1. Mehdi Mousavi M.D. Interventional Cardiologist Assistant Professor Alborz University of Medical Sciences Dr.mousavi@albzums.ac.ir

2.  Approximately 2% of pregnancies involve maternal cardiovascular disease  This poses an increased risk to both mother and fetus

3.  Lightheadedness  Dizziness  Shortness of breath  Peripheral edema  Syncope

4.  Cardiac disease may sometimes be manifested for the first time in pregnancy because the hemodynamic changes may compromise a limited cardiac reserve  The symptoms and signs of a normal pregnancy may mimic the presence of cardiac disease.

5.  The plasma volume ↑ in the sixth week of pregnancy and by the 2d trimester approaches 50% above baseline  Slightly lesser rise in red cell mass → relative anemia of pregnancy  Heart rate ↑ about 20% above baseline

6.  The venous pressure in the lower extremities ↑ ⇨ 80% of healthy pregnant women develop pedal edema.  Uterine blood flow ↑ ⇨ ↓ in peripheral resistance ⇨ ↓ BP in the 1st trimester.  Cardiac output ↑ begins in 1 st trimester and by the end of the second trimester approaches 30% to 50% above baseline. 

7.  ↑ volume load ⇨ compromise a patient who has impaired ventricular function and limited cardiac reserve  Stenotic valvular lesions (e.g., AS) are less well tolerated than regurgitant lesions because the ↓ in peripheral resistance ↑ the gradient across the aortic valve.

8.  The tachycardia of pregnancy reduces the time for diastolic filling in a patient with MS ⇨ ↑ in left atrial pressure.  With a lesion such as MR, the afterload reduction helps offset the volume load on the LV that gestation imposes.

9.  Lightheadedness, dizziness, shortness of breath, peripheral edema, and even syncope often occur in the course of a normal pregnancy.

10.  With each uterine contraction, ∼500 mL of blood is released into the circulation, prompting a rapid ↑ in CO & BP  NVD ⇨ ∼400 mL of blood is lost.  CS ⇨ ∼ 800 mL of blood is lost. 

11.  ↑ in venous return, in part because of autotransfusion from the uterus + the baby no longer compresses the IVC.  24 to 72 hours after delivery, pulmonary edema may occur.

13.  (1) Prior cardiac event (e.g., heart failure, transient ischemic attack, or stroke before pregnancy) or arrhythmia  (2) baseline NYHA class > II or cyanosis  (3) left-sided heart obstruction (mitral valve area smaller than 2 cm 2, aortic valve area less than 1.5 cm 2, or peak left ventricular outflow tract gradient more than 30 mm Hg by echocardiography)  (4) reduced systemic ventricular systolic function (EF < 40%).

14.  Estimated risk of a cardiac event in pregnancies:  0 = 5%  1 = 27%  >1 = 75%

15.  In general, patients who cannot achieve more than 70% of their predicted functional aerobic capacity are unlikely to tolerate a pregnancy safely.

16.  The maternal risk of pregnancy is very high  The patient should be counseled to avoid pregnancy  Sometimes even to consider termination of pregnancy if it occurs

17.  Pulmonary hypertension: Systolic PAP > 60% to 70% of the systemic pressure  HF (DCM), LVEF < 40%  Significant stenotic cardiac lesions: AS, MS, PS, Coarctation of aoera  Cyanotic lesions

18.  Mechanical prosthetic valves  Dilated aortic root > 40 mm (particularly Marfan syndrome) are vulnerable to progressive aortic dilation, dissection, and rupture during pregnancy (not only increased stroke volume but also the gestational hormonal changes)

19.  Male and female ⇨ The decision to use a barrier method therefore depends on how critical it is for the woman to avoid pregnancy and on compliance and the ability to use a condom correctly.

20.  A vasovagal response occurring in a patient with idiopathic PAH or secondary PH, such as Eisenmenger syndrome, could be life- threatening, and many physicians therefore avoid use of an IUD in such patients.

21.  For the woman with heart disease, however, concern exists because of increased risk of venous thromboembolism, atherosclerosis, HLP, HTN & IHD, particularly for those who are > 40 years and for those who smoke.

