancy
Mortality
: 19%
and
performance
23%
(13/57)
(<20
Witlin
AGPPCM
Am J Obstet Gynecol 1997; Sliwa K J Am Coll Cardiol
• Data
The
largest
series
of 123 cases
of
Fractional
shortening
%
•
Only
anecdotal
reports
of
successful
pregnancy
in patients
post
In
Recovered
the
above
LV
report
function
of
123
<<
patients
Persistent
LV32%)
dysfunction
Further
reduction
in the mean
LVEF
(36
to
reserve
(assessed
by
dobutamine
challenge)
was significantly
Cardiac
transplantation
rate
:
4%
2000) – Contractile
LVEDD
≥6
cm
transplantation
for PPCM
HFBut
symptoms
: compared
7delivery
patients
Cesarean
elevated
compared
:%
40%
the
(largely
general
for population
obstetric
indications)
impaired
toto(mean
matched
controls
– Elevated
Mortalitycardiac
rate : 10
follow-up
of
2
yrs)
troponin
Toccurred in 25%
Premature
delivery
:(<37
6 years
Preterm
birth
weeks)
Transplant
rate
:
7%
at
8.6
(Felker
GM et al. Am Heart J 2000)
– ICDMB
– 3%
Lampert
et
al.
Contractile
reserve
inrelated
patientstowith
peripartum
cardiomyopathy
and
Therapeutic
abortion
:
4
In women
addition
to thewas
problems
pregnancy
after
heart
Series•– of
Mean
28
birth
weight
(recovered
3.1
to
an
kg
(range
LVEF
≥50%)
1.4
to
during
5.0
kg),
subsequent
pregnancy
PPI U–left
2%ventricular
recovered
function.
Am J Obstet Gynecol 1997
Elkayam
et
Engl5.9
Jsensitivity
Med
2001
Baseline
LVEF
has
limited
transplantation
Death
due
to PPCM
is usually
caused
byfor prediction of improvement in individual
No
Small
deaths
foral.N
date:
%
patients
Progressive
pump
failure
Reduction
Two
stillbirths;
in did
therisk
mean
one
neonatal
LVEF
(56death
to transplantation
49%)
and
four had congenital
anomalies
May
be
at
for
graft
failure
due
to
recurrent
disease
• JD
Among
who
not
die
or
require
Fett
et
al.
Brief
communication:
Outcomes
of
subsequent
pregnancy
after
•Severely
Infell
summary,
some
women
who
recover
LV function
anperipartum
initial
depressed
baseline
LVEF
–women
Not
an indication
for after
premature
useepisode
of
Sudden
death
LVEF
by
more
than
20%
in
six
(21%)
These
women
should
be
strongly
advised
to
avoid
future
pregnancy
cardiomyopathy:
a case
series
fromand
Haiti.
Annat
Intern
Med 2006
–PPCM
Mean
LVEF
increased
from
28%
diagnosis
toduring
46 % a subsequent
Thromboembolic
events
of
will
have
significant
decline
in
LV
function
aggressive
therapies
(VAD
cardiac
transplantation)
Subsequent
HF
symptoms
pregnancy
:
6
patients
Worsening
HF : 53
– Recovery
to %
an LVEF > 50% occurred in 54% of patients
pregnancy
The
risks
-Incompletely
defined
1 death
from worsening
HFwas
10 months
postpartum
–
Degree
of
recovery
greatest
in those
with a baseline LVEF >30%
Adverse
prognostic
factors
PPCM
is
associated
with
significant
extracardiac
morbidity
TheSeveral
persistent
small
risk
case
may
series
be
related
suggest
to
high
subtle
complication
residual
dysfunction
rateby 6 months
not detected
women
didofnot
develop
worsening
HF about
•Seven
These
women
should
be
counseled
the
potential
risks
prior
to on
Worse
NYHA
functional
class
–
Almost
all
the
recovery
of
LV
function
occurred
after
Study
ofcontinued
182
women
(All
had
improvement
andhave
normalization
of LVof
function
(LVEF ≥50 %) within 30
resting
evaluations
(Especially
who do not
full recovery
LV function)
pregnancy
diagnosis
Black
women
One-third
of patients
with
transplantation-free survival had residual brain
months
of the
subsequent
pregnancy)
Multiparity
•damage
Carefully
monitored
for
signs
of ventricular
dysfunction
if they
choose
as
aMaternal
result
ofand
CVAfetal
or cardiomyopathy:
cardiopulmonary
arrest
Elkayam
UU
et
clinical
characteristics
and
comparison
Elkayam
etal.
al.Pregnancy-associated
outcomes
of subsequent
pregnancies
ina women
withto
between
early
and
late
presentation.
