37th Annual Advanced Practice in Primary and Acute Care Conference: October 9-11, 2014 2:45 SESSION D5 Session Description: The Heart of the Matter: Cardiac Disease in Pregnancy Brad M. Dolinsky, MD, MFM S E S S I O N D5 Cardiac disease in pregnancy can be a complex milieu of physiology and seem overwhelming. The effects of the disease on the pregnancy, and the pregnancy on the disease can be complex. This lecture will attempt to review cardiac diseases seen in pregnancy, provide a tool for counseling patients with cardiac disease in pregnancy, and provide a tool for rapid management of hypertension in pregnancy. Learning Objectives: Following my presentation, participants will be able to: 1. Identify cardiac lesions that are amenable to drops in systemic vascular resistance. 2. Review a rapid assessment to risk stratify pregnant patients with cardiac disease. 3. Review management of hypertension in pregnancy.
Clinical Pearls for Cardiovascular Disease in Pregnancy The Heart of The Matter: Cardiac Disease in Pregnancy Provide general overview of cardiac physiologic changes in pregnancy Review common cardiac diseases seen clinically Provide a tool for counseling patients with known structural cardiac disease Review breakdown of lesions that are amenable to decrease in systemic vascular resistance Provide a rapid tool for management of hypertensive emergency Increase in Heart rate (about 20%) Increase in Cardiac Output (40%) Increase in Blood Volume (50%) Decrease in SVR(20%) Goals Physiologic adapatations Cardiac output INCREASES In Labor During Valsalva With pain With infection(chorio) High cardiac output state immediately after delivery of placenta and for 4 weeks Cardiac output decreases by 20% when supine, and 16% in dorsal lith Five principles of pregnancy that complicate cardiac disease of pregnancy Decreased SVR Increase in intravascular volume Postpartum increase in intravascular volume from auto-transfusion of blood from the contraction of uterus and mobilization of fluid Hypercoaguable Increase in CO during parturition 1
General management Activity modification (avoid bedrest though) Treat co-existing medical conditions(anemia/htn/thyroid disease) Collaborative care Labor in lateral decubitous Pain control, minimize hypotension O2 as necessary General management continued Invasive monitoring w/ PAC-reserve for sickest patients such as those with critical AS and Pulmonary HTN. TEE used more recently to guide fluid management. Cesarean delivery for obstetric indication (exception is a recent MI within 1 week) Class I-asymptomatic with greater than normal activity Class II-symptomatic with greater than normal activity(stairs) Class III-symptomatic with normal activity(walking) Class IV-symptomatic at rest New York Heart Association classification The Good-Minimal mortality (<1%) ASD VSD Pulmonic or Tricuspid valve disease Corrected TOF Bioprosthetic heart valve Mitral Stenosis NYHA I and II Marfan syndrome normal aorta Aortic or mitral insufficiency Hypertrophic cardiomyopathy (IHSS) The Good, Bad, and Ugly The Bad-5-15% mortality Mitral Stenosis NYHA III and IV Artifical heart valve Aortic stenosis Coarctation of aorta Uncorrected TOF MI The Ugly- >25% mortality Pulmonary Hypertension Coarctation-complicated Marfan aortic root dilation Dilated Cardiomyopathy The Good, Bad, and Ugly The Good, Bad, and Ugly 2
Marfan syndrome The Root of the Problem At risk for Aortic root aneurysm Aortic root >4cm, in preconception period, pregnancy is contraindicated <5 % vs about 10-25% risk for mortality Avoid hypertension Beta-blockade (long term use slows blockade), serial echocardiograms Early epidural use in labor Controversy on management of >4cm in pregnancy Eisenmenger s syndrome/pulmonary HTN 30% of women have a false diagnosis by echo (PA pressures >30mm Hg) When in doubt, in labor, pulmonary artery catheter Eisenmenger s-maternal death is high from hypoxemia and Pulmonary Embolism Cardiac Diseases Cardiac Diseases Eisenmenger s syndrome/pulmonary HTN Hypotension- reverse the shunt to right to left - avoided Run wet Use agents that decrease pulmonary vascular resistance w/ sparing of SVR IV prostocycline, nitric oxide Mitral Stenosis Generally good prognosis if MV is >1.5cm Stenosis less than this LV filling limited Fixed cardiac output Pulmonary edema Cardiac Diseases Mitral Stenosis Tachycardia should be avoided (short acting beta blockade goal HR 90-100). Improves diastolic filling Normal wedge is 6-9mm Hg, MS patients need predelivery target of 14mmHg to maintain left ventricular filling Patients with moderate stenosis and only mild fluid overload, can be managed w/ fluid restriction Mitral Stenosis percutaneous baloon valvuloplasty can safely be performed in pregnancy 3