22.  There is a paucity of data about adverse effects of progesterone agents on the cardiovascular system, but these are probably safe for most women with heart disease.  Are less reliable than combined preparations  Injectable progesterone: Cardiovascular contraindications are otherwise the same as those for progesterone

23.  Impaired ventricular function from any cause (EF < 40%) ⇨ AVOID Estrogen  History of any prior thromboembolic event ⇨ AVOID Estrogen  Patients with congenital heart disease who have cyanosis, atrial fibrillation or flutter, mechanical prosthetic heart valves, or a Fontan circulation probably should avoid estrogen-containing preparations.

25.  Not obtained routinely in any pregnant patient because of concern about radiation to the fetus  Considered in any patient when there are concerns about her cardiac status and new onset of dyspnea or failure.  The chest radiograph in a normal healthy patient may show slight prominence of the PA, and as pregnancy advances, elevation of the diaphragm may suggest an ↑ in the cardiothoracic ratio (CTR).

26.  Cornerstone of cardiac evaluation in pregnancy  Facilitates differentiation of the features of cardiac disease from those of a normal pregnancy

27.  Seldom performed during pregnancy  Can be performed safely, although careful monitoring of maternal oxygen saturation is necessary if midazolam is used for sedation  May be necessary in valvular disease, the presence or absence of a shunt, intracardiac thrombus, presence or absence of valvular vegetation or perivalvular abscesse (endocarditis)

28.  Imaging of the fetal heart can usually be obtained by 20 weeks’ gestation  Typically, the heart should be smaller than one third of the size of the fetal thorax.

30.  Congenital  Rheumatic heart disease  Cardiomyopathies: dilated hypertrophic  Valvular disease: bicuspid aortic valve mitral valve prolapse  Pulmonary hypertension  Coronary artery diseas

31.  Secundum atrial septal defect is the most common congenital heart defects  Patients with even a large secundum atrial septal defect usually tolerate pregnancy without complication unless there is coexistent PH or AF  DVT could precipitate a paradoxical embolus and stroke

32.  VSD: Patients with small defects usually tolerate pregnancy without difficulty  PDA: Small ducts with normal or near-normal pressures usually cause no hemodynamic perturbations during pregnancy.

33.  Those with severe aortic stenosis (valve area smaller than 1 cm 2 ) or a mean gradient greater than 50 mm Hg should be counseled not to have a pregnancy  Pregnancy is usually considered to be contraindicated if the aortic dimension is larger than 4.5 cm  ↓ in peripheral resistance during pregnancy ⇨ ↑ the aortic gradient and may precipitate symptoms.

34.  Epidural analgesia needs to be carefully and slowly administered, and spinal block should be avoided because of the potential for hypotension.  Several small reports have reviewed percutaneous aortic balloon valvuloplasty during pregnancy

35.  Women with coarctation may present for the first time during pregnancy because of systemic hypertension.  Because of the associated aortopathy, the entire aorta is vulnerable to dilation, aneurysm, and dissection.  Therapeutic options include antihypertensive therapies, percutaneous balloon or stenting of the coarctation, or surgical intervention.

36.  Pulmonary stenosis is usually well tolerated during pregnancy, particularly if the right ventricular pressure is < 70% of systemic pressure and sinus rhythm is maintained  If necessary, balloon pulmonary valvuloplasty can be performed, with shielding of the fetus from radiation.

37.  Cyanosis poses risks for both mother and fetus  ↑ in peripheral resistance that accompanies pregnancy augments the right-to-left shunt and may exaggerate the maternal cyanosis.  Because of the erythrocytosis that accompanies cyanosis and the propensity to thrombosis, women who develop venous thrombosis are at risk of paradoxical embolus and stroke.

38.  In the setting of severe pulmonary vascular disease (Eisenmenger syndrome), maternal mortality may approach 50%.  The volume load of pregnancy may compromise the poorly functioning right ventricle and precipitate heart failure.  The fall in peripheral resistance augments right-to-left shunting and may precipitate more cyanosis.

