Heart Diseases in Heart Diseases in PregnancyPregnancy

Faisal Alatawi ,M.DFaisal Alatawi ,M.D

Consultant CardiologistConsultant Cardiologist

PSCCPSCC

OutlineOutline

PhysiologyPhysiology

Incidence& Risk assessment Incidence& Risk assessment

Congenital heart diseaseCongenital heart disease

Acquired heart disease Acquired heart disease

AnticoagulationAnticoagulation

SBE prophylaxisSBE prophylaxis

Basic heamodynamicsBasic heamodynamics

Stroke volume(SV)=amount of blood Stroke volume(SV)=amount of blood ejected per cycleejected per cycle

COP=SV*HRCOP=SV*HR

Blood pressure=COP*SVR Blood pressure=COP*SVR

Starling’s low:increase preload SVStarling’s low:increase preload SV

Systemic vas. resistance(SVR) SVSystemic vas. resistance(SVR) SV

Heamodynamics In pregnancyHeamodynamics In pregnancy

Heamodynamics In pregnancyHeamodynamics In pregnancy

Haemodynamic changesHaemodynamic changes

Supine hypotensive (uterocaval) syndrome Supine hypotensive (uterocaval) syndrome of pregnancy occurs in 11 % of womenof pregnancy occurs in 11 % of women

Decrease HR&BP due to compresion on Decrease HR&BP due to compresion on IVCIVC

Weakness ,nausea and dizziness even Weakness ,nausea and dizziness even syncope avoid by lateral positioningsyncope avoid by lateral positioning

Haemodynamic changesHaemodynamic changes

Changes during labor:Changes during labor:

3 fold increase in oxygen consumption3 fold increase in oxygen consumption

Increase COIncrease CO

Increase in BP mainly in 2Increase in BP mainly in 2ndnd stage stage

Pain reduction, local and epidual Pain reduction, local and epidual anesthesia limit hamodynamic changes anesthesia limit hamodynamic changes and O2 consumption and O2 consumption

The hemodynamic changes during The hemodynamic changes during the the post-partumpost-partum state state

Mainly due to relief of vena caval Mainly due to relief of vena caval compression after delivery.compression after delivery.

Increase in venous return augments Increase in venous return augments cardiac output and causes a brisk diuresis. cardiac output and causes a brisk diuresis.

The hemodynamic changes return to the The hemodynamic changes return to the pre-pregnant baseline within 3 to 4 weeks pre-pregnant baseline within 3 to 4 weeks following deliveryfollowing delivery

Characteristic Characteristic signs and symptomssigns and symptoms of normal of normal pregnancypregnancy

Due to hemodynamic changes associated with pregnancyDue to hemodynamic changes associated with pregnancy

Fatigue, dyspnea, and decreased exercise capacity. Fatigue, dyspnea, and decreased exercise capacity.

Pregnant women usually have peripheral edema and jugular venous Pregnant women usually have peripheral edema and jugular venous distension.distension.

Most pregnant women have Full and collapsing pulseMost pregnant women have Full and collapsing pulse

Displaced and enlarged apex, RV heaveDisplaced and enlarged apex, RV heave

A physiologic third heart sound (S3), reflecting the volume overloaded state, A physiologic third heart sound (S3), reflecting the volume overloaded state, can often be appreciatedcan often be appreciated

Most have audible physiologic systolic murmurs, created by augmented Most have audible physiologic systolic murmurs, created by augmented blood flow.blood flow.

Normal exam can mimic heart disease Normal exam can mimic heart disease

Not normal : S4, Loud SM, DM, Fixed split S2Not normal : S4, Loud SM, DM, Fixed split S2

Cardiac assessmentCardiac assessment

Electrocardiogram:Electrocardiogram: The electrocardiogram may reveal a leftward shift of the electrical axis, especially The electrocardiogram may reveal a leftward shift of the electrical axis, especially during the third trimester when the diaphragm is pushed upwards by the uterusduring the third trimester when the diaphragm is pushed upwards by the uterus

Chest radiograph:Chest radiograph: Routine chest radiographs should be avoided, especially in the first trimester Routine chest radiographs should be avoided, especially in the first trimester

Echocardiography :Echocardiography :Of choice tool for diagnosis and evaluation of suspected cardiac disease in the Of choice tool for diagnosis and evaluation of suspected cardiac disease in the pregnant patient.pregnant patient.

