Valve Disease in the Pregnant Patient

Transcription

1 Valve Disease in the Pregnant Patient Julie B. Damp, MD December 6, 2012 VanderbiltHeart.com

2 If single, do not allow marriage. If fertile, do not allow pregnancy. If pregnant, do not allow delivery. If delivered, do not allow breastfeeding.

3 Objectives Understand the normal cardiovascular changes that occur during pregnancy Understand major principles of treatment of valve disease during pregnancy

4 Maternal Cardiac Disease Complicates 1-4 % of pregnancies in US Major cause of nonobstetric maternal morbidity and mortality ~ 16% of maternal deaths Management more complicated than cardiac disease in nonpregnant women Much of data is not recent and is observational

5 Hemodynamic changes in pregnancy Normal changes in Intravascular volumes Cardiac output SVR BP Begin early in pregnancy (weeks 5-8) Impact cardiovascular exam and tests

6 Intravascular volumes

7 Labor & Delivery Anxiety, pain, exertion, contractions, bleeding, anesthesia With uterine contraction Displacement of blood into circulation BP Mimic of Valsalva Cardiac output 15-50% in labor 80% post partum

8 Echo Indications Valvular/congenital disease Grade 3 systolic murmur Diastolic murmur Significant dyspnea or CHF signs

9 Predictors of risk Prior cardiac events heart failure, TIA, CVA NYHA functional class >II or cyanosis Valvular or outflow tract obstruction Myocardial dysfunction From Siu SC, Sermer M, et al.circulation. 2001;104:

10 Valvular Heart Disease

11 General Principles Ideally seen prior to pregnancy or early as possible Counseling, including maternal and fetal risks Baseline echo and functional status Adjust medications to optimize fetal risk

12 General Principles High risk lesions correction prior to pregnancy High risk lesion early in pregnancy discuss termination Evaluate once a trimester and for any change in symptoms VanderbiltHeart.com

13 General Principles Cardiac surgery Refractory Class III or IV symptoms Maternal risks nonpregnant patients High risk of fetal distress, IUGR, and fetal demise (19-29%) L & D scheduled and induced when possible with close monitoring

14 Case - 22 year old female Desires to get pregnant. Mild LE edema. PMH: Rheumatic heart disease with severe MR s/p repair 2004 All: NKDA Meds: Multivitamin FH: No cardiac disease Soc: No tobacco, alcohol or illicit drugs PE: 125/ % Normal JVP CTAB Regular, S1, S2, III/VI systolic murmur at LLSB to apex Soft, NT Trace 1+ edema

15 22 year old female

16 22 year old female VanderbiltHeart.com

17 22 year old female

18 Mitral Stenosis (Deteriorate in 3 rd trimester and labor) volume LA filling pressures, dyspnea exercise tolerance HR transmitral gradient diastolic filling time CO of 46% with contractions Ramsey, et al. Amer J Perinat 2001;18(5):

19 Severe MS 67% pulmonary edema or arrhythmia Maternal mortality 5% with Class III-IV Fetal mortality 30% with Class IV Heart failure prematurity and IUGR Atrial fibrillation risk of hemodynamic deterioration Anticoagulation VanderbiltHeart.com

20 Mitral Stenosis Medical management Prevention of tachycardia Maintenance of LV preload Diuretics cautiously if needed PA catheters for symptomatic patients Epidural anesthesia better tolerated than general anesthesia

21 Mitral Stenosis Severe MS correct prior to pregnancy Percutaneous balloon valvuloplasty Bridge patient through pregnancy Failed medical management during pregnancy Timing weeks gestation Success rate 95% Symptomatic improvement = surgical correction Fetal complications 5% vs 38% with surgery De Souza, JA, Martinez, et al. J Am Coll Cardiol 2001; 37:900

22 22 year old female Not candidate for valvuloplasty Advised to delay pregnancy Seen by cardiac surgery recommendation for bioprosthetic valve Choose to proceed with pregnancy and delivered without complications

