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ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY.

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Presentation on theme: "ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY."— Presentation transcript:

1 ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY

2 INTRODUCTION Prevalence of maternal heart disease -< 1%, its presence increases the risk of adverse maternal, fetal, and neonatal outcomes 0.2–4% of all pregnancies in western industrialized countries. {Am J Obstet Gynecol 1998;179:1643–1653.}. In western countries maternal heart disease is now the major cause of maternal death during pregnancy

3 RHD dominates in non-western countries [56–89% ] Congenital heart disease [just 9–19%]. Eur J Heart Fail 2008;10: , Circulation 2001;104:

4 STUDY A Canadian study analyzed the outcomes of pregnancy in a group of women with congenital or acquired heart disease (562 women and 599 pregnancies) CARPREG study (Circulation.2001;104: )

5 Maternal outcomes Incidence of adverse maternal cardiac events – 13% of completed pregnancies – More likely if: EF below 40% Left heart obstruction (AS with a valve area of less than 1.5 cm2 or MS with a valve area of less than 2.0 cm2) Previous cardiovascular events or arrhythmia NYHA class > II or cyanosis. These events occurred in: – 4% of the women with none of these risk factors – 27 % of those with one risk factor – 62 % of those with two or more risk factors – The 3 women that died had two or more risk factors Sui et al

6 Fetal outcomes NYHA class III or IV and left heart obstruction were predictors of fetal outcomes also. Other predictors of adverse fetal outcomes include: The use of anticoagulant drugs Smoking during pregnancy. Multiple gestation. Mother’s age (> 35 yrs or < 20 yrs). ZAHARA study Fetal mortality : 4 % among pregnancies in women with one or more of these risk factors. 2% among those with none of these risk factors.

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8 WHO CLASS II Most arrythmias WHO CLASS II/III Mild LV impairment VHD not included in class IV WHO CLASS III Mechanical valve

9 CLASS IV Pulmonary hypertension of any cause Previous PCM with LV impairment Severe MS and severe symptomatic AS Severe LV dysfunction

10 Evaluation The evaluation- Pre conceptional and entail a full cardiac assessment. H/o exercise capacity, current or past evidence of heart failure and associated arrhythmias. Cardiac hemodynamics -PAP and the severity of valve dysfunction - assessed by echo. Exercise testing - Assessment of functional capacity. During pregnancy evaluation of each trimester - Assess any deterioration in maternal cardiac status.

11 INVESTIGATIONS -ECHO Gradients in RVOT and LVOT increase Increased stroke volume cause increase in severity of regurgitation. LVEDD increased TEE can be performed safely Fetal echo best in 20 weeks gestation.

12 TMT 80% of predicted heart rate No evidence of spontaneous abortion Dobutamine stress should be avoided Assessment of myocardial reserve pre pregnancy in PPCM & VHD Nuclear stress tests are avoided.

13 Fluoroscopy risks Majority of procedures are < 1mGy to fetus RCR guidelines During the first 14 days of fertilization -no risk After 14 days major risk occurs if doses > 100mGy Doses <50 mGy –no risk mGy –risk not clear

14 