Normal changes attributable to pregnancy include increased left ventricularNormal changes attributable to pregnancy include increased left ventricular mass and mass and dimensionsdimensions

27 years female 27 years female

,pregnant,pregnant

C/O SOBC/O SOB

EchocardiographyEchocardiography

Heart disease in pregnancyHeart disease in pregnancy

1-4% of pregnancies involve maternal CV 1-4% of pregnancies involve maternal CV diseasesdiseases

CV disease does not preclude pregnancy CV disease does not preclude pregnancy but poses increased risk to mother and but poses increased risk to mother and fetusfetus

RISK ASSESSMENT RISK ASSESSMENT

Preconception counselingPreconception counseling

Discussion of contraception,Discussion of contraception,

Maternal and fetal risks during pregnancy,Maternal and fetal risks during pregnancy,

Potential long-term maternal morbidity and Potential long-term maternal morbidity and mortality.mortality.

The New York Heart Association(NYHA) The New York Heart Association(NYHA) functional class is often used as a predictor of functional class is often used as a predictor of outcome.outcome.

RISK ASSESSMENTRISK ASSESSMENT

Women with NYHA class III and IV Women with NYHA class III and IV face a mortality rate upwards of 7% face a mortality rate upwards of 7% and a morbidity rate of over 30%. and a morbidity rate of over 30%.

These women should be strongly These women should be strongly cautioned against pregnancy.cautioned against pregnancy.

In a study of 252 completed pregnancies in In a study of 252 completed pregnancies in women with cardiac disease, five factors were women with cardiac disease, five factors were found to be predictive of maternal cardiac found to be predictive of maternal cardiac complicationscomplications

Prior CHF, TIA, stroke or arrhythmiaPrior CHF, TIA, stroke or arrhythmia

Baseline NYHA class >II or cyanosisBaseline NYHA class >II or cyanosis

Left heart obstructionLeft heart obstructionMVA <2 cmMVA <2 cm22, AVA <1.5cm, AVA <1.5cm

LVOT gradient >30 mm Hg by echoLVOT gradient >30 mm Hg by echo

systemic vent dysfunction (EF <40%)systemic vent dysfunction (EF <40%)

RISK ASSESSMENTRISK ASSESSMENT

Low RiskLow Risk

Ventricular septal defect Ventricular septal defect

Atrial septal defectAtrial septal defect

Patent ductus arteriosus Patent ductus arteriosus

Asymptomatic AS with low mean gradient and normal LV function Asymptomatic AS with low mean gradient and normal LV function (EF>50%) (EF>50%)

AR with normal LV function and NYHA class I or II AR with normal LV function and NYHA class I or II

MVP (isolated or with mild/moderate MR and normal LV function) MVP (isolated or with mild/moderate MR and normal LV function)

MR with normal LV function and NYHA class I or II MR with normal LV function and NYHA class I or II

Mild/moderate MS (MVA >1.5 cmMild/moderate MS (MVA >1.5 cm22, mean gradient <5 mm Hg) without , mean gradient <5 mm Hg) without severe pulmonary hypertension severe pulmonary hypertension

Mild/moderate PS Mild/moderate PS

Repaired acyanotic congenital heart disease without residual cardiac Repaired acyanotic congenital heart disease without residual cardiac dysfunctiondysfunction

Intermediate RiskIntermediate Risk

Large left to right shunt Large left to right shunt

Coarctation of the aorta Coarctation of the aorta

Marfan's syndrome with a normal aortic root Marfan's syndrome with a normal aortic root

Moderate/severe MS Moderate/severe MS

Mild/moderate AS Mild/moderate AS

Severe PS Severe PS

History of prior peripartum cardiomyopathy with History of prior peripartum cardiomyopathy with no residual ventricular dysfunction no residual ventricular dysfunction

High risk High risk

Eisenmenger's syndrome Eisenmenger's syndrome

Severe pulmonary hypertension Severe pulmonary hypertension

Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, tricuspid atresia) tricuspid atresia)

