How to manage the pregnant woman with heart disease

Transcription

1 How to manage the pregnant woman with heart disease Dr Fiona Walker, The Heart Hospital,UCLH, London Dr Sara Thorne, University Hospital Birmingham Dr Cathy Head, The Heart Hospital, UCLH, London Dr Kate English, The Yorkshire Heart Centre, Leeds

2 Why you need to know Dr Fiona Walker Consultant Cardiologist The Heart Hospital, UCLH NHS Trust, London No conflict of interest

3 Prevalence maternal heart disease ~ 1-3% Author / Year Country No Preg Prev of Rh HD Congenital HD Other HD Maternal with HD Maternal HD Mort Etheridge Australia 764.5% 83% 13% 4% 1.3% Sugrue Ireland 387.5% Mc Faul N.Ireland % Bitsch Denmark 87.3%

4 Maternal heart disease UCL High-Risk Obstetric service Acquired heart disease Congenital heart disease 131

5 Impact of Infant Heart Surgery 1 Surgery GOS % alive 5 new population Natural history 1 mnth 1 yr 5 yrs 15 yrs

6 198 Adult CHD patients Paediatric CHD patients 21 Adult CHD patients Paediatric CHD patients

7 North East Regional Database Birth 1 year 16 years new cases per year require LTFU in UK 72 91/year + = Infants O Sullivan, Wren BCS 2 >Infants Follow-up ~ 16-2 patients in UK

8 GUCH Population More adults than children with Tetralogy! Fallot s Almost no children with Mustard or Senning

9 Circulatory changes in pregnancy Oxygen consumption 2% Term Plasma volume 45-5% 32 weeks SVR 2% 24 weeks PVR 34% 34weeks SBP 9% 28 weeks DBP HR 2-3% term SV 1-3% Term CO 3-5% Term

10 The haemodynamic changes of pregnancy Peripheral vascular resistance CO PVR Baseline CO pregnancy Labour & delivery puerperium

11 Maternal mortality 25 m ortality per 1, m aternities maternal mortality direct mortality indirect mortality cardiac

12 Indirect maternal mortality (deaths per 1, maternities) all indirect cardiac suicide cancer other indirect

13 Maternal mortality UK Rate per million maternities Thromboembolism HT Haemorrhage AFE Sepsis Trauma Anaesthetic Cardiac Psychiatric Data from Why mothers die

14 Deaths from heart disease & Rheumatic SBE Coronary Other

15 Maternal Cardiac deaths CHD 2% cardiomyopathy aneurysm MI PHT other CEMACH deaths from heart disease Substandard care in 4%

16 Lesion specific pregnancy outcome data Maternal lesion No pregnancies No abhortion Maternal mortality % Maternal CVS comp % Live births % MS AS (a) Severe AS Repaired CoA Repaired TOF Mustard Fontan Marfan (a) PHT Cy + / no PHT Mechanical Valve (c) 83 Tissue valve U. Thilen, SB Olsson. Eur J Obs & Gynae and Reproductive biology 75(1997) 43-5

17 Toronto prospective multicentre study of pregnancy outcomes in women with heart disease 562 women, 599 pregnancies, 13 centres Review at <28/4, 28-37/4, peripartum,6/52 postpartum, 6/12 post CHD (445) 74%, acquired (127) 24%, arrhythmia (27) 4%, PHT (25) 4% Baseline: 21 (4%) NYHA III, Cy+ 4 13% pregnancies complicated by pulmonary oedema, arrhythmia or stroke % mortality (Sui et al ; Circulation;14:July 22)

18 The 4 predictors of maternal cardiac events are ; Prior episode of heart failure, TIA, CVA, or arrhythmia NYHA II or cyanosis Left heart obstruction (MVA < 2 cm2, AVA < 1.5 cm2, Peak LVOTO > 3 mmhg on echo) Reduced LV function (EF < 4%) predictors - risk of a cardiac event is 5% 1 predictor - risk of cardiac event 27% > 1- risk of cardiac event is 75% (Sui et al, Circulation;14:July 22)

19 Obstetric Problems which increase Maternal risk > Twins Pre-eclampsia Haemorrhage Premature Labour Hydramnios

20 Motto; 6P s Prior planning, prevents poor performance (outcome)

21 Pre-Pregnancy counselling ; 1. The complexity of the heart lesion 2. Appreciate impact of normal haemodynamic changes on lesion 3. Detailed knowledge of prior surgical correction(s)/interventions 4. Detailed knowledge of residua / sequelae 5. A discussion re ; long-term prognosis & risk of recurrence in offspring? 22q11 6. Optimisation of clinical status including drugs 7. Knowledge of other co-morbid medical problems

22 Pre - Pregnancy work-up Clinical review and examination Up to date TTE / stress echo ETT or CPEX Optimise and change Meds Communicate with obstetric team & local cardiologist Plan place & frequency of reviews

23 Labour & delivery planning Obstetric unit or cardiac unit Early or term Vaginal delivery v s C-section Epidural / Spinal/ Natural Haemodynamic monitoring - invasive / non-invasive CVS drugs Endocarditis prophylaxis Duration of monitoring / observation post-partum

24 If single do not allow marriage, If fertile do not allow pregnancy If pregnant do not allow delivery(!?) If delivered do not allow breast feeding XIX century Obstetric aphorism referring to women with heart disease

25 Manpower for the high risk cardiac obstetric service Anaesthesia GUCH cardiologist Obstetrician Haematologist Obstetric physician Neonatologist Foetal medicine Specialist nurse Intensive care

26 Thankyou!