Circulation
2005those
Goland
S etsome
al. Clinical
profile
and
predictors
of
complications
in peripartum
cardiomyopathy.
J Card Fail
Although
women
tolerate
pregnancies,
with persistent
LV dysfunction
become
pregnant
again
peripartum
cardiomyopathy.
N further
Engl J Med
2001
2009
should be advised to avoid pregnancy due to the risk of HF progression and death
Risks of prosthetic valves in pregnancy
• Variety of complications
– Structural failure
of the
Bioprosthetic
valves
: valve, Infection, HF, Thromboembolism and
bleeding due to anticoagulation
Do not require anticoagulation, independent of position
• (unless
Overallthere
incidence
of complications in appropriately managed,
are other thromboembolic risk factors)
nonpregnant patients with prosthetic valves is 3̴ %/yr
Significantly higher incidence of valve failure than mechanical
• valves
Mechanical heart valves  Increased incidence of
thromboembolic events during pregnancy
Particular concern for young women
• Therapeutic anticoagulation throughout pregnancy is
essential
• Absence of adequate prospective controlled trials -- preferred
anticoagulant regimen is uncertain
Bioprosthetic valves in pregnancy
Structural
failure survival
of bioprosthetic
North RA et al. Long-term
and valve-relatedvalves
complications in young women with cardiac
Similar
findings
replacements. Circulation 1999
•valve
30
-35%
10 - 20%
of homograft
prostheses
Jamieson
WR etof
al.heterograft
Pregnancy and and
bioprostheses:
influence
on structural
valve
deterioration.
Ann10
Thorac
Surg
1995
fail within
-15
years
of implantation
Evaluation
of the
risk
of pregnancy
Natural
history study
of 232 young
women regurgitation
with prosthetic valves
– Leaflet
degeneration
 Severe
237
≤35 years
of groups
age with
55 towomen
60 % in each
of these
hadbioprostheses
at least one pregnancy
–
Progressive
valve
calcification
 Significant stenosis
52
of the
women hadand
94 72
pregnancies
73 had
a bioprosthesis
a homograft
yearspregnancy accelerate deterioration of bioprosthetic
•At 10
Does
Structural
valve deterioration
and valve
loss:
structural
valve deterioration
: 55
vsMore
46% common with bioprosthetic valves
valves?
valve-related mortality : 8 vs 7 %
The
10
ratestudies:
of did
valvenot
loss
(valve
replacement or
valve-related
death)
– year
Initial
Yes
Pregnancy
group
have
a significantly
higher
rate of events
bioprosthetic
: 82%
Vongpatanasin
W et al. Prosthetic heart valves. N Engl J Med 1996
Sbarouni E: et
homografts
28al.%Outcome of pregnancy in women with valve prostheses. Br Heart J 1994
Durability of pulmonary autografts in pregnant women
Limited
data
The risk
of valve
deterioration: mitral >> aortic or tricuspid site (Seven fold)
NoRecent
evidence
of valve:deterioration
in two reports of 55 pregnancies in 29
10 year
patient
survival:
–
studies
No
women
bioprosthetic
: 84%
Avila WS et al.