Marfan's syndrome with aortic root or valve involvement Marfan's syndrome with aortic root or valve involvement

Severe AS with or without symptoms Severe AS with or without symptoms

Aortic and/or mitral valve disease with moderate/severe LV dysfunction Aortic and/or mitral valve disease with moderate/severe LV dysfunction (EF<40%) (EF<40%)

NYHA class III to IV symptoms associated with any valvular disease or NYHA class III to IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology with cardiomyopathy of any etiology

History of peripartum cardiomyopathy with persistent LV dysfunctionHistory of peripartum cardiomyopathy with persistent LV dysfunction

AS = aortic stenosis, LV = left ventricle, EF = ejection fraction, AR = aortic regurgitation, NYHA = New York Heart Association, MVP = mitral valve prolapse, MS = mitral stenosis, MVA = mitral valve area, PS = pulmonary stenosis, TOF = tetralogy of Falot, TA = Truncus arteriosus, TGA = transposition of the great arteries Adapted from reference 3.

High riskHigh risk

The high-risk conditions are associated The high-risk conditions are associated with increased maternal and fetal with increased maternal and fetal mortality. Pregnancy is not advised.mortality. Pregnancy is not advised.

If pregnancy should occur, therapeutic If pregnancy should occur, therapeutic abortion to be considered . abortion to be considered .

These patients are best managed with the These patients are best managed with the assistance of a cardiologistassistance of a cardiologist

Women with congenital heart Women with congenital heart disease outcome of pregnancydisease outcome of pregnancy

Good outcome is expected in Good outcome is expected in presence of acyanotic CHDpresence of acyanotic CHD– Disease natureDisease nature– Surgical repairSurgical repair– PAP, LV dysfunction,PAP, LV dysfunction,– Functional capacity Functional capacity – LV obstructionLV obstruction– ArrhythmiaArrhythmia

Fetal wastage in 45 % of cyanotic mothers Fetal wastage in 45 % of cyanotic mothers compared tocompared to 20 % in non cyanotic20 % in non cyanoticLow birth weightLow birth weight Prematuritey Prematuritey Risk of Cong.HD (4 to 8 %) Risk of Cong.HD (4 to 8 %)

Women with congenital heart Women with congenital heart disease outcome of pregnancydisease outcome of pregnancy

Women with congenital heart Women with congenital heart disease :disease :Labor and deliveryLabor and delivery

Elective induction of labor when maturity is Elective induction of labor when maturity is confirmedconfirmed

Vaginal delivery is recommendedVaginal delivery is recommended

Oxygen, pain control, fluid loss Oxygen, pain control, fluid loss management, Antibiotic prophylaxis management, Antibiotic prophylaxis

ASDASD– Well tolerated even with large shunts. No Well tolerated even with large shunts. No

need for AB prophylaxis( if no association)need for AB prophylaxis( if no association)

VSDVSD– Usually tolerated. CHF, arrhythmia are Usually tolerated. CHF, arrhythmia are

reported. Hypotension and fluid loss can reported. Hypotension and fluid loss can enhance shunt reversal in those with enhance shunt reversal in those with pulmonary HTNpulmonary HTN

PDAPDA– Shunt reversal need to be avoided. CHF has Shunt reversal need to be avoided. CHF has

been reportedbeen reported

Congenital Aortic StenosisCongenital Aortic Stenosis– Moderate and severe AS has been associates Moderate and severe AS has been associates

with maternal morbidity and mortalitywith maternal morbidity and mortality– Symptoms include SOB, chest pain and Symptoms include SOB, chest pain and

syncopesyncope– Severe AS managed by abortion followed by Severe AS managed by abortion followed by

AVR, or continuation of pregnancy with AVR, or AVR, or continuation of pregnancy with AVR, or AVB in case of clinical deteriorationAVB in case of clinical deterioration

AO CoarctationAO Coarctation– HTN, CHF, Aortic dissection have been HTN, CHF, Aortic dissection have been

reported. Avoid exertion, control BP reported. Avoid exertion, control BP

Pulmonary StenosisPulmonary Stenosis– Well tolerated. Balloon valvoplasty is Well tolerated. Balloon valvoplasty is

considered in case of progressive R considered in case of progressive R ventricular failure, increased cyanosis due to ventricular failure, increased cyanosis due to associated shuntsassociated shunts

