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Download Pregnancy in patient with Fallot`s Tetralogy
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Pregnancy in patient with Fallot’s Tetralogy WHAT IS THE RISK AND HOW TO MANAGE Background TOF is most common cyanotic CHD accounting for 5%-6% of all congenital heart malformations Intra-cardiac 1950s Surgical repair has been performed since results after repair TOF have remained excellent for decades with long term survival of 95% Background Pregnancy is generally well tolerated with no long term sequelae It is listed as WHO Class II for pregnancy Background Pregnancy is generally well tolerated with no long term sequelae It is listed as WHO Class II for pregnancy So What’s the concern? Pregnancy in patient with Fallot’s Tetralogy : What’s the Risk? As outcome data emerges, it becomes apparent that a substrate of patients develop long-term complications that have serious implications for women desiring to become pregnancy. Outcomes of Pregnancy with Tetralogy of Fallot •Study VELTMAN 2004 Pg WOMEN PREGNANCIES LIVE BIRTHS SAB 43 112 82 (73%) 30 (27%) KHAIRY 2005 15 15 15 (100%) 0 Pedersen 2008 25 54 41 (75% 8 (15%) Balchi 2011 74 157 123 (78%) 30 (19%) 157 238 261 68 (28%) Pregnancy in patient with Fallot’s Tetralogy (TOF) : What’s the risk? The physiological , hemodynamic (volume overload) hormonal consequences of pregnancy may contribute to physiologic remodeling of the subpulmonic RV leading to: Increased dilatation Additional pulmonary regurgitation, and RV volume load on a subpulmonary ventricle exposed to hemodynamic stress and surgical scars may predispose to atrial or ventricular arrhythmias Pregnancy in patient with Fallot’s Tetralogy (TOF) : What’s the risk? Cardiac events associated in TOF patients , particularly those with dilated RV at baseline and severe PR Heart Pulmonary Pulmonary Spontaneous abortions PROM Pre-eclampsia Fetal outcomes Premature deliveries (SVT,VT) Small for gestational age embolism Low birth weight CHD anomalies failure Arrhythmias Obstetrical events hypertension Pregnancy in patient with Fallot’s Tetralogy (TOF) : What’s the risk? Predictors Prior of adverse events PVR * Arrhythmias Obstetrical Off History event spring events of pre pregnancy arrhythmia Cardiovascular Off Use events spring event of cardiac drugs prior to pregnancy Balci 2011 Am Heart Jnl Pregnancy in patient with TOF How to Manage? Preconception Degree RV Evaluation of pulmonary regurgitation size and function History of arrhythmias Medication Family history history of CHD Pregnancy in patient with TOF : How to Manage? Preconception Diagnostic Evaluation Echocardiogram RV systolic and diastolic function Degree Exercise Stress of pulmonary regurgitation Stress Test induced arrhythmias Pregnancy in patient with Fallot’s Tetralogy (TOF) : How to Manage? Preconception Management In symptomatic patient with severe RV dilatation due to severe PR PVR with bioprosthetic valve or transcatheter valve implantation Ablation for clinically significant arrhythmias Pregnancy in patient with TOF Pregnancy Management TOF Class II with no residual effects may be treated similar to general population Initial evaluation – ACHD cardiologist Delivered Vaginal locally term delivery Pregnancy in patient TOF Pregnancy Management TOF Class III Initial up evaluation ACHD center with close follow- Echocardiogram each trimester Planned delivery ( IOL) at 39wks and delivery at ACHD center Pregnancy in patient with TOF Pregnancy Management TOF Class III Start of 3rd trimester develop delivery plan and distribute to team including L&D staff On admission BNP IOL protocol Telemonitoring if history of arrhythmias /failure SaO2 monitoring Pregnancy in patient with TOF Pregnancy Management TOF Class III Delivery Vaginal delivery C S reserved for OB indication; cardiac decompensation Shortened second stage Epidural Hemodynamic monitoring – heart failure Pregnancy in patient with TOF Pregnancy Management TOF Class III Post Partum I f clinically stable throughout deliver transfer to PP Telemonitoring If decompensated , transfer to ICU for monitoring and management Contraception SUMMARY For majority, pregnancy in TOF is well tolerated with good neonatal outcomes For a subset of patients, those with marked RV dysfunction and severe PR there is increased maternal and neonatal risk Careful and thorough preconception evaluation is required for all patients