Influence of pregnancy after bioprosthetic valve replacement in young
homograft
: 96%five-year study. J Heart Valve Dis 2002
women: avalves
prospective
The rate of valve loss was not higher for those who had completed a pregnancy
Prosthetic valves – pregnacy care
Delivery
Prior
to conception
possible,
delivery should be planned
•Whenever
Preconception
counseling
Modality should be discussed with the obstetricians,
•hematologists
Informed discussion
about the maternal and fetal risks
and anesthetists
associated with available anticoagulation options
– Riskdelivery
of life threatening
thromboembolic
events and a thrombotic
Vaginal
is preferred
in most cases
stroke exists regardless of the anticoagulant regimen utilized
Cesarean delivery should be reserved
• Continue
oral anticoagulation
until pregnant
Specific obstetrical
indications
Significant
cardiovascular
disease
places
woman
(Risk
of warfarin
embryopathy
is lowthat
in the
firstthe
6 weeks
of at
gestation)
additional risk during labor
• Prompt pregnancy test if menses are delayed
Prosthetic valve thrombosis during pregnancy
• Valve thrombosis -- a life-threatening complication
• The procoagulant state of pregnancy increases the risk
• Depends upon the type and location of the prosthetic valve
– Mechanical valves >> Bioprosthetic valves or homografts
– Older mechanical valves >> Newer generation mechanical valves
– Mitral position
Other factors
– H/o prior thromboembolic event
– AF
– Multiple prosthetic valves
• Risk appears to be increased with UFH and LMWH (lesser
degree) compared to warfarin
Prosthetic valve thrombosis during pregnancy
• Experience is limited
• Controlled data do not exist
• Published reports are mostly from case series
• Heparin may be considered for small, nonobstructive thrombi
• For obstructive valve thrombosis, the treatment options are
surgical thrombectomy and thrombolysis
• No direct comparisons between surgery and thrombolysis
exist
Management of valve thrombosis during pregnancy
• Both surgery and thrombolysis carry substantial fetal and
maternal risks
• Series of 10 women treated for 12 episodes of valve thrombosis
– Surgery (4 cases)
– Thrombolysis (7 cases)
– Heparin (1 case)
Maternal
death
Fetal death
Bleeding
events
Surgery
1
1
(additional)
0
Thrombolysis
2
0
1
Sahnoun-Trabelsi I et al. [Prosthetic valve thrombosis in pregnancy. A single-center
study of 12 cases]. Arch Mal Coeur Vaiss 2004
Cardiac surgery and thrombolysis during
pregnancy
•
Weiss BM et al. Outcome of cardiovascular surgery and pregnancy: a systematic
review of the period 1984-1996. Am J Obstet Gynecol 1998
–
–
–
–
•
Turrentine MA et al. Use of thrombolytics for the treatment of thromboembolic
disease during pregnancy. Obstet Gynecol Surv 1995
–
–
–
–
–
•
Review of cardiac surgery during pregnancy
70 patients
Perioperative maternal mortality – 6%
Fetal mortality - 30%
Review of thrombolysis during pregnancy
172 patients
Maternal mortality – 1.2%
Hemorrhagic complications – 8%
Fetal mortality - 5.8%
Both of these series included patients treated for a variety of conditions at a
number of centers over an extended period of time (12 years for the surgical series
and 34 years for thrombolysis)
Pregnancy after cardiac transplantation
• Preconception
Escalating number
of female heart transplant recipients of
care
The AST consensus conference recommedations for timing of pregnancy:
childbearing age
Preconception
counseling
Overall
increase
heart
transplantation
in adults
• –No
rejection
thein
past
year
Reason
forinthe
mother's
cardiac transplant
• –Adequate
and stable
graft
functionpopulation
Aging
heart
transplant
Risk
ofpediatric
recurrence
in
mother
(PPCM) or offspring (CHD)
• No acute infections that might impact the fetus
• Maintenance immunosuppression at stable dosing
of
pregnancy
• Timing
- First
reportcare
of team
pregnancy
after
heartthroughout
transplantation
• 1988
A multidisciplinary
should be
available
Avoidand
during
the firstperiod
year post transplantation
pregnancy
the postpartum
Risk of rejection is greatest
• Pregnancy
- generally been
discouraged
by most heart
Immunosuppressive
therapy
- Most aggressive
transplantation centers
– Contraception
Potential risks toduring
the prospective
mother
this period
is important (fertility is
– not
Possible
teratogenic
effects from immunosuppressive drugs
affected
by medications)
Maternal physiology and the heart transplant
recipient
Physiologic changes
Associated concern in the transplant recipient