Tetrology Of FallotTetrology Of Fallot– Repaired ( do well)Repaired ( do well)– Un repaired or those with residual lesions Un repaired or those with residual lesions

have increase risk mainly due to deterioration have increase risk mainly due to deterioration of cyanosisof cyanosis

Eisenmenger SyndromeEisenmenger Syndrome

High risk of maternal morbidity and mortality (40 %)High risk of maternal morbidity and mortality (40 %)

Pregnancy is not allowed, and abortion is recommended.Pregnancy is not allowed, and abortion is recommended.

Close follow-up for those insist to proceed with Close follow-up for those insist to proceed with

pregnancy. hyperviscositey, infection should be pregnancy. hyperviscositey, infection should be

monitored. Anticoagulation is recommended in third monitored. Anticoagulation is recommended in third

trimester.trimester.

Vaginal delivery is preferred with shortening of 2Vaginal delivery is preferred with shortening of 2ndnd stage. stage.

Inhaled NO has been used to reduce PAP and improve Inhaled NO has been used to reduce PAP and improve

oxygenation oxygenation

Women with Rhematic HDWomen with Rhematic HDAcute RF:rare during pregnancyAcute RF:rare during pregnancy

Chronic RHDChronic RHD

Restriction of activity in symptomatic patientsRestriction of activity in symptomatic patients

Antibiotic prophylaxisAntibiotic prophylaxis

Haemodynamic monitoring during labour and 24 Haemodynamic monitoring during labour and 24

hour post partum in patients who hadhour post partum in patients who had– LV FailureLV Failure

– with severe diseasewith severe disease

– pulmonary HTNpulmonary HTN

Rheumatic heart disease in Rheumatic heart disease in pregnancy pregnancy

Stenotic lesions: get worseStenotic lesions: get worse– Because of increase flowBecause of increase flow

Regurgitant Lesions : well tolerated Regurgitant Lesions : well tolerated – Because of decrease vascular resistantBecause of decrease vascular resistant

Rheumatic Mitral stenosis Rheumatic Mitral stenosis

Increase maternal morbidity but no mortalityIncrease maternal morbidity but no mortality

Symptoms in moderate and severe stenosis Symptoms in moderate and severe stenosis worsens by 1, or 2 NYHA classworsens by 1, or 2 NYHA class

Increased blood volume, HR increase MV Increased blood volume, HR increase MV gradient and hence LA pressure and predispose gradient and hence LA pressure and predispose AF and pulmonary edema. AF and pulmonary edema.

Rx: activity restriction, fluid and salt restriction. Rx: activity restriction, fluid and salt restriction. B-blockers, digoxin, diuretics.B-blockers, digoxin, diuretics.

In severe cases unresponsive to medical In severe cases unresponsive to medical therapy Balloon valvoplastey or surgery is therapy Balloon valvoplastey or surgery is recommendedrecommendedMaternal Risk of MV repair or replacement Maternal Risk of MV repair or replacement is comparable to non pregnant women.is comparable to non pregnant women.Foetal daeth during open heart surgery Foetal daeth during open heart surgery (20-30%)(20-30%) Closed commissurotomy is associated Closed commissurotomy is associated with minimal risk to the fetus. with minimal risk to the fetus.

Rheumatic Mitral stenosis Rheumatic Mitral stenosis

Rheumatic heart disease in Rheumatic heart disease in pregnancy pregnancy

MR is well toleratedMR is well toleratedAR well tolerated AR well tolerated

Aortic stenosis : severe disease mandate Aortic stenosis : severe disease mandate termination or valve surgery,Valvoplasty in termination or valve surgery,Valvoplasty in experienced center experienced center

Present in 1.2 % of pregnant womenPresent in 1.2 % of pregnant women

B-blockers can be used for significant B-blockers can be used for significant

symptomssymptoms

AB prophylaxis:if associated with MRAB prophylaxis:if associated with MR

Mitral valve prolapse

Marfan syndromeMarfan syndrome

Patients with dilated aorta or with history of Patients with dilated aorta or with history of dissection should be advised against pregnancydissection should be advised against pregnancy