39.  The highest incidence of maternal death is during parturition and the puerperium.  There may be an abrupt decrease in afterload as the baby is delivered, and hypovolemia from blood loss can cause hypoxia, syncope, and sudden death.  Vagal responses to pain may also be life- threatening.  Death may also occur from pulmonary embolism or in situ pulmonary infarction

40.  Current recommendations are still that termination of pregnancy is the safer option  The mode of delivery needs to be discussed carefully.  Cesarean section delivery is probably preferable [19] with cardiac anesthesia

41.  MS tends to worsen during pregnancy because of ↑ CO coupled ↑ HR  The cornerstone of therapy for the symptomatic patient is beta blockade.  Cardioselective beta blocker may prevent deleterious effects of epinephrine blockade on myometrial tissue.  The judicious use of diuretics is appropriate if there is pulmonary edemaBed rest may also be helpful to slow the heart rate and to minimize cardiac demands. .

42.  Anticoagulants should probably be given if the patient is on bed rest and should certainly be administered in the setting of atrial fibrillation.  In unusual circumstances, when the mother is refractory to medical therapy, balloon valvuloplasty may be performed if the valve anatomy is favorable and there is no concomitant mitral regurgitation  Rarer still, surgical valvotomy may be performed

43.  MR & AR are fairly well tolerated in pregnancy, provided the regurgitation is no more than moderate, the mother is symptom free before pregnancy, and ventricular function is well preserved.  MR & AR can usually be managed medically with diuretics and vasodilator therapy.

44.  Surgery during pregnancy should be contemplated only for control of refractory symptoms  If surgery is required for MR, repair is always preferred

46.  Can she become pregnant?  Is there a risk for mother or fetus?  If so what to do with Warfarin?

47.  Pregnancy ⇨ Maternal blood is highly thrombogenic because there is an increased concentration of clotting factors and increased platelet adhesiveness combined with decreased fibrinolysis.  The risk of valve thrombosis and thromboembolism significant.

48.  Poses risks for mother and baby  Mechanical prostheses, have a greater longevity but require anticoagulation, and whichever anticoagulant strategy is chosen during pregnancy, there is a higher chance of fetal loss, placental hemorrhage, and prosthetic valve thrombosis.

49.  Serial echocardiograms particularly useful  The valve area calculation& pressure half- time determination, more helpful than a simple measurement of valve gradient  Valve gradient may ↑ as pregnancy advances because the circulation becomes more hyperkinetic and cardiac output increases.

50.  For patients in sinus rhythm, they confer the advantage that warfarin is not required  Many patients take a daily baby aspirin (81 mg)  Vulnerable to structural degeneration and calcification, which occurs more rapidly in younger patients

51.  Mitral prostheses tend to degenerate faster than those in the aortic position  There is some evidence that pregnancy may accelerate valve degeneration  In some retrospective series, a second valve replacement was necessary in approximately one third of patients within 2 years of delivery

52.  Large molecule that does not cross the placenta and does not cause developmental abnormalities in the fetus.  UFH has been used subcutaneously and intravenously and is often begun in the first trimester, as soon as pregnancy is diagnosed, to minimize fetal exposure to warfarin at the critical time of fetal embryogenesis.

53.  Some physicians continue heparin throughout pregnancy to avoid any fetal exposure to warfarin, but unfractionated heparin has been shown to be a poor anticoagulant in pregnancy  Heparin early in the first trimester virtually eliminates the risk of fetal embryopathy but at the expense of maternal valve thrombosis, which occurred with a frequency of 9%.

54.  If warfarin is discontinued between weeks 6 and 12 of gestation, replace with continuous intravenous UFH, dose-adjusted UFH, or dose-adjusted subcutaneous LMWH (Class I: ACC/AHA).  The aPTT ratio should be maintained at a level of at least 2 (Class I: ACC/AHA)

55.  LMWH is an attractive alternative to unfractionated heparin because of its ease of use and superior bioavailability  Deaths have been reported with its use, however, usually associated with maternal valve thrombosis.  The use of low-molecular-weight heparin remains controversial

56.  If dose-adjusted LMWH is used, the LMWH should be administered twice daily subcutaneously to maintain the anti-Xa level between 0.7 and 1.2 unit/mL 4 hours after administration (Class I: ACC/AHA).

