Valve Disease in the Pregnant Patient Julie B. Damp, MD December 6, 2012 VanderbiltHeart.com
If single, do not allow marriage. If fertile, do not allow pregnancy. If pregnant, do not allow delivery. If delivered, do not allow breastfeeding.
Objectives Understand the normal cardiovascular changes that occur during pregnancy Understand major principles of treatment of valve disease during pregnancy
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
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
Intravascular volumes
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
Echo Indications Valvular/congenital disease Grade 3 systolic murmur Diastolic murmur Significant dyspnea or CHF signs
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;104:515-21.
Valvular Heart Disease
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
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
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
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: 125/70 62 14 100% Normal JVP CTAB Regular, S1, S2, III/VI systolic murmur at LLSB to apex Soft, NT Trace 1+ edema
22 year old female
22 year old female VanderbiltHeart.com
22 year old female
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): 245-265
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
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
Mitral Stenosis Severe MS correct prior to pregnancy Percutaneous balloon valvuloplasty Bridge patient through pregnancy Failed medical management during pregnancy Timing 22-26 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 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
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: 142/101 85 14 100% Normal JVP CTAB Regular, S1, S2, III/VI systolic murmur at USB radiating to neck Soft, NT No edema
26 year old female
26 year old female
Aortic Stenosis Bicuspid valve most common Severe AS Decompensates late 2 nd /early 3 rd trimester Maternal mortality 17% Fetal mortality 32%
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
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
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
Right Sided Valves Pulmonary stenosis well tolerated Balloon valvuloplasty for refractory right sided failure Isolated TR well tolerated
Prosthetic Valves
Prosthetic Valves DiSaia P. Obstet Gynecol Review 1966;28:469-472
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;71:196-201
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
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
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 0.7 1.2 units/ml
Mechanical Aortic Valve Replacement in Young Women Planning on Pregnancy J Am Coll Cardiol. 2012;59(12):1110-1115. doi:10.1016/j.jacc.2011.10.899 VanderbiltHeart.com
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):1116-8 VanderbiltHeart.com
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
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