Aortic Stenosis Mortality related to degree of stenosis- >100mm Hg shunt is associated w/ 15-20% mortality. Hypotension and decreased preload can lead to drop in cardiac output (avoid) May consider PAC for goal of 15-17mm Hg Hypovolemia is more dangerous than pulmonary edema Peripartum cardiomyopathy Cardiomyopathy with EF<45% during last 4 weeks and 5 months postpartum without an identifiable cause Management- serial echo Antepartum- diuretics, afterload reduction (hydralazine and or beta blockers) Postpartum-ACE inhibitors May need digoxin antepartum or postpartum Cardiac Diseases Cardiac Diseases Peripartum cardiomyopathy Consider PAC for severe patients antepartum with EF <35%, may also consider VTE prophylaxis Future- echo after recovery predicts outcome in subsequent pregnancy normal echo may have a 21% risk for CHF in future pregnancy, but less than 5% risk of maternal death Mrs Smith presents for preconception counseling 23 year-old Gravida 0 History of a cardiac disease structural Repaired as a child What are the risks to her getting pregnant? Case Patients have multiple problems Which problem is more important? How does the combined problem correlate with my patient sitting in front of me? How do you counsel this patient sitting in front of you? Case Case 4
N O P E Risk for an Event Event defined as pulmonary edema, arrhythmia, stroke, death N NYHA >2 Positive= 1 point O = Obstruction (Left heart obstruction) MV<2cm or AV<1.5cm or Gradient across valve >30mm Any of these positive =1 point P Prior event (prior to pregnancy) Any = 1 point E Ejection Fraction <40% Positive= 1 point 5
Risk for event with 0 points=5% 1 point=27% > 1 point= NOPE (Don t get pregnant) 75% Divide lesions that tolerate a decrease in systemic vascular resistance vs those that do not Why is this important? Can they get an epidural or spinal or not? Cardiac Lesions and Decrease in SVR But there are so many lesions C A T P I E Cardiac Lesions and Decerease in SVR Cardiac Lesions that do not tolerate epidural/spinal Coarctation of Aorta Aortic Stenosis Tetralogy of Fallot (uncorrected) Pulmonary hypertension IHSS (Idiopathic Hypertrophic Subaortic Stenosis) Eisenmenger syndrome CATPIE lesions Bad-go on leave, give to your partner Decrease in SVR(epidural, blood loss, hypotension) not well tolerated Run wet, risk of pulmonary edema, but worse risk for hypoperfusion(syncope, cardiac ischemia, stroke) 6
Blood pressure? What is this? What are the components of this? BP=Flow X Resistance Elevated flow is from too much volume Causes: Fluid Hypercontractility Corticosteroids Increased work of heart Resistance is from too much vasoconstriction Causes: Catecholemines Hypocarbia Pheo Thyroid Cocaine Pregnancy HTN is either a flow problem or a resistance problem How do you treat a flow/volume problem? How do you treat a resistance problem? Volume problem Beta blocker or diuretic 7
Resistance problem Afterload reduction or vasodilators Assumption of a normal pregnancy heart DBP reflects degree of vasoconstriction 130/100 suggests vasoconstriction as a cause of the hypertension Gestalt of the Blood Pressure SBP- DBP= Pulse pressure Increased PP suggests a volume problem(hyperdynamic or fluid overload) What is ELEVATED PULSE PRESSURE? Speed limit is 55 Decreased (Narrow)PP suggests a vasoconstriction problem Gestalt of the Blood Pressure Gestalt of the Blood Pressure Examples 160/110 What is the pulse pressure? How would you calculate? How would you treat this? 190/100 What is the pulse pressure? How would you calculate? How would you treat this patient? Gestalt of the Blood Pressure Gestalt of the Blood Pressure 8
QUIZ TIME What is NOPE? What are the lesions that can not get a spinal? Clinical pearl Type I DM presenting in DKA with end organ damage What should be considered??? 9