Increased blood volume
Hemodilution may affect serum drug levels
Increased heart rate
Exacerbation is possible due to cyclosporine
Increased cardiac
output
In a denervated heart, the CO increases primarily from
volume changes and circulating catecholamines
Increased stroke volume Rejection may create systolic/diastolic dysfunction
RV enlargement / TR
Potential to worsen TR if serial EMB required
Sodium retention
↓ glucose tolerance
Exacerbation of reflux
Risk increased / symptoms exacerbated with prednisone
Decreased T-helper cells Risk increased secondary to immunosuppressive drugs
↑ risk of UTI
↑ risk of cholelithiasis
Risk increased with azathioprine
Post cardiac transplantation
complications during pregnancy
Maternal
risks in pregnancy
Infection
risks -- 2004 NTPR report
%
of pregnancies
•11Fetal
Rejection
CMV – Fresh infection and reactivation
• Infection
Preterm delivery (32 - 36%)
Hypertension and preeclampsia
• Hypertension
Major factors responsible for the increased prevalence of preterm delivery and IUGR in
LBW (20
- 80%)
recipients
•transplant
Preeclampsia
No increased incidence of spontaneous abortions
Rejection
HTN/preeclampsia – 72%
Preterm delivery
– 40% and chronic rejection is not increased
• The incidence
of acute
SGA – 20%
JR et al. Pregnancy
in heart
transplant recipients:
and outcome.
Obstet Gynecol 1993
•ScottRejection
was
reported
in 21%management
(33 cardiac
transplant
recipients with 54 pregnancies) -- 2004 National
HTN during pregnancy -- 46%
Transplantation
Registry
Preeclampsia --Pregnancy
10% ---2004 NTPR
report(NTPR) report
• Hyperemesis gravidarum  Decreased absorption and
inadequate immunosuppression
Post cardiac transplantation – Peripartum care
Intrapartum risks and management
Mode of delivery
• Vaginal delivery induced at or near term
• Cesarean delivery should be reserved for the usual obstetrical
indications
• Cesarean: Transplant recipients Vs controls -- 33 Vs 23 %
Wagoner LE et al. Immunosuppressive therapy, management, and outcome of heart
transplant recipients during pregnancy. J Heart Lung Transplant 1993
Antibiotic prophylaxis
• Cardiac "valvulopathy" in a transplanted heart
– Valvulopathy : Documentation of substantial leaflet pathology and
regurgitation
Post cardiac transplantation – Peripartum care
Anesthesia
• im or iv opiates are used to relieve pain and apprehension
• Lumbar epidural anesthesia is recommended (lowers pain-induced
elevations of sympathetic activity)
• Epidural anesthesia has been used successfully in cardiac transplant
recipients for both vaginal and cesarean delivery
Stress dose steroids
Maternal monitoring
• Continuous ECG monitoring during delivery to evaluate for ischemia
and/or arrhythmias
• Coronary vasculopathy is more common in these organs
• Denervated state of the transplanted heart: Clinical signs and
symptoms of ischemia are greatly attenuated
Post cardiac transplantation – Peripartum care
Postpartum risks and management
• Increased risk of maternal compromise: CO increases to 80% above
prelabor values due to autotransfusion
• Drug toxicity is more likely postpartum
• Cardiac biopsy -- if acute rejection is suspected
• Breastfeeding is generally discouraged
– Passage of immunosuppressive drugs (cyclosporine) to the baby
– Continuing immunosuppressive therapy is vital for the mother and
should be carefully maintained
– The AST consensus opinion: Breast feeding need not be viewed as
absolutely contraindicated
Summary
• Stenotic lesions are less tolerable during pregnancy
• Severe the stenosis worse the outcomes
• Cardiac indications for cesarean delivery
–
–
–
–
–
•
•
•
•
Refractory heart failure
Aortopathy, aneurysm, dissection
Warfarin within 2 weeks
Severe PAH
Lack of facilities for cardiac monitoring and labor management
Routine IE prophylaxis not required
PPCM – Better avoid pregnancy irrespective of cardiac status
ACS in pregnancy – Drug modification
Prosthetic heart valves : Warfarin is the best
Group
Cardiac disease
Risk of cardiac
complications
Mortality
I
Bioprosthetic valve
Isolated MVP without significant
regurgitation
Valvular regurgitation with normal
ventricular systolic function
Low risk
<1%
II
MS
Mechanical prosthetic heart valve
AS
Previous MI
Moderate to severe LV dysfunction
H/O PPCM without residual dysfunction
Intermediate
risk
5-15%
III
Severe PAH
NYHA class III and IV symptoms
Severe AS
H/O PPCM with residual dysfunction
High risk
25-50%
Questions
Pregnant woman with prosthetic valve developed acute limb ischemia.
