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Cardiovascular Disease in Pregnancy

Cardiovascular Disease in Pregnancy

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Cardiovascular Disease in Pregnancy

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  1. Cardiovascular Disease in Pregnancy Songsak Kiatchoosakun M.D. Cardiology, Medicine Khon Kaen University

  2. Introduction • Pregnancy, labor and delivery are associated with burdens on the cardiovascular system • The outcome of pregnancy is related to functional class and underlying heart disease

  3. Hemodynamic Modifications during Pregnancy • Blood volume starts to rise at 5th week • Systemic vascular resistance and blood pressure are decreased • Resting heart rate increases by 10-20 beats/min • Cardiac output increases by 30-50%

  4. High Risk Pregnancy • Advise avoidance of pregnancy • Mitral stenosis with functional class II-IV • Mitral and aortic regurgitation with functional class III, IV • Severe pulmonary hypertension • Left ventricular dysfunction • Marfan’s syndrome with dilated aortic root (> 40 mm) • Cyanotic heart disease • Severe obstructive lesion (aortic stenosis, pulmonary stenosis)

  5. High Risk Pregnancy • Close follow up required • Prosthetic valve • Mild to moderate valvular heart disease • Marfan’s syndrome without aortic root dilatation

  6. Signs and Symptoms in Normal Pregnancy • History • Dyspnea • Orthopnea • Palpitation • Physical examination • Edema • Systolic murmur < grade II/VI • Increased of S1, P2

  7. Suspicious Symptoms and Signs of Cardiac Disease in Pregnancy • Progressive dyspnea • Syncope • Chest pain • Cyanosis • Left parasternal heave • A grade III/VI or greater systolic murmur • Any diastolic murmurs • S4 gallop • Fixed split of S2 • Opening snap

  8. Cardiovascular Disease in Pregnancy • Valvular Heart disease • Rheumatic heart disease • Prosthetic heart valves • Hypertension • Congenital heart disease • Peripartum cardiomyopathy • Marfan syndrome and aortic regurgitation • Arrhythmias

  9. Valvular Heart Disease and Maternal Outcomes % Hameed A. J Am Coll Cardiol 2001;37:893

  10. Valvular Heart Disease and Fetal Outcomes % Hameed A. J Am Coll Cardiol 2001;37:893

  11. Mitral Stenosis • Most common valve disease in pregnancy • Valve area < 1.5 cm2 increases risk of • Pulmonary edema • Heart failure • Arrhythmias • Intrauterine growth retardation • Closed follow up is necessary • Doppler echo at 3 and 5 month and monthly thereafter

  12. Diagnostic Assessment Echocardiography • Confirm diagnosis • Determine the severity of stenosis • Pulmonary artery pressure and RV function • Mitral valve score to determine the success of percutaneous mitral balloon valvuloplasty

  13. Medical Management • Most pregnant woman with mitral stenosis can be managed medically • Limit activity • Restrict salt and fluid • Diuretic if needed

  14. Medical Management • Digoxin is useful in atrial fibrillation • Rheumatic prophylaxis • Penicillin V 250 mg X 2 • Benzathine Penicillin IM q 3 weeks • Betablocker

  15. Beta-blocker in Pregnancy • Beta-1 selective agents ;metoprolol and atenolol limits the risk interaction with uterine contraction • Cross placenta and excrete in breast milk • No serious adverse effects on neonates • Fetal bradycardia and hypoglycemia have been reported

  16. Percutaneous Balloon Mitral Valvuloplasty (PBMV) • Should be considered after failure of aggressive medical treatment • Radiation exposure and technical difficulties are major limitations • Transesophageal echocardiography guidance may decrease the fluoroscopy time and maternal complications

  17. Surgical Intervention • Indicated in patients who failed medical treatment • Should be performed between 24-28 weeks’ gestation • Maternal mortality rate 1.5-5% • Fetal mortality rate 20-30 % in open heart surgery • Closed mitral valvotomy is preferable • safe for mother • fetal mortality of 2-12%

  18. Regurgitation Valve Disease • Pregnancy is generally well tolerated even in severe valve regurgitation • The decrease in vascular resistance and tachycardia during pregnancy reduces the regurgitation fraction • Medical therapy in patients with heart failure • Nitrate • Dihydropyridine calcium blockers • ACE inhibitors and ARB are contraindicated

  19. Pregnancy with Heart Valve Prostheses • Problems • Hypercoagulable state during pregnancy • Use of oral warfarin is associated with fetal anomalies (nasal hypoplasia, epiphysis stippling, CNS anomalies) • Overall risk is 5% • Dose related; low risk if daily dose < 5 mg

  20. Regimens of Anticoagulant • Regimen 1-Warfarin sodium through out pregnancy with unfractionated heparin sodium near term • Regimen 2-Substitution or warfarin with unfractionated heparin between 6-12 weeks and near term • Regimen 3-Unfractionated heparin through pregnancy

  21. % Fetal Complications Chan WS. Arch Intern Med 2000;160:191

  22. % Maternal Complications Chan WS. Arch Intern Med 2000;160:191

  23. Conclusions • Risk of embryopathy (4-6%) when warfarin is used during 6-12 week of gestation • Subcutaneous heparin does not provide adequate anticoagulation • No advantage in the use of heparin during 6-12 week of gestation to prevent fetal wastage • Heparin in first trimester is associated with high incidence of thromboembolism

  24. Recommendations • Warfarin therapy throughout pregnancy is the safest therapeutic option for the mother • Patients who choose not to take warfarin should receive unfractionated heparin or low molecular weight heparin (aPTT 2-3 time control, predose anti Xa ~ 0.7) • Warfarin should be replaced by heparin at the 36th week to avoid neonatal intracranial hemorrhage

  25. Hypertension in Pregnancy • Complicates 6-8 % of all pregnancies • Complications • Cerebral hemorrhage • Hepatic failure • Acute renal failure • Abrutio placenta • Pregnancy outcomes relate with underlying causes of HT

  26. Pharmacological Treatment • Methydopa: first line agent; 750 mg-4 g • Betablocker • Calcium channel blocker • Hydralazine • Diuretics: • Contraindicated in preeclampsia • May reduce uteroplacental flow • ACEI and ARB blocker: renal agenesis

  27. Cardiovascular Drugs in Pregnancy Drug Use in pregnancy Safety Digoxin HF, arrhythmia Safe Beta-blocker HT,MS, IHD Safe Nifedipine HT Safe Hydralazine HT, HF Safe Nitrate IHD Limited data Diuretics HF,HT +/- ACEI HT, HF Unsafe Amiodarone Arrhythmias Unsafe

  28. Cardiovascular Evaluation in Pregnancy • History • Physical examination • Investigations • ECG • Echocardiography

  29. Management • Low risk patients • HT stage I without end organ damage • Control of HT before conception • Frequent supervision is essential • High risk patients • Severe HT with end organ damage and co-morbidity condition • Need frequent assessment

  30. Hypertensive Disorder Classification and definition • Chronic HT: HT prior or before 20 wks of gestation • Preeclampsia-eclampsia: proteinuria with new HTafter 20 wks of pregnancy • Pre-eclampsia superimposed on chronic HT: increased BP (30/15); change in proteinuria or target organ damage • Gestational HT: new HT after 20 wks of pregnancy without proteinuria • Transient HT: elevated HT during or after pregnancy without sings of preeclampsia