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PREGNANT RHEUMATIC:
Pre-natal and Post-natal
Care
Ma. Socorro C. Bernardino, M.D. FPOGS
“The management of cardiac
disease during pregnancy poses
a double challenge.....”
(
“...To ensure maternal survival but
at the same time promote fetal
well-being and to allow a
gestational period sufficient for
adequate fetal maturity.”
(
•
Management should be
MULTIDISCIPLINARY
– OB
– Cardiologist
– Anesthesiologist
– Accurate diagnosis
– Assessment of the severity
– Degree of impairment
– Evaluation of concomitant therapy
– Optimizing management
• Pregnancy
• Labor and Delivery
– Preconceptional counseling
– Hemodynamic changes during pregnancy
– Effects of Pregnancy on maternal cardiac
disease
– Effect of Maternal cardiac disease on
pregnancy
– General Measures for the care of pregnant
patients with heart disease
•HEMODYNAMIC CHANGES IN NORMAL
PREGNANCY
Non-pregnant
Pregnant
Cardiac output (L/min)
4.3+-0.9
6.2 +- 1.0
Heart rate (beats/min)
71 +- 10
83 +- 10
Systemic vascular
resistance (dyne.cm.sec) 1530+-520
1210 +-266
Pulmonary vascular
resistance
78 +- 22
119 +- 47
Colloid oncotic pressure 20.8 +-1.0
(mmHg)
18.0 +- 1.5
•HEMODYNAMIC CHANGES IN NORMAL
PREGNANCY
Non-pregnant
Mean arterial pressure
Pulmonary capillary
wedge
(mmHg)
6.3 +- 2.1
86.4 +- 7.5
90.3 +-5.8
pressure
7.5 +- 1.8
Central venous pressure 3.7 +-2.6
Left ventricular stroke
volume
41 +- 8
Clark et al, 1989
Pregnant
3.6 +-2.5
48 +- 6
•
EFFECT OF PREGNANCY ON MATERNAL
CARDIAC DISEASE
– Periods during pregnancy when the danger of cardiac
decompensation is great:
1. 12 – 16 weeks – start of hemodynamic
changes in pregnancy
2. 28 – 32 weeks – hemodynamic changes of
pregnancy peak and cardiac demands are at a
maximum
•
DURING LABOR
sympathetic response to pain + uterine contractions
1. 300-500 ml blood injected into general circulation/contraction
2. Increase in systemic vascular resistance
increase stroke volume by 50%
Stress in CVS
•
DURING LABOR
During the second stage of labor, maternal pushing
decreases the venous return to the heart
decrease in cardiac output
•
AFTER DELIVERY AND PLACENTAL
SEPARATION
Sudden transfusion of blood from the lower extremities and the uteroplacental vascular tree to the systemic circulation
Large and abrupt increase in blood volume
•
EARLY SIGNS OF CARDIAC COMPROMISE
– Starts at first trimester
– Peak at 20-24 weeks
• CO reaches maximum
– Beyond 24 weeks
• CO maintained at high levels
– Post-partum
• CO only begins to decline
“Intensive monitoring should be
continued for at least 72 hours after
delivery, preferably in a high care or
intensive care environment”
(Mulder BJM et al. Valvular heart disease in pregnancy. New England Journal of
Medicine 2003)
•
When an underlying valvular disease is
present , its not surprising that signs and
symptoms of cardiac failure do occur
“Following delivery the cardiovascular status of
patient will normalize at 6-8 weeks post
delivery”
(Van Oppen ACA et al. A longitudinal study of the maternal hemodynamics during
normal pregnancy. Obstetrics and Gynecology 1996; 88:40-6)
– EFFECTS OF MATERNAL CARDIAC DISEASE
IN PREGNANCY
– Pregnancy outcome is compromised by the
presence of cardiac disease.
•
•
Fetal Death – usually secondary to chronic
severe or acute maternal deterioration
Fetal morbidity – secondary to preterm
delivery and fetal growth
restriction
> relative inability to
maintain an adequate uteroplacental circulation
– EFFECTS OF MATERNAL CARDIAC DISEASE
IN PREGNANCY
•
•
Fetal morbidity – secondary to preterm
delivery and fetal growth
restriction
Frequency of effects is related to severity of
functional impairment of the heart and severity
of chronic tissue hypoxia
GENERAL MEASURES FOR THE CARE OF PREGNANT
CARDIAC PATIENTS
THE LEVEL OF ANTEPARTUM CARE REQUIRED BY A
PREGNANT WOMAN DEPENDS ON THEIR RISK
CLASSIFICATION:
NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION
FUNCTIONAL CLASS
DESCRIPTION
I
No limitations of activities
No symptoms from ordinary activity
II
Mild limitation of activity
Comfortable with rest or mild exertion
III
Marked limitation of activity