Pregnant
Young lady
lady
with
with
severe
severe
AS,MS
planning
& valvepregnancy.
not suitable
Which
for BMV,
is inappropriate
presents
in 2nd
2
• 23/F,
newly
married,
asymptomatic,
TTEHF
– MVA 1.2 cm Which is
Pregnant
woman
with
valvular
HD and
Which
iswith
appropriate
trimester
persistent
class
III symptoms.
Nextsymptoms.
best step?
inappropriate
ECHO
D dimermedications
Optimise
Counselling
Exercise
testing
Urine eosinophils
Class
None
IIa
of the above
Digoxin
CT
angiogram
Valve
intervention is reasonable for pregnant patients with severe MS (MVA ≤1.5
Metoprolol
TEE
cm2,
Class
I stage D) and valve morphology not favorable for PMBV only if there are
Enalapril
refractory
Class
IIa NYHA class IV HF symptoms (LoE: C)
Furosemide
• Percutaneous
mitral balloon commissurotomy is recommended before
Exercise testing is reasonable in asymptomatic patients with severe AS (aortic
2
Class
I
pregnancy
for
asymptomatic
patients
with
severe
MS
(MVA
≤1.5
cm
Class
velocity
III: Harm
≥4 m/s or mean pressure gradient ≥40 mm Hg, stage C) before pregnancy
TEE
should
behave
performed
all
pregnant
patients
with
mechanical
stageoperation
favorable
valve
morphology
(LoE:
C) awith
Valve
(LoE:
C)C) who
should
not be in
performed
in pregnant
patients
valve stenosis
Class
III: Harm
valve
whoHF
have
prosthetic
inprosthetic
the absence
of severe
symptoms
(LoE:valve
C) obstruction or experience an
1. ACE inhibitors
and
embolic
event (LoE
: C)ARBs should not be given to pregnant patients with
• Counsel to avoid pregnancy until BMV is done
valve regurgitation (LoE: B)
Questions
• Pregnant woman with mitral bioprosthesis in 2nd trimester is on oral
penicillin, metoprolol, frusemide. What is missing?
Class I
• Low-dose aspirin (75 mg to 100 mg) once per day is recommended for
pregnant patients in the second and third trimesters with either a
mechanical prosthesis or bioprosthesis (LoE: C)
Questions
•
Pregnant woman with mechanical valve in 1st trimester is maintaining
therapeutic INR with warfarin 4mg. Not willing for heparin injections.
Class IIa
• Continuation of warfarin during the first trimester is reasonable for pregnant
patients with a mechanical prosthesis if the dose of warfarin to achieve a
therapeutic INR is 5 mg per day or less after full discussion with the patient
about risks and benefits (LoE: B)
Class IIb
• Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of
0.8 U/mL to 1.2 U/mL, 4 to 6 hours postdose) during the first trimester may
be reasonable for pregnant patients with a mechanical prosthesis if the dose
of warfarin is 5 mg per day or less to achieve a therapeutic INR (LoE: B)
Questions
• Pregnant woman with mechanical valve is admitted in a hospital with
limited facilities. Which is inappropriate
•
•
•
•
Warfarin
UFH
LMWH
None of the above
Class III: Harm
• LMWH should not be administered to pregnant patients with mechanical
prostheses unless anti- Xa levels are monitored 4 to 6 hours after
administration (LoE: B)