Progressive dilatation of the aorta leading to AR Progressive dilatation of the aorta leading to AR and CHF. Aortic dissectionand CHF. Aortic dissection

Aortic diameter less then 40 mm is usually Aortic diameter less then 40 mm is usually toleratedtolerated

Avoid physical exertion. B-blocker decrease Avoid physical exertion. B-blocker decrease aortic dilatationaortic dilatation

CS is preferred in patients with dilated aorta or CS is preferred in patients with dilated aorta or with dissection with dissection

Cardiomyopathy: Cardiomyopathy: HOCMHOCM

CHF is reported in 20 % of patientsCHF is reported in 20 % of patients

Arrhythmias (SVT,AF, VT). SCDArrhythmias (SVT,AF, VT). SCD

Up to 50% inheritanceUp to 50% inheritance

Rx: B-blockers, Ca-channel blockers, diuretics. Pacing. Rx: B-blockers, Ca-channel blockers, diuretics. Pacing. ICD ICD

Vaginal delivery with shortening of 2Vaginal delivery with shortening of 2ndnd stage. stage.

Spinal and epidural anesthesia should be used with Spinal and epidural anesthesia should be used with caution.caution.

Fluid replacement and AB prophylaxis Fluid replacement and AB prophylaxis

Peripartum cardiomyopathyPeripartum cardiomyopathy

Form of DCM reported in up to 1in 1000 in Form of DCM reported in up to 1in 1000 in certain parts of Africa. Develop during certain parts of Africa. Develop during pregnancy or 6 mo post partumpregnancy or 6 mo post partumCommon in multiparous, preeclampsia, and twin Common in multiparous, preeclampsia, and twin pregnancy, as well as in women > 30 ypregnancy, as well as in women > 30 yUnknown etiologyUnknown etiology50 to 60 % of patients show complete or near 50 to 60 % of patients show complete or near complete recoverycomplete recoveryDeath or cardiac Tx in 12 to 18 %Death or cardiac Tx in 12 to 18 %Relapse can occur with a mortality of 2 % in Relapse can occur with a mortality of 2 % in those with recovered LVF, and up to 17 % in those with recovered LVF, and up to 17 % in those with residual LVD. those with residual LVD.

CAD In PregnancyCAD In Pregnancy

Exclude Coronaries and aortic dissectionExclude Coronaries and aortic dissection

Coronary angio, aortic imaging Coronary angio, aortic imaging

PCI, CABGPCI, CABG

ThrombolysisThrombolysis

Consider if angio not availableConsider if angio not available

High-riskHigh-risk

Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy

Most CV drugs cross placenta and Most CV drugs cross placenta and secreted in breast milksecreted in breast milk

Weigh risk/benefit ratio - avoid when Weigh risk/benefit ratio - avoid when possible possible

Use drugs with long safety recordUse drugs with long safety record

Prescribe lowest dose for shortest durationPrescribe lowest dose for shortest duration

Avoid multi-drug regimensAvoid multi-drug regimens

No drug is completely safeNo drug is completely safe

Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy

ACE inhibitors - ContraindicatedACE inhibitors - Contraindicated

30% fetal morbidity 30% fetal morbidity

Fetal renal tubular dysplasiaFetal renal tubular dysplasia

Neonatal renal failure - oligohydramniosNeonatal renal failure - oligohydramnios

Lack of cranial ossification, IUGRLack of cranial ossification, IUGR

Angiotensin II receptors blocker - Angiotensin II receptors blocker - contraindicatedcontraindicated

Beta - blocker In PregnancyBeta - blocker In Pregnancy

Effective and relatively safeEffective and relatively safe

Metoprolol, Atenolol, LabetalolMetoprolol, Atenolol, Labetalol

IndicationsIndications

Arrhythmias, aortic disease, HCM, HTNArrhythmias, aortic disease, HCM, HTN

Concerns - fetal and neonatalConcerns - fetal and neonatal

IUGR, apnea, HR, hypoglycemiaIUGR, apnea, HR, hypoglycemia

Calcium Antagonists In Calcium Antagonists In PregnancyPregnancy

Relatively safe for mother and fetusRelatively safe for mother and fetus

Tocolytic effect - stop near termTocolytic effect - stop near term

Dysfunctional labor, postpartum hemorrhageDysfunctional labor, postpartum hemorrhage