Comfortable only at rest
IV
Should be at complete rest, confined to bed or chair
Any physical activity brings discomfort
Symptoms occur at rest
“A New York Heart Association functional class III or IV
has been estimated to carry a > 7% risk of mortality
and a 30% risk of morbidity”
“ Although women in these functional classes should be
counselled against childbearing, it is not infrequent
that they are encountered in the prenatal clinic (or
even in labor ward, or at the theater door!”
(Joubert IA and Dyer RA. Anaesthesia for the pregnant patient with acquired valvular heart
disease.Update in Anesthesia. Issue 19 2005 Article 9)
FIVE RISK FACTORS PREDICATIVE OF POOR
MATERNAL AND OR NEONATAL OUTCOME
•
•
•
•
•
1. Prior cardiac event
– heart failure, transient ischemic attack or stroke
2. Prior arrythmia
– symptomatic brady or tachy arrhytmia requiring therapy
3. New York functional > class II or the prescence of cyanosis
4. Valvular or outflow tract obstruction
– Aortic valve area < 1.5 cm2 or mitral valve area < 2 cm2
– Left ventricular outflow tract pressure gradient > 30 mmHg
5. Myocardial dysfunction
– Left ventricular EF < 40%
– Restrictive or hypertrophic cardiomyopathy
(Siu SC et al. Rik and predictors for pregnancy-related complications in women
with heart disease. Circulation 1997; 96: 2789-94)
COMPLICATIONS ASCRIBED TO VALVULAR
HEART DISEASE
– 1. Increased incidence of maternal cardiac failure
and mortality
– 2. Increased risk of premature delivery
– 3. Lower APGAR scores and low birth weight
– 4. Higher incidence of interventional and assisted
deliveries
(Malhotra M et al. Maternal and fetal outcome in valvular heart disease. International
Journal of Gynecology and Obstetrics 2004;84:11-6)
LOW Maternal
and Fetal Risk
HIGH Maternal and
Fetal Risk
HIGH
Maternal Risk
HIGH
Neonatal Risk
Asymptomatic aortic stenosis
low mean outflow gradient
(<50mmHg) with normal left
ventricular function
Severe aortic stenosis with or without
symptoms
Reduced left ventricular
systolic function
(LVEF <40%)
Maternal age <20 yr or >35 yr
Aortic regurgitation of NYHA
class I or II
with normal left ventricular
syustolic function
Aortic regurgitation with NYHA class III
or IV symptoms
Previous heart failure
Use of anticoagulant therapy
throught pregnancy
Mitral regurgitation of NYHA
class I or II with normal left
vertricular systolic function
Mitral regurgitation with NYHA class III
or IV symptoms
Previous stroke or
transient ischemic attack
Smoking during pregnancy
Mild to moderate mitral
stenosis (valve area >1.5cm2,
gradient <5mmHg) without
severe pulmonary hypertesion
Mitral stenosis with NYHA class II, III or
IV symptoms
Mitral valve prolapse with no
mitral regurgitation or with
mild to moderate mitral
regurgitation and with normal
left ventricular systolic
function
Aortic valve disease, mitral valve
disease, or both, resulting in severe
pulmonary hypertension (pulmonary
pressure > 75% of systemic pressures)
Mild to moderate pulmonary
valve stenosis
Aortic valve disease, mitral valve
disease, or both, with left ventricular
systolic dysunction (EF <40%)
Maternal cyanosis
NYHA class III and IV
Multiple gestations
GENERAL MEASURES FOR THE CARE OF PREGNANT
CARDIAC PATIENTS
MULTIDISCIPLINARY TEAM APPROACH:
I. Primary care physician/high-risk pregnancy specialist
- monitor fetal condition and maternal cardiac function
at frequent intervals in order to determine if the
physiological changes elicited by pregnancy are exceeding
the functional capacity of the heart
- use medications to limit the extent of changes and
improve outcome.
GENERAL MEASURES FOR THE CARE OF PREGNANT
CARDIAC PATIENTS
MULTIDISCIPLINARY TEAM APPROACH:
II. Anesthesiologist
- consulted early in pregnancy to assess anesthetic risk
of the patient
- discuss pain control during labor and delivery
GENERAL MEASURES FOR THE CARE OF PREGNANT
CARDIAC PATIENTS
MULTIDISCIPLINARY TEAM APPROACH:
III. Cardiologist
- consult on a regular basis and be available if primary
care physicians sees signs of compromise
IV. Neonatologist
- if fetus is affected by a congenital heart disease