57.  Fetal exposure to warfarin in the first trimester may be associated with fetal embryopathy  The reported fetal risk of embryopathy varies widely but probably averages 6%  Warfarin also appears to increase the risk of fetal loss and spontaneous abortion.

58.  For the woman with an older generation or tilting disc mitral prosthesis, particularly if she is in atrial fibrillation, the safer approach may be to treat her with warfarin for the first 34 to 35 weeks of pregnancy, particularly if her dose is less than 5 mg/day.  If warfarin is used, the INR goal should be 3.0 (range, 2.5 to 3.5) (Class I: ACC/AHA).

59.  For those patients at lesser risk, heparin therapy (with the provisos noted earlier) may be selected as soon as pregnancy is diagnosed, warfarin substituted at 13 to 14 weeks, and heparin restarted at approximately 35 weeks in anticipation of delivery.

60.  It is reasonable to give low-dose aspirin (75 to 100 mg/day) in the second and third trimesters of pregnancy in addition to anticoagulation with warfarin or heparin (Class IIa: ACC/AHA)

61.  Concern in the third trimester about labor and delivery because the immature fetal liver does not metabolize warfarin as rapidly as the mother's liver  Reversal of anticoagulation in the fetus may take up to 1 week because of the immature fetal liver.  Vaginal delivery when the fetus is anticoagulated is contraindicated because of the risk of fetal hemorrhage.

62.  Warfarin should be discontinued starting 2 to 3 weeks before planned delivery and continuous intravenous UFH given instead Class I: ACC/AHA)  It is reasonable to resume UFH 4 to 6 hours after delivery and begin oral warfarin in the absence of significant bleeding (Class IIa: ACC/AHA).

63.  LMWH should be discontinued at least 24 hours before delivery if epidural analgesia is to be used because it has a prolonged effect and there is risk of spinal hematoma.  UFH can be substituted for LMWH peridelivery because it can be started and stopped abruptly.

65.  Pregnancy is usually contraindicated if the ascending aorta is larger than 40 mm in diameter  Many patients are receiving long-term treatment with beta-adrenergic blockers to slow the progression of aortic regurgitation.  Beta blockers should be continued during pregnancy if there is any aortic dilation.

66.  Echocardiography every 6 to 8 weeks is recommended to monitor the mother's aortic root size  Any chest pain should be promptly evaluated to rule out dissection.  During labor and delivery, pushing should be avoided, with an assisted second stage if necessary.

67.  NYHA Class I or II may need to limit strenuous exercise and to have adequate rest  Supplementation of iron and vitamins to minimize the anemia of pregnancy  Low-salt diet if there is concern about ventricular dysfunction  Regular cardiac and obstetric evaluations

68.  Patients who are NYHA Class III or IV may need hospital admission for bed rest and close monitoring and may require early delivery if there is maternal hemodynamic compromise.

69.  Cardiac surgery is seldom necessary during pregnancy and should be avoided whenever possible.  In the first trimester ⇨ Higher risk of fetal malformation and loss if cardiopulmonary bypass is performed  In the last trimester ⇨ Higher likelihood of precipitating premature labor  The “optimal time” appears to be between 20 and 28 weeks of gestation

71.  For most patients with cardiac disease, a vaginal delivery is feasible and preferable; a cesarean section is indicated only for obstetric reasons.  If vaginal delivery is elected, fetal and maternal electrocardiographic monitoring should be performed.  The second stage should be assisted, if necessary (e.g., forceps or vacuum extraction), to avoid a long labor.

72.  Patient anticoagulated with warfarin because the baby is also anticoagulated, and vaginal delivery carries an increased risk to the fetus of ICH  Patients who have a dilated unstable aorta (e.g., Marfan syndrome)  Severe pulmonary hypertension  Severe obstructive lesion such as AS

73.  Patients who are most vulnerable to the deleterious effects of endocarditis are those with cyanotic heart disease and prosthetic valves or a prior history of endocarditis  Antibiotics are considered optional  Many institutions routinely give antibiotics because of the documented bacteremia. This can occur even during an uncomplicated delivery

75.  Hypertension in pregnancy is an important cause of maternal morbidity and mortality  ∼ 50% of patients will develop preeclampsia  Hypertension is just one feature of the diffuse endothelial dysfunction, which is associated with vasospasm, reduced end-organ perfusion, and activation of the coagulation cascade

76.  Hypertension (blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic) present before pregnancy or that is diagnosed before the 20th week of gestation  Preeclampsia develops in approximately 25% of patients with chronic hypertension

77.  New hypertension with a blood pressure of 140/90 mm Hg on two separate occasions  A rise in pressure of 30/15 mm Hg or more  Arising de novo after the 20th week of pregnancy  Blood pressure normalizes by 12 weeks post partum.

