RF & RHD Workshop 22 nd March MANAGEMENT of RHEUMATIC HEART DISEASE in PREGNANCY. Dr Dorothy Radford

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1 RF & RHD Workshop 22 nd March 2016 MANAGEMENT of RHEUMATIC HEART DISEASE in PREGNANCY Dr Dorothy Radford

2 PREGNANCY PHYSIOLOGY Increased cardiac output 30%-50% Increased blood volume 30%-50% Increased heart rate bpm at rest Increased red cell mass 20-30% Relative anaemia Decreased vascular resistance Decreased blood pressure

3 LABOUR & DELIVERY Uterine contractions cause an extra 300 to 500 mls of blood to enter circulation Increased BP Increased HR Increased CO (at delivery, up to 80% above pre-pregnancy level)

4 CLINICAL FINDINGS IN PREGNANCY Hyperdynamic circulation Systolic murmur > 90% Third heart sound > 80% Venous hum Mammary souffle Diastolic murmur of severe mitral stenosis can be missed.

5 PREGNANCY IN RHEUMATIC HEART DISEASE Circulatory load will exacerbate existing problems. Need to discuss and plan ahead with young women. Contraceptive advice. Appropriate intervention before pregnancy.

6 RISK FACTORS Predictors of increased maternal & foetal risk Stenotic lesions Mitral & Aortic stenosis (Regurgitant lesions better tolerated) Pulmonary hypertension Reduced LV function History of heart failure Symptoms before pregnancy Atrial fibrillation Mechanical valve- warfarin

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8 PREGNANCY SCAN FOETAL ULTRASOUND ECHOCARDIOGRAM

9 MITRAL STENOSIS

10 MITRAL STENOSIS

11 RHEUMATIC MITRAL VALVE For MITRAL STENOSIS intervene when Symptomatic - dyspnoea Mitral Valve Area < 1.5 cm2 Pulmonary Artery Pressure > 50 mmshg

12 BALLOON MITRAL VALVOTOMY

13 SEVERE CALCIFIC MITRAL STENOSIS

14 AORTIC STENOSIS

15 AORTIC INCOMPETENCE

16 RHEUMATIC AORTIC INCOMPETENCE Indications for Surgery Symptoms LVEDD > 70 mms LVESD > 55 mms LVEF < 55%

17 RHEUMATIC MITRAL STENOSIS AND INCOMPETENCE Long axis view of MV. Patient QW of Mornington Is

18 Four chamber view of Mitral valve with Stenosis & Incompetence Patient QW

19 Four chamber colour Doppler view of Mitral valve Patient QW

20 MITRAL REGURGITATION - INDICATIONS FOR SURGERY SYMPTOMS ECHO- Reduced EF >60% Dilated LV LVESD >40mms PHT PAS > 50 mms Hg OPERATION of choice MV repair MVR if calcified leaflets etc Avoid mechanical MVR if likely future pregnancy or concern about warfarin adherence

21 Pre-op view of Mitral valve by 3D echo Patient QW

22 MITRAL VALVE REPAIR WITH ANNULOPLASTY RING

23 TISSUE MITRAL VALVE REPLACEMENT

24 MECHANICAL MITRAL VALVE REPLACEMENT

25 PREGNANCY & RHEUMATIC HEART DISEASE Stenotic lesions MS / AS a concern Regurgitant lesions are tolerated Reduced LV function/ prior heart failure/ symptomatic valve disease Prosthetic heart valves / Anticoagulants

26 PROSTHETIC VALVES BIOPROSTHETIC No anticoagulants Valve deterioration Re-operation risk MECHANICAL Require anticoagulant Risk to mother & foetus

27 TISSUE VALVES PIG COW HUMAN Porcine xenograft Bovine pericardial valve Homograft or Allograft

28 DOUBLE JEOPARDY ANTICOAGULATION in PREGNANCY WARFARIN Crosses the placenta embryopathy risk of miscarriage risk of foetal bleed neonatal cerebral haemorrhage HEPARIN Does not cross the placenta thrombocytopaenia osteoporosis alopecia risk of valve thrombosis

29 WARFARIN EMBRYOPATHY COAGUCHECK Nasal hypoplasia Stippled epiphyses Short fingers & neck Low birth weight Careful control of INR is essential Dose < 5mg warfarin daily is unlikely to cause embryopathy

30 ANTICOAGULANTS PREGNANCY IS A HYPERCOAGUABLE STATE Warfarin gives effective protection Higher risk with higher dose Need to change to heparin 2-4 weeks before delivery (Risk of fetal brain haemorrhage in birth canal) Heparin seems to offer inferior protection Fetal loss from placental haemorrhage Need frequent self injections Need stringent monitoring Increasing dose requirement

31 DRUGS in PREGNANCY Category A No known foetal risk B - No known human risk. Animal study + C - Pharmacological effect may harm D - Incidence of foetal malformations X - High risk of foetal damage Prescribing medicines in Pregnancy 4 th Edition 1999 Australian categorisation Therapeutic Goods Administration. Web

32 ARRHYTHMIAS IN PREGNANCY Pregnancy is arrhythmogenic Cardioversion can be used safely Antiarrhythmic drugs Adenosine B Digoxin A Flecainide B Beta-blockers C Verapamil C Amiodarone C

33 C.C.F. THERAPY in PREGNANCY Digoxin A Diuretics C Beta-blockers C ACE inhibitors D (Can cause in utero foetal death, neonatal anaemia & renal failure) N.B. Natural vasodilatation in pregnancy

34 INDICATIONS for CAESARIAN SECTION Obstetric reasons Obstructive lesions Pulmonary hypertension Anticoagulation with warfarin (failure to switch to heparin)

35 Endocarditis Prophylaxis at Delivery RECOMMENDED In the setting of possible bacteraemia Ampicillin + Gentamycin

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