Patients who are otherwise healthy
 require little or no specific treatment
 usual obstetric recommendations and monitoring.

NYHA Class I or II





may need to limit strenuous exercise
adequate rest, supplementation of iron and vitamins
low-salt diet
regular cardiac and obstetric evaluations
NYHA Class III or IV
 may need hospital admission for bed rest and close
monitoring
 may require early delivery if there is maternal
hemodynamic compromise.
GENERAL MEASURES FOR THE CARDIAC PATIENT
ANTEPARTUM:
Bed rest/Activity restriction
Diet Modification – dietary salt restriction (4-6 g
daily)
- limitation of fluid intake (1-1.5 l/day)
GENERAL MEASURES FOR THE CARDIAC PATIENT
ANTEPARTUM:
Prenatal visits – every 2 weeks until 28 weeks
then weekly thereafter
Emphasis:
1. Pulse rate check
2. Presence of palpitations
Lanoxin 0.25 mg tab OD
Metoprolol – may cause fetal growth
restriction
GENERAL MEASURES FOR THE CARDIAC PATIENT
ANTEPARTUM:
Prenatal visits –
3. Signs of congestion
Furosemide 20 mg tab OD
- may cause oligohydramnios
GENERAL MEASURES FOR THE CARDIAC PATIENT
ANTEPARTUM:
Prenatal visits –
Fetal growth monitoring and status of
amniotic fluid done with ultrasound
Instruction:
Left lateral decubitus position
GENERAL MEASURES FOR THE CARDIAC PATIENT
ANTEPARTUM:
Antibiotic prophylaxis:
Pen V 250 mg cap BID or Erythromycin 250
mg cap BID
RHEUMATIC HEART DISEASE:
RHEUMATIC FEVER
Rheumatic fever seldom occurs for the first time young adults and
usually preceeded by an episode during childhood (mean age 13)
Uncommon in western countries but still prevalent in developing
countries
Women with a history of rheumatic fever should take daily
penicillin before and throughout pregnancy
RHEUMATIC HEART DISEASE:
RHEUMATIC FEVER
Acute rheumatic fever is managed similarly in pregnant and nonpregnant patients
Acute streptococcal infection mandates a full bactericidal dose for
10 days
Manifestations of pericarditis, symptoms of heart failure, cardiac
murmurs and heart enlargement necessitates prompt
suppression with prednisone and bed rest
RHEUMATIC HEART DISEASE:
CHRONIC RHEUMATIC HEART DISEASE
Mitral stenosis:
- the most common rheumatic heart lesion
- one of the most dangerous in pregnant women
Pregnancy hemodynamic burdens:
1. Increase cardiac output
2. Increase heart rate
3. Expansion of blood volume
4. Increase demand for oxygen
RHEUMATIC HEART DISEASE:
CHRONIC RHEUMATIC HEART DISEASE
Mitral stenosis:
- Critical pregnancy periods:
1. Latepregnancy
- Increased blood volume, CO and HR near
term
2. During labor
- further 10-15% increase in CO augmented during
uterine contractions resulting in autotransfusion of 300 to 500 ml
of blood
RHEUMATIC HEART DISEASE:
CHRONIC RHEUMATIC HEART DISEASE
Mitral stenosis:
- Critical pregnancy periods:
3. Immediately after delivery
- Increase in preload and blood volume from the
contracted uterus and release of aortocaval compression
- Elevated CO persists several days postpartum and
gradually declines over a 2 week period