78.  Proteinuria (>0.3 g during 24 hours or ++ in two urine samples) in addition to new hypertension. Edema is no longer included in the diagnosis because of poor specificity. When proteinuria is absent, suspect the disease when increased blood pressure is associated with headache, blurred vision, abdominal pain, low platelets, or abnormal liver enzymes.

79.  Preeclampsia tends to occur more commonly Primiparous women  Twin pregnancies  Young age  Older age  Multiple gestations  Concomitant heart disease  Concomitant renal disease  Chronic hypertension

80. PreeclampsiaChronic Hypertension  Older (>30 years)  Multigravida  Before 20 weeks of pregnancy  Weight gain and edema: gradual  Funduscopy: Arteriovenous nicking, exudates  Young (<20 years)  Primigravida  After 20 weeks of pregnancy  Weight gain and edema: sudden  Funduscopy: Spasm, edema

81. PreeclampsiaChronic Hypertension  SBP <160 mm Hg  LVH: Rare  Proteinuria: Present  Plasma uric acid level ↑  BP after delivery: NL  SBP >160 mm Hg  LVH: More common  Proteinuria: Absent  Plasma uric acid level→  BP after delivery: ↑

82.  the only other effective strategy to prevent preeclampsia is the use of low doses of aspirin.  The only cure for preeclampsia is delivery

83.  Although antihypertensive medications are effective in treating chronic hypertension that has worsened during pregnancy, they are not effective in preventing preeclampsia  Drug treatment of maternal BP does not improve perinatal outcome and may be associated with fetal growth retardation

84.  Nonpharmacologic treatment (including close supervision and restriction of activities) should be considered with SBP 140-149 mm Hg or DBP 90-95 mm Hg (ACC/AHA).

85.  In the presence of gestational hypertension (with or without proteinuria), drug treatment is indicated at blood pressure ≥140/90 mm Hg (ACC?AHA)  SBP levels ≥170 or DBP >110 mm Hg should be considered an emergency requiring hospitalization. Most authorities recommend antihypertensive drugs only if DBP > 100 mm Hg.

86.  Oral methyldopa, labetalol, calcium antagonists, and (less frequently) beta blockers are drugs of choice

87.  Nitroglycerin is the drug of choice  Diuretic therapy is inappropriate because plasma volume is reduced

88.  IV labetalol  Oral methyldopa  Oral nifedipine  IV hydralazine is no longer the drug of choice because of excess perinatal adverse effects.  IV infusion of sodium nitroprusside is useful in hypertensive crises, but prolonged administration should be avoided.

89.  If pregnancy begins while a woman is receiving antihypertensive drug therapy, medications including diuretics but excluding ACEIs and ARBs are usually continued  The mother should be protected and that the fetus will not suffer from any sudden hemodynamic shifts that occur when therapy is first begun.

90.  Methyldopa ⇨ Safe; considered by some to be the drug of choice for hypertension in pregnancy  Calcium channel blockers ⇨ Relatively safe; few data; concern regarding uterine tone at the time of delivery

91.  Hydralazine ⇨ Safe; no major adverse effects  As emergency, IV hydralazine is no longer the drug of choice because of excess perinatal adverse effects (ACC/AHA).