May uteroplacental perfusionMay uteroplacental perfusion

Beta-blocker preferred if toleratedBeta-blocker preferred if tolerated

Diuretics In PregnancyDiuretics In Pregnancy

Best not to use during pregnancyBest not to use during pregnancy

Fetal electrolyte and platelet effectFetal electrolyte and platelet effect

maternal intravascular volumematernal intravascular volume

utero-placental perfusionutero-placental perfusion

Use only in setting of CHFUse only in setting of CHF

Better to start before pregnancyBetter to start before pregnancy

Anticoagulation In PregnancyAnticoagulation In Pregnancy

Hematological changesHematological changes

clotting factor concentrationclotting factor concentration

platelet adhesivenessplatelet adhesiveness

fibrinolysisfibrinolysis

risk thrombosis and embolismrisk thrombosis and embolism

Anticoagulation In PregnancyAnticoagulation In Pregnancy

Low Dose AspirinLow Dose Aspirin

Safe - antithrombotic effect not provenSafe - antithrombotic effect not proven

Recommended for pt with shunts, cyanosis and Recommended for pt with shunts, cyanosis and biological valvesbiological valves

Possible incidence of preeclampsiaPossible incidence of preeclampsia

Low molecular weight heparinLow molecular weight heparin

Not enough information available in Not enough information available in

Thrombolytic therapyThrombolytic therapy

Emergency use onlyEmergency use only

Warfarin EmbryopathyWarfarin Embryopathy

Bone and cartilaginous abnormality 30%Bone and cartilaginous abnormality 30%

ChondrodysplasiaChondrodysplasia

Nasal hypoplasiaNasal hypoplasia

Optic atrophy with micropthalmiaOptic atrophy with micropthalmia

Developmental delayDevelopmental delay

Miscarriage or stillbirth 37%Miscarriage or stillbirth 37%

Very low risk <5mgVery low risk <5mg

Bio-Prosthetic Valves: Bio-Prosthetic Valves: PregnancyPregnancy

Tissue prosthesisTissue prosthesis

degeneration in degeneration in young young

73% in 10 years 73% in 10 years

Accelerated Accelerated degenerationdegeneration

Possible in Possible in pregnancypregnancy

Reoperation riskReoperation risk

Metallic Valve Disease In Metallic Valve Disease In PregnancyPregnancy

MechanicalMechanical Thrombosis riskThrombosis risk

High mortality 10%High mortality 10%

Limited Rx optionsLimited Rx options

Anticoagulation In PregnancyAnticoagulation In Pregnancy

Anticoagulation In PregnancyAnticoagulation In Pregnancy

Labor and DeliveryHigh Risk Time

Planned DeliveryStop heparin peripartum

Resume after 4 - 6 hr

IE Prophylaxis In PregnancyIE Prophylaxis In Pregnancy

AHA guidelinesAHA guidelines

IE prophylaxis not required during IE prophylaxis not required during uncomplicated deliveryuncomplicated delivery

Not required Not required

Isolated ASDIsolated ASD

6 months after PDA or VSD closure6 months after PDA or VSD closure

Reasonable to administer IEReasonable to administer IE

prophylaxis in high-risk patientsprophylaxis in high-risk patients

Endocarditis ProphylaxisEndocarditis Prophylaxis

GI/GU regimenGI/GU regimen

Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im

or iv 30 min before procedureor iv 30 min before procedure

6 hrs later6 hrs later

Ampicillin 1 gm im or iv or Amoxicillin 1 gm poAmpicillin 1 gm im or iv or Amoxicillin 1 gm po

PCN allergicPCN allergic

Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5 Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5 mg/kg (<120 mg) im or ivmg/kg (<120 mg) im or iv

Complete Rx within 30 min of procedureComplete Rx within 30 min of procedure

Thank you Thank you

Best LuckBest Luck