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Cardiac Disease in Pregnancy Dr Jason Reidy Cardiac Disease in Pregnancy Why the interest? Women consistently die form cardiac disease associated with pregnancy CEMACH Reports Cardiac Deaths Congenital heart disease Acquired heart disease Cardiovascular Changes in Pregnancy Cardiovascular Changes in Pregnancy Pregnancy SVR Diastolic BP Cardiac output 20% by 8/40 40% by 20-28/40 SV Circulating volume Physiological LVH HR Cardiovascular Changes in Pregnancy Labour Cardiac output 1st stage ~15% 2nd stage ~50% Sympathetic output Uterine contractions Autotransfusion Cardiovascular Changes in Pregnancy Immediately Post-partum Cardiac output 60-80% Rapid decline to pre-labour levels ~2h 2 weeks post-partum Back to pre-pregnancy Cardiovascular Changes in Pregnancy Cardiovascular disease can manifest or worsen in pregnancy due to the dynamic physiological demands placed on the cardiovascular system Maternal Deaths due to Cardiac Disease CEMACH 2003-2005 Cardiac Deaths Commonest indirect and overall cause 48 deaths Upward trend in deaths from IHD and myocardial infarction CEMACH 2003-2005 Cardiac Deaths Triennium Congenital n(%) Acquired n(%) Acquired n(%) Ischaemic Other Total Rate Per 100,00 Maternities 1985-1987 10 (43) 9 (39) 4 (17) 23 1.01 1988-1990 9 (50) 5 (28) 4 (22) 18 0.76 1991-1993 9 (24) 8 (22) 20 (54) 37 1.60 1994-1996 10 (26) 6 (15) 23 (59) 39 1.77 1997-1999 10 (29) 5 (14) 20 (57) 35 1.65 2000-2002 9 (20) 8 (18) 27 (61) 44 2.20 2003-2005 4 (8) 16 (33) 28 (58) 48 2.27 CEMACH 2003-2005 Cardiac Deaths Triennium Congenital n(%) Acquired n(%) Acquired n(%) Ischaemic Other Total Rate Per 100,00 Maternities 1985-1987 10 (43) 9 (39) 4 (17) 23 1.01 1988-1990 9 (50) 5 (28) 4 (22) 18 0.76 1991-1993 9 (24) 8 (22) 20 (54) 37 1.60 1994-1996 10 (26) 6 (15) 23 (59) 39 1.77 1997-1999 10 (29) 5 (14) 20 (57) 35 1.65 2000-2002 9 (20) 8 (18) 27 (61) 44 2.20 2003-2005 4 (8) 16 (33) 28 (58) 48 2.27 CEMACH 2003-2005 Cardiac Deaths Triennium Congenital n(%) Acquired n(%) Acquired n(%) Ischaemic Other Total Rate Per 100,00 Maternities 1985-1987 10 (43) 9 (39) 4 (17) 23 1.01 1988-1990 9 (50) 5 (28) 4 (22) 18 0.76 1991-1993 9 (24) 8 (22) 20 (54) 37 1.60 1994-1996 10 (26) 6 (15) 23 (59) 39 1.77 1997-1999 10 (29) 5 (14) 20 (57) 35 1.65 2000-2002 9 (20) 8 (18) 27 (61) 44 2.20 2003-2005 4 (8) 16 (33) 28 (58) 48 2.27 CEMACH 2003-2005 Cardiac Deaths Triennium Congenital n(%) Acquired n(%) Acquired n(%) Ischaemic Other Total Rate Per 100,00 Maternities 1985-1987 10 (43) 9 (39) 4 (17) 23 1.01 1988-1990 9 (50) 5 (28) 4 (22) 18 0.76 1991-1993 9 (24) 8 (22) 20 (54) 37 1.60 1994-1996 10 (26) 6 (15) 23 (59) 39 1.77 1997-1999 10 (29) 5 (14) 20 (57) 35 1.65 2000-2002 9 (20) 8 (18) 27 (61) 44 2.20 2003-2005 4 (8) 16 (33) 28 (58) 48 2.27 CEMACH 2003-2005 Cardiac Deaths Indirect Late Aortic dissection 9 0 Myocardial infarction 12 4 Ischaemic heart disease 4 0 Sudden Adult Death Syndrome (SADS) 3 9 Peri-partum cardiomyopathy 0 12 Cardiomyopathy 1 4 Myocarditis or myocardial fibrosis 5 0 Mitral stenosis or valve disease 3 0 Infectious endocarditis 2 2 Right or left ventricular hypertrophy or hypertensive heart failure 2 1 Pulmonary Hypertension 3 0 Congenital Heart Disease 3 2 47 34 Acquired Congenital Totals CEMACH 2003-2005 Cardiac Deaths Indirect Late 9 0 12 4 Ischaemic heart disease 4 0 Sudden Adult Death Syndrome (SADS) 3 9 Peri-partum cardiomyopathy 0 12 Cardiomyopathy 1 4 Myocarditis or myocardial fibrosis 5 0 Mitral stenosis or valve disease 3 0 Infectious endocarditis 2 2 Right or left ventricular hypertrophy or hypertensive heart failure 2 1 Pulmonary Hypertension 3 0 Congenital Heart Disease 3 2 47 34 