Pregnancy and Heart Disease Shilpa Kshatriya, MD, FACC Heartland Cardiology, PA
Pregnancy and the Heart 2 % of pregnancies involve maternal CV disease CV disease does not preclude pregnancy but poses risk to the MOTHER and FETUS
Hemodynamic Changes > 40% increase in blood volume Decrease in SVR and PVR Increase in HR 30 % increase C.O Little change in BP USUALLY WELL TOLERATED
Hemodynamic Changes Labor and Delivery C.O increases by 60 to 80% (HR and BP changes) Volume Changes Increase blood volume with uterine contraction Increased Venous Return Volume loss during delivery
Mode of Delivery Vaginal-preferable in most Facilitate 2 nd stage C-section OB reasons Warfarin anticoagulation Rare CV reasons-severe PHTN, severe obstructive lesions, unstable aorta
Advise Against Pregnancy Severe pulmonary arterial hypertension Severe obstructive lesions- AS, MS, PS, HCM, Coarct Ventricular dysfunction- Class III or IV CHF, EF < 40%, Prior PPCM Dilated or unstable aorta-marfan with aorta > 40 to 45mm Severe cyanosis
Preconception Evaluation
Prepregnancy Risk Assessment Risk of pregnancy depends on specific heart disease and clinical status of the patient CARPREG ZAHARA WHO Classification
WHO Risk and Prenatal Care Class I -- one or two CV visits Class II CV f/u every trimester Class III monthly/bimonthly CV f/u Class IV pregnancy is contraindicated Consider termination If pregnancy continues monthly or bimonthly
Tetralogy of Fallot One of the most common forms of cyanotic CHD and most adults have had previous repair. In unrepaired TOF, including those with previous palliative shunts, pregnancy is not advised because of poor maternal and fetal outcomes. After surgical repair, pregnancy is generally well tolerated in those women who have good functional capacity and no hemodynamically significant residual lesions. A significant percentage of patients develop pulmonary regurgitation after repair of TOF, which may lead to RV enlargement and dysfunction, decreased exercise tolerance, and arrhythmias.
TOF
Pulmonary Hypertension 4% to 10% of all patients with CHD result of long-term left to right shunting and excessive pulmonary circulation. In some patients with large left to right shunts at birth, the pulmonary pressure equals the systemic pressures, resulting in shunt reversal and cyanosis (known as the Eisenmenger syndrome)
Pulmonary HTN Pregnancy in mothers with Eisenmenger syndrome is contraindicated because of high maternal and fetal mortality.---up to 50% maternal mortality. Death occurs most commonly in the third trimester or first few weeks after successful delivery, so that continued monitoring in the postpartum period is required
Left to Right Shunts Uncomplicated ASD/VSD/PDA without pulm. HTN are well tolerated in pregnancy Large defects a/w pulm. HTN are associated with increased risk---arrhythmias, ventricular dysfunction, worsening pulm. HTN
Pregnancy in Marfan Preexisting medial changes Changes with pregnancy Physiologic, hormonal Unpredictable maternal risk Dissection, IE, CHF Fetal- 50% inheritance (AD) Oxytocin-implicated in dissection
CV history, FH, meds Aortic Imaging Aorta > 45mm------no pregnancy Aorta 40 mm-----reasonable Aorta 40 to 45mm----individualize
Pregnancy In Aortic Disorders During pregnancy---beta blocker, Aortic imaging, fetal echo Peripartum ---facilitated vaginal delivery, C- section for Ao > 40mm or increasing size, IE prophylaxis Postpartum-dissection risk persists
Supraventricular Tachycardia
SVT Acute treatment- iv adenosine Hemodynamic instability- DC cardioversion Maintenance beta blocker, calcium channel blocker, sotalol, flecainide Ablation
Ventricular Tachycardia Underlying heart disease PPCM Long QT- beta blocker ICD recommended prior to pregnancy Idiopathic VT (healthy patients)- beta blocker, verapamil, sotalol, flecainide, propafenone Unstable VT-DC cardioversion, iv amiodarone Catheter ablation-refractory cases
Hypertrophic Cardiomyopathy Most common genetic cardiac disease Risk higher if symptomatic prior to pregnancy Heart failure symptoms Arrhythmias- afib, PVCs, NSVT, VT Risk in pregnancy increased if high outflow tract gradient Beta blockers Low risk cases-vaginal delivery Epidural-vasodilation and hypotension caution in severe LVOT obstruction
Acute MI in Pregnancy 3 to 6 per 100,000 deliveries Mortality 7% Age > 35 years, multiparous, non-hispanic white or African American Risk factors- chronic HTN, DM, older age, eclampsia/preeclampsia, smoking Exclude SCAD (delivery, early postpartum) and aortic dissection
Acute MI in Pregnancy PCI- bare metal stent, CABG-limited date (drug eluting stents not recommended) Thrombolysis if cath/pci not available Heparin/aspirin/beta blocker/nitrates Nitrates excreted in breast milk- fetal methemoglobinemia Plavix- safety not established during pregnancy Statins-possibly teratogenic
Valvular Heart Disease AORTIC STENOSIS Main cause in reproductive age bicuspid aortic valve Cardiac morbidity dependent on symptoms and severity Heart failure occurs in 10% severe AS Arrhythmias- 3 to 25% Risk of aortic dilatation/dissection
Aortic Stenosis Interventions during pregnancy- valvuloplasty if minimal aortic regurgitation. Valve replacement after prompt C-section Mode of delivery-c-section for severe AS
Mitral Stenosis Moderate or severe MS poorly tolerated during pregnancy CHF ( MVA < 1.5cm2) Afib can occur----increases risk of pulm. Edema Mgt- beta blockers, diuretics, anticoagulation if in afib Percutaneous mitral commissurotomy after 20 weeks
VHD in Pregnancy Tissue Prosthesis Increased degeneration in young Reoperation risk Possible accelerated degeneration in pregnancy
VHD in Pregnancy Mechanical Prosthesis Anticoagulation Increased thrombosis risk
Anticoagulation in Pregnancy Hematologic changes clotting factor concentration platelet adhesiveness fibrinolysis and protein S activity risk thrombosis and embolism
Warfarin in Pregnancy Low molecular weight---crosses placenta Fetal anticoagulation effect (decreased vit K dependent factors in fetal liver) Increased risk fetal loss, prematurity, stillbirth, fetal IC hemorrhage, retroplacental hemorrhage Embryopathy risk---exposure 6 to 12 weeks Incidence 4 to 10% Dose related
Prosthetic Valves and Pregnancy Fetal Complications Warfarin 5mg 5/33 (15%) No embryopathy Warfarin 5mg 22/25 (88%) 9% embryopathy Vitale N et al, JACC 1999
Anticoagulation in Pregnancy Low dose Aspirin - Safe---antithrombotic effect not proven - Used in pt with shunts, cyanosis, bioprosthesis - Possible incidence in preeclampsia Thrombolytic therapy -Emergency use only NOAC -No safety data
Pregnancy and the Heart CVD 1 to 2 % pregnancies Congenital heart disease most common cause Does not preclude pregnancy Increased risk to mother and fetus Individual assessment---preferably prior to conception