mitral stenosis
▪ increase in cardiac output with the
increase in heart rate shortens the
diastolic filling time and exaggerates the
mitral valve gradient
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
 added volume load may result in symptoms of
dyspnea and heart failure in women with
impaired LV function and those with limited
cardiac reserve
 Stenotic valvular lesions are less well tolerated
than regurgitant ones
 increased heart rate associated with
pregnancy reduces the time for diastolic filling,
which can be extremely troublesome for many
patients, especially those with MS







exertional dyspnea and fatigue-1st symptoms
of MS
decreased exercise capacity
Orthopnea
paroxysmal nocturnal dyspnea
pulmonary edema
atrial fibrillation, or an embolic event
Rarely, patients may present with
hoarseness, hemoptysis or dysphagia
PRETERM LABOR:
 Tocolytic agents that are positively
chronotrophic are contraindicated
 Magnesium sulfate
 Both maternal and fetal
outcomes are directly related to
the severity of MS and the prepregnancy NYHA functional class

intrauterine growth retardation
low birth weight, prematurity
fetal/neonatal death

has been estimated at approximately


 33% in severe MS
 28 % in moderate MS
 14% in Mild MS
 Associated with 10% maternal
mortality
 Mortality rises to >50% in NYHA class
III and IV
 Mortality rises between 5-10% if with
concomitant atrial fibrillation
 Many px w/ moderate to severe
MS can be managed successfully
with medical therapy w/c
includes strict control of heart
rate ,volume status and frequent
monitoring

Reduce Heart rate
 Beta Blockers or calcium Channel Blockers
▪ Metoprolol( beta blocker)-preferred beta blocker
▪ Atenolol-can cause IUGR,bradycardia and Death
▪ Digoxin-used in px w/AF for control of ventricular rate and
is generally safe, well tolerated and has fewer side effects
 Restriction of physical activity

Reduce left atrial pressure
 Diuretics- caution must be exercised to avoiud
uteroplacental hypoperfusion associared w/ use of
diuretics
“Severe symptomatic disease, threatening
maternal or fetal well-being is an accepted
indication for either balloon vulvoplasty or valve
replacement”
“ Valve replacement is usually undertaken during
2nd trimester. Cardiopulmonary bypass and
hypothermia carry substantial risk for the fetus.
Fetal bradycardia and death are not
uncommon”
(Unger F et al . Standards and concepts in valve surgery. Report of the task force: European Heart Institute (EHI) of the
European Academy of Sciences and Arts and the International Society of Cardiothoracic Surgeons (ISCTS). Indian
Heart Journal 2000;52:237-44)

Patients with severe mitral stenosis who
develop decompensation during pregnancy
should undergo percutaneous trans-mitral
commissurotomy

Percutaneous mitral valvuloplasty can be
performed with few or no complications to
the mother or the fetus and excellent clinical
and hemodynamic results



The “optimal time” appears to be between 20
and 28 weeks of gestation
Obstetric monitoring of the fetus during the
procedure
Maternal functional class is an important
predictive factor for maternal death.
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
 Anticoagulation with Warfarin or
Heparin can be considered for px with
severe left atrial dilatation and Severe
MS despite the presence of sinus
rhythm, because of the
hypercoagulable state of pregnancy
PREGNANT RHEUMATIC: Labor and
Delivery
GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:




Labor and delivery in lateral decubitus position
Continuous monitoring with pulse oximetry
Control of rate of IV fluid administration to 75
cc/hr
Adequate pain relief (epidural narcotics)
GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:






Antibiotic prophylaxis
Short Vaginal delivery with excellent
anesthesia
Cesarean section per obstetric indications
Invasive monitoring if needed
Medical therapy optimization of loading
conditions
Prevention and treatment of pulmonary
edema
Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or
gastrointestinal procedures
Category
Drug and dosage
High-risk patient
Ampicillin, 2 g IM or IV,
plus
gentamicin sulfate (Garamycin), 1.5 mg/kg
IV 30 min before procedure; ampicillin, 1 g
IV, or amoxicillin (Amoxil, Trimox, Wymox),
1 g PO 6 hr after procedure
High-risk patient who has penicillin allergy
Vancomycin HCl (Vancocin, Vancoled), 1 g
IV over 2 hr,
plus
gentamicin sulfate, 1.5 mg/kg IV 30 min
before procedure
•
EPIDURAL ANESTHESIA
– Desirable for vaginal delivery
– Performed using small increments of local
anesthetic to achieve T8-T10 level
•
GENERAL ANESTHESIA
– Best option for NYHA class III and IV
– Avoid atropine, pancuronium, meperidine,
ketamine
Shortening of the second stage of labor
and assisted vaginal delivery is strongly
recommended
 Cesarean section are performed for
Obstetrics indications

CARDIOVASCULAR DRUGS IN
PREGNANCY:

ANGIOTENSIN-CONVERTING ENZYME
INHIBITORS

contraindicated in pregnancy
▪ abnormal renal development in the fetus
▪ oligohydramnios and intrauterine growth retardation
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

BETA-ADRENERGIC RECEPTOR BLOCKERS
▪ been used extensively during pregnancy for
treatment of arrhythmias, hypertrophic
cardiomyopathy, and hypertension
▪ cross the placenta but are not teratogenic
▪ demonstrated to cause fetal growth retardation
▪ be associated with neonatal bradycardia and
hypoglycemia
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

CALCIUM CHANNEL BLOCKERS
▪ used to treat both arrhythmias and
hypertension
▪ limited data regarding use
▪ Most experience probably exists with
verapamil, and no major adverse fetal
effects have been recorded
▪ Diltiazem and nifedipine have also been
used, but studies are limited.
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

DIGOXIN
▪used during pregnancy for many decades
▪cross the placenta
▪no adverse effects with its use have been
reported
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
 DIURETICS
▪ most commonly furosemide
▪ treat congestive heart failure during pregnancy and
treatment of hypertension.
▪ may cause reduction in placental blood flow and
have a detrimental effect on fetal growth.
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

WARFARIN
▪ contraindicated in the first trimester of
pregnancy
▪ crosses the placenta and may cause fetal
embryopathy
▪ third trimester (about labor and delivery)
▪ 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
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
POST NATAL CARE:
Postnatal Care:
Counseling on contraception
Permanent sterilization after delivery discussed
during prenatal visits
 Surgical management prior to the next pregnancy


Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

failure rate of approximately 15 pregnancies/100
woman-years of use

use of a barrier method depends on how critical it is
for the woman to avoid pregnancy, compliance and
the ability to use a condom correctly.
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

Combination estrogen-progesterone oral preparations
▪ increased risk of venous thromboembolism, atherosclerosis,
hyperlipidemia, hypertension, and ischemic heart disease
▪ congenital heart disease who have cyanosis, atrial fibrillation
or flutter, mechanical prosthetic heart valves, or a Fontan
circulation should avoid estrogen-containing preparations
▪ impaired ventricular function from any cause or with a
history of any prior thromboembolic
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

Progesterone-only contraceptives
 There is a paucity of data about adverse effects
of progesterone agents on the cardiovascular
system, but probably these are safe for most
women with heart disease
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
 fluid retention and irregular menstruation
 cardiovascular contraindications are the same as
those for progesterone
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

performed laparoscopically or via a laparotomy

tenuous cardiac hemodynamics
▪ risk of cardiac instability = cardiac anesthesia may
be preferable

tubal sterilization has been accomplished with the use
of an intrafallopian plug inserted endoscopically
Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.