Acquired Aortic dissection Myocardial infarction Congenital Totals Trends in Cardiac Deaths Malhotra & Yentis IJOA 2006 288 maternal cardiac deaths in 30 year period from CEMD/CEMACH Trends in cardiac deaths with or without known disease or risk factors Trends in Cardiac Deaths Deaths in women with diagnosed disease 26% Deaths in women with documented risk factors 22% De Novo deaths 52% Congenital Heart Disease Congenital Heart Disease Improved survival with better surgery Growing population Good quality of life Normal fertility Pregnancy is a challenge for their repaired CVS They are not cured! Estimates of the number of people with congenital heart disease (simple and complex), 2000 and 2010, United Kingdom Complex congenital heart disease (Incidence - 1.5/1,000 births) Simple congenital heart disease (Incidence - 4.5/1,000 births) Date of birth Number of births in the UK Number born with congenital heart disease First year survival rate Survivors at 12 months 18 year survival rate Survivors at 18 years 1940-1960 16,620,000 24,930 20% 4,986 10% 2,493 1960-1980 17,260,000 25,890 50% 12,945 35% 9,062 11,555 in year 2000 1980-1990 7,550,000 11,325 70% 7,928 50% 5,663 17,218 in year 2010 1940-1960 16,620,000 74,790 90% 67,311 90% 67,311 1960-1980 17,260,000 77,680 90% 69,912 90% 69,912 137,223 in year 2000 1980-1990 7,550,000 33,980 90% 30,582 90% 30,582 167,805 in year 2010 All congenital heart disease 148,778 in the year 2000 185,023 in the year 2010 Congenital Heart Disease Deaths are decreasing Unplanned pregnancy No pre-pregnancy counselling Ischaemic Heart Disease What do we know? Upward trends in deaths from IHD and myocardial infarction Maternal risk factors Increasing maternal age Obesity Diabetes Pre-existing hypertension Higher parity Smoking Family history Maternal Age CEMACH Percentages of maternities by age <20 20-24 25-29 30-34 35-39 ≥40 19971999 7.66 18.04 30.47 29.46 12.26 2.11 20002002 7.58 18.24 26.98 30.04 14.49 2.67 20032005 7.15 18.87 25.25 29.64 15.87 3.22 Maternal Age CEMACH Percentages of maternities by age <20 20-24 25-29 30-34 35-39 ≥40 19971999 7.66 18.04 30.47 29.46 12.26 2.11 20002002 7.58 18.24 26.98 30.04 14.49 2.67 20032005 7.15 18.87 25.25 29.64 15.87 3.22 Maternal Age CEMACH Death rates per 100,000 maternities by age 20032005 Age <20 20-24 25-29 30-34 35-39 ≥40 9.9 9.8 12.4 14.5 19.1 29.4 Maternal Age CEMACH Death rates per 100,000 maternities by age 20032005 Age <20 20-24 25-29 30-34 35-39 ≥40 9.9 9.8 12.4 14.5 19.1 29.4 Maternal Obesity CEMACH 64% of women who died of cardiac disease were overweight or obese 31% had a BMI 25-30 33% had a BMI >30 60% of these >35 33.3% of these >40 Maternal Obesity CEMACH BMI > 25 Direct Thromboembolism 20(65%) Pre-eclampsia/Eclampsia 9(50%) Haemorrhage 7(47%) AFE 6(43%) Early Pregnancy 2(33%) Sepsis 8(73%) Anaesthetic 2(50%) Indirect Total Cardiac 29(64%) Other 27(39%) Psychiatric 6(46%) Malignancies 3(43%) 119(52%) Maternal Obesity CEMACH BMI > 25 Direct Thromboembolism 20(65%) Preeclampsia/Eclampsia 9(50%) Haemorrhage 7(47%) AFE 6(43%) Early Pregnancy 2(33%) Sepsis 8(73%) Anaesthetic 2(50%) Indirect Total Cardiac 29(64%) Other 27(39%) Psychiatric 6(46%) Malignancies 3(43%) 119(52%) Maternal Obesity & Age Percentage distribution of BMI by age Health Survey for England 2003 Percentage in each age group 16-24 25-34 35-44 18.5 or under 7.4 1.0 1.0 18.6-25 61.2 51.8 43.5 25.1-30 18.3 28.3 33.3 30.1-40 11.1 15.1 18.6 Over 40 2.0 3.0 3.5 BMI Maternal Obesity & Age Percentage distribution of BMI by age Health Survey for England 2003 Percentage in each age group 16-24 25-34 35-44 18.5 or under 7.4 1.0 1.0 18.6-25 61.2 51.8 43.5 25.1-30 18.3 28.3 33.3 30.1-40 11.1 15.1 