23 Case - 26 year old female Asymptomatic, desires to get pregnant. PMH: Bicuspid AV, HTN, G5P2123 All: NKDA Meds: Multivitamin FH: No cardiac disease Soc: Smokes, no alcohol or illicit drugs PE: 142/ % Normal JVP CTAB Regular, S1, S2, III/VI systolic murmur at USB radiating to neck Soft, NT No edema

24 26 year old female

25 26 year old female

26 Aortic Stenosis Bicuspid valve most common Severe AS Decompensates late 2 nd /early 3 rd trimester Maternal mortality 17% Fetal mortality 32%

27 Aortic Stenosis Medical management Control tachycardia Avoid vasodilation Avoid volume depletion Reduction of physical activity Epidural anesthesia used cautiously due to vasodilatory effects VanderbiltHeart.com

28 Aortic Stenosis Severe AS corrected prior to pregnancy Percutaneous balloon valvuloplasty Prior to pregnancy to delay repair Refractory to medical management Consider with peak gradient > 50mmHg (cath) Bicuspid AV and root dilatation May predispose to aortic dissection Considered a high risk lesion in combination

29 Regurgitant Lesions Chronic mild to moderate MR and AI well tolerated Severe MR or AI corrected prior to pregnancy Close hemodynamic monitoring Diuretics Vasodilator therapy Epidural anesthesia VanderbiltHeart.com

30 Right Sided Valves Pulmonary stenosis well tolerated Balloon valvuloplasty for refractory right sided failure Isolated TR well tolerated

31 Prosthetic Valves

32 Prosthetic Valves DiSaia P. Obstet Gynecol Review 1966;28:

33 Prosthetic Valves Cardiologist involved as early as possible Valve choice Anticoagulation? higher complications with mechanical Pregnancy loss Preterm delivery Maternal cardiac complications? increased degeneration of bioprosthetic valves Sbarouni E, et al. Br Heart J 1994;71:

34 Warfarin > maternal protection (5.7% death or embolic) Crosses placenta fetal death and premature birth Fetal bleeding and cerebral hemorrhage can occur Warfarin embryopathy Nasal hypoplasia, depressed nasal bridge, IUGR, eye defects, punctate epiphyseal dysplasia 1 st trimester exposure CNS abnormalities after any trimester exposure Incidence 5-67% Risk lower with <5mg daily

35 Unfractionated Heparin Safer for the fetus Does not cross the placenta No fetal bleeding or teratogenicity Can cause uteroplacental junction bleeding Risk of maternal thrombocytopenia and osteopenia Thromboembolic complications (12 24%) Target PTT of at least twice the control

36 Low Molecular Weight Heparin Does not cross the placenta Advantages Ease of administration Less thrombocytopenia and osteoporosis More predictable dose response Potential for less monitoring Lower risk of bleeding complications Monitor plasma anti-xa levels 4-6h after morning dose Target level is units/ml

37 Mechanical Aortic Valve Replacement in Young Women Planning on Pregnancy J Am Coll Cardiol. 2012;59(12): doi: /j.jacc VanderbiltHeart.com

38 Recommendations based on risk (differ in US and Europe) High Risk Old generation MV, AF, prior TE? Higher target levels? Add ASA Low Risk New generation MV, AV Elkayam, et al, JACC 2012 Mar 20;59(12): VanderbiltHeart.com

39 Reasonable Strategies 1. LMWH or UFH weeks 6-12 and close to term (week 35-36), with warfarin at other times OR 2. Aggressively dose adjusted UFH throughout OR 3. Aggressively dose adjusted LMWH throughout Decision with patient, OB, and cardiologist

40 Conclusions Hemodynamic changes associated with pregnancy Left sided obstructive lesions, poor functional class, LV dysfunction not well tolerated Prosthetic valve choice/anticoagulation controversial Counseling ideally done prior to pregnancy including maternal and fetal risks Cardiologists involved as early as possible in the care of these patients