Management of Heart Disease in Pregnancy

1. Management of Heart Disease in Pregnancy

2. Dr. Sarita Bhalerao Consultant Obstetrician and Gynaecologist Bhatia , Saifee and Wadia maternity Hospitals Mumbai

3. Pre-conceptional Counselling • This is an important aspect of management or the cardiac patient planning a pregnancy. • Ideally, the obstetrician and cardiologist should work together to help the patient make an informed decision. • Prevent an unwanted pregnancy and avoid the risks associated with pregnancy continuation or termination

4. Risk Assessment • Poor functional status (NYHA class III or IV) or cyanosis • Left ventricular systolic dysfunction (ejection fraction < 0.40) • Left heart obstruction (mitral valve area <2.0 cm2, aortic valve area < 1.5 cm2, or peak left ventricular outflow tract gradient > 30 mm Hg)

5. Risk Assessment • A cardiac event (arrhythmia, stroke, transient ischemic attack, or pulmonary edema) before pregnancy but since a prior cardiac surgical procedure.

6. Risk Assessment • Siu developed a risk index incorporatingthese factors. • In a woman with heart disease and no other risk factors, the likelihood of a cardiac event during pregnancy is about 5%, increasing to 25% with one risk factor & 75% with more than one risk factor. Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515–521.

7. Maternal mortality risk and cardiac disease Group Cardiac disease Associated mortality risk I Atrial septal defect* <1% Ventricular septal defect* Patent ductus arteriosus* Pulmonary/tricuspid valve disease Corrected tetralogy of Fallot Bioprosthetic valve Mitral stenosis, NYHA Class I, II

8. Maternal mortality risk and cardiac disease Group Cardiac disease Associated mortality risk II Coarctation of aorta without valvular involvement 5% - 15% Uncorrected tetralogy of Fallot Marfan’s syndrome with normal aorta Mechanical prosthetic valve Mitral stenosis with atrial fibrillation or NYHA Class III, IV Aortic stenosis Previous myocardial infarction

9. Maternal mortality risk and cardiac disease Group Cardiac disease Associated mortality risk III Pulmonary hypertension—primary or secondary 25% - 50% Coarctation of aorta with valvular involvement Marfan’s syndrome with aortic involvement Peripartum cardiomyopathy *Uncomplicated

10. Maternal mortality risk and cardiac disease • A careful history is obtained to identify previous cardiac complications. • The patients functional status as per The New York Heart Association(NYHA) is defined

11. NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OFCARDIAC DISEASE CLASS I No functional limitation of activity. No symptoms of cardiac decompensation with activity. CLASS II Mild amount of functional limitation. Patients are asymptomatic at rest. Ordinary physical activity results in symptoms. CLASS III Limitation of most physical activity. Asymptomatic at rest Minimal physical activity results in symptoms. CLASS IV Severe limitation of physical activity results in symptoms. Patients may be symptomatic at rest/heart failure at any point of pregnancy. CLASS V If patient is on ionotropic support, ventilator, Assisted circulation or having comprised renal or pulmonary function necessitating dialysis/EMCO to maintain vital signs. The criteria committee of the New York Heart Association, Nomenclature and criteria for diagnosis of diseases of heart and great vessels, Edi 8, New York Association,1979.

12. Antepartum Care • The chief aim of management of the patient in pregnancy is to keep patient within her cardiac reserve. • It is preferable to have detailed baseline information prior of pregnancy.

13. Antepartum care • Limiting activity is helpful in severely affected women with ventricular dysfunction, • left heart obstruction, or class III or IV symptoms. • Hospital admission by mid-second trimester may be advisable for some.

14. Antepartum care • Problems should be identified early and treated aggressively, especially pregnancy induced hypertension, hyperthyroidism, infection, and anemia.

15. Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures 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,plusgentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

16. Arrhythmias should be treated if warranted • Premature atrial or ventricular beats are common in normal pregnancy, and in patients with preexisting arrhythmias, • Pregnancy may exacerbate their frequency and hemodynamic severity. • These usually are not treated.

18. Peripartum Management Cesarean section is indicated only for the following conditions: • Aortic dissection • Marfan syndrome with dilated aortic root • Taking warfarin within 2 weeks of labor. • Preterm induction is uncommon. • However, once fetal lung maturity is assured, a planned induction and delivery may be warranted for high-risk patients to ensure that appropriate staff and equipment are available.

19. Peripartum Care • Antibiotic prophylaxis for endocarditis is not routine. AHA guidelines do not recommend routine endocarditis prophylaxis for cesarean section delivery or for uncomplicated vaginal delivery without infection. • However, some centers do administer endocarditis prophylaxis for vaginal delivery in women with structural heart disease, as an uncomplicated delivery cannot always be anticipated.

20. Peripartum Care • Positioning the patient on her left side lessens the hemodynamic fluctuations associated with contractions when the patient is supine. • Forceps or vacuum extraction should be considered at the end of the second stage of labor to shorten and ease delivery • Because hemodynamics do not return to baseline for many days after delivery, patients at intermediate or high risk may require monitoring for at least 72 hours postpartum.

21. Peripartum care • Lactation should be encouraged unless patient is in failure. • Cardiac output is not compromised during lactation. • Lactation is a pathway for fluid excretion and diuretic requirement may actually fall.

22. Thank you