18.6 Over 40 2.0 3.0 3.5 BMI Cardiac Disease in Pregnancy Who’s Going to Have a Problem? Who’s going to have a problem? Risk stratification Traditional assessment for non-cardiac surgery Probably not appropriate Extrapolation from a physiologically different population Cardiac Disease in Pregnancy How do we stratify risk in the pregnant population? Who’s going to have a problem? Siu et al, Circulation 2001 Prospective study 562 women with 599 pregnancies in women with heart disease Pregnancy & neonatal outcomes Receiving comprehensive prenatal care Who’s going to have a problem? Heart Disease 74% Congenital 22% Acquired 4% Arrhythmic 80 Cardiac Events (13%) Pulmonary oedema Arrhythmic Stroke Cardiac death (3) Siu et al Who’s going to have a problem? Siu et al 1. 4 Main predictors of adverse maternal cardiac event Prior history of 2. Heart failure TIA/Stroke Arrhythmia NYHA ≥ Class II or Cyanosis Who’s going to have a problem? 3. Left Heart Obstruction 4. Mitral valve < 2cm2 Aortic valve <1.5cm2 Gradient of >30mmHg Reduced LV Function EF<40% Siu et al Who’s going to have a problem? Siu et al No RF, then < 5% risk of CVS event 1 RF, then >20% risk of CVS event 2 RF, then >60% risk of CVS event Who’s going to have a problem? Lupton et al, Curr Opin Obst Gyn, 2002 More geared to congenital lesions Aimed to stratify risk of mortality Low Intermediate High Low Risk Lupton et al Mortality 0.1-1.0% Most repaired lesions Uncomplicated left-to-right shunts Regurgitant valve lesions Intermediate Risk Lupton et al Mortality 1-5% Metal valves Single ventricles Systemic right ventricle Switch procedure Unrepaired cyanotic lesions Stenotic valve lesions High Risk Lupton et al Mortality 5-30% NYHA III or IV Severely impaired LV function Severe aortic stenosis Marfan’s Syndrome with aortic valve lesion or dilated aortic root Pulmonary hypertension Mortality 30-50% Management of Heart Disease in Pregnancy Management of Heart Disease in Pregnancy Pre-conception Counselling Start essential early Discussion of the effect of pregnancy on the lesion Discussion of risks for cardiac events/death Drug regimen optimisation CVS optimisation Management of Heart Disease in Pregnancy Antenatally Multidisciplinary approach Obstetrics Midwifery Cardiology/cardiothoracics Anaesthesia Multidisciplinary planning meetings are helpful in forming plans for delivery Management of Heart Disease in Pregnancy Antenatally Regular review in pregnancy Including echocardiography Low threshold for admission Formal assessment Optimisation Management of Heart Disease in Pregnancy Antenatally Major CVS changes in first 20 weeks Cardiac decompensation Watch for pre-eclampsia Management of Heart Disease in Pregnancy Antenatal deterioration Mother or foetus Optimise mother medically Consider Surgical intervention Termination IOL or LSCS Monitoring Monitoring Large CVS changes should be anticipated perinatally Degree of monitoring will depend on nature and severity of the lesion Monitoring Continuous ECG Consider for all Continuous SpO2 Consider for all Especially useful where shunting or pulmonary oedema are a possibility Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Monitoring Arterial line Any lesions associated with high risk of mortality Severe symptoms/impairment Pre-eclampsia High risk of haemorrhage Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Monitoring Central Line Useful in Heart failure Patients sensitive to hypovolaemia Vasoactive substances Drawbacks What are you monitoring? Technicality of insertion Complications Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Monitoring Trans-oesophageal Echo/Doppler ? Role Not well tolerated at LSCS Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Mode of Delivery Mode of Delivery in Cardiac Disease Low risk Labour with epidural High risk Elective caesarean Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24, 761-81 Labour Epidural analgesia for ALL Including Low fixed output states dose Except Therapeutic anticoagulation Clopidogrel ± Aspirin Minimal pushing in 2nd stage! Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) LSCS GA or Regional? Either done carefully is acceptable Multifactorial Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) LSCS Influences Arrhthymias SVR Pulmonary hypertension Anticoagulants/antiplatelets Need for post-op ITU Mortality & maternal attitude Associated airway anomalies Anaesthetist’s preference Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Peri-partum Problems Haemorrhage Some lesions tolerate blood loss poorly Aortic stenosis Fontan circulation risk due to anticoagulation risk due to lack of uterotonics Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Uterotonics Oxytocin Tachycardia/hypotension SVR, CO Ischaemic changes Bolus Vs. infusion Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Uterotonics Ergometrine Hypertension Pulmonary vasoconstriction Pulmonary hypertension Safe i.m in less severe lesions in the absence of hypertension Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Uterotonics Carboprost Hypertension CVS collapse Pulmonary oedema Largely unsuitable in cardiac disease Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Uterotonics Misoprostol Increasingly used Not evidence in cardiac disease Good side effect profile Uterotonic efficacy Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Pulmonary Oedema Cardiac Obstetric Iatrogenic Careful fluid balance in labour or at LSCS Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Arrhythmias Cardiac filling Cardiac output Coronary perfusion Avoid precipitants Oxytocin Ephedrine Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Acute Pulmonary Hypertension Severe/catastrophic Even in mild disease Pulmonary hypertensive changes may be accelerated Adapted from Dob & Yentis, IJOA, 2006: 15(137-144) Peri-partum Problems Chest Pain Aortic dissection Acute surgical emergency Bypass has 20% foetal mortality Coronary ischaemia/myocardial infarction Atheromatous changes Coronary artery dissection Peri-partum Problems Management of AMI Occur mostly peri-partum Coronary dissection > atheroma Thrombolysis contra-indicated in dissection Important to exclude PPCM if heart failure present Rx of choice Immediate angiography +/- coronary stenting Normal coronaries in up to 47% Beyond 2nd trimester safe for foetus Thrombolysis is not contra-indicated in pregnancy Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24, 761-81 Peri-partum Problems Management of AMI Ongoing management to be directed jointly by cardiology and obstetrics Nitrates, aspirin, b-blockers, clopidogrel safe ACE-I and statins not safe Mortality Estimated 37% But up to 50% if delivery within 2 weeks of AMI Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24, 761-81 Post-Partum Post-Partum Fluid balance Post-partum pre-eclampsia Good analgesia Thromboprophylaxis Close monitoring should continue How long? Summary Cardiac deaths increasing Congenital Ischaemia Maternal risk factors Age Obesity Summary What’s important Close supervision High index of suspicion Especially More for ischaemia attention to risk factors Summary Management principles Understand the physiology of the lesion Appropriate monitoring Cardiovascular stability Good epidural analgesia in labour Careful anaesthesia for LSCS Awareness that delivery is not the end of the problem Thank you