92.  Beta blockers ⇨ particularly labetalol have been used with good effect  Beta-blocking agents should not be taken in the first trimester, if possible (ACC/AHA)  Cardioselective beta blocker may prevent deleterious effects of epinephrine blockade on myometrial tissue.  More concern exists with regard to Atenolol

93.  Lasix ⇨ Safe; caution regarding maternal hypovolemia and reduced placental blood flow  ACE inhibitors ⇨ Contraindicated; IUGR, oligohydramnios, renal failure, abnormal bone ossification; FDA class X

94.  When preeclampsia develops, bed rest is usually initiated, with salt restriction and close monitoring, and magnesium sulfate is often administered in an effort to prevent eclamptic seizures and to prolong the pregnancy  Caution is needed to avoid volume overload because pulmonary edema is the most common cause of maternal mortality.

96.  A cardiomyopathy manifesting between the last month of pregnancy and 6 months post partum  Inflammatory factors are highly implicated  Women who recover are at increased risk of recurrences with subsequent pregnancies  Peripartum cardiomyopathy Versus a chronic cardiomyopathy exacerbated by the volume load occurring during pregnancy

97.  Shortness of breath  Exertional Dyspnea  Orthopnea  Paroxysmal Nocturnal Dyspnea (PND)  Cheyne-Stokes Respiration  Acute Pulmonary Edema  Fatigue  Anorexia  Nausea  Early sataity  abdominal pain and fullness  Congestion of the liver  Nocturia

98.  Pulmonary crackles (Rales)  Pleural effusions  Cool peripheral extremities  Cyanosis of the lips and nail beds  S3 & S4  The murmurs MR or TR  Pulse pressure ↓  JVP ↑  Abdomino-jugular reflux⇨ +  Giant v waves in JVP ⇨ TR  Hepatomegaly  Ascites  Peripheral edema  Sinus tachycardia  Joundice

99.  ECG ⇨ LBBB, Q-Wave, LVH  CXR ⇨ PH, interstitial or pulmonary edema  Echocardiography ⇨ EF, Diastolic function, LVH

100.  Most commonly furosemide, may be used to treat CHF during pregnancy and sometimes are used for the treatment of HTN.  Aggressive use of diuretics, however, may cause reduction in placental blood flow and have a detrimental effect on fetal growth.

102.  Particularly in the setting of diabetes and tobacco abuse  AMI is rare, and when it occurs, pregnancy ↑ the maternal risk 3-4 fold  The most common cause is coronary artery dissection  The treatment should be urgent coronary angiography, with a consideration of PCI

104.  The heart may be more vulnerable to arrhythmias during pregnancy - Increase in preload - Increased heart rate - Fluid and electrolyte shifts - Changes in catecholamine levels

105.  The presenting symptom complex may be difficult to separate from the normal symptoms of pregnancy, including a sensation of fast heartbeat and skipped beats, which most commonly are supraventricular ectopics.

106.  Laboratory tests, such as CBC, electrolyte level measurement, and thyroid function test  If there is any doubt after the clinical examination, a transthoracic echocardiogram should be obtained

107.  Commonly used antiarrhythmic drugs cross the placental barrier to some extent  Because of the potential problem of recurring tachyarrhythmias during pregnancy, the policy of withdrawing antiarrhythmic drugs and resuming them later can be recommended only as an alternative in selected cases.

108.  Supraventricular and ventricular ectopic beats (PAC, PVC) require no therapy  PAC (commonly observed during pregnancy), are generally benign and well tolerated. In patients with mild symptoms and structurally normal hearts, no treatment other than reassurance

109.  Class I: Vagal maneuver [C], Adenosine [C], DC cardioversion [C]  Class IIa: Metoprolol,* propranolol* [C]  Class Iib: Verapamil [C]  Prophylactic therapy; Class I: Digoxin [C] Metoprolol*  Prophylactic therapy; Class IIa: Propranolol* [B], Sotalol,* flecainide [†] [C]

110.  They cross the placenta but are not teratogenic  They have been demonstrated to cause fetal growth retardation  Associated with neonatal bradycardia and hypoglycemia  Beta-blocking agents should not be taken in the first trimester, if possible

111.  Cardioselective beta blocker may prevent deleterious effects of epinephrine blockade on myometrial tissue.  Beta blockers have been used safely during pregnancy, although it is recommended that fetal growth be monitored more carefully  More concern exists with regard to Atenolol

112.  Digoxin has been used during pregnancy for many decades, and although it does cross the placenta, no adverse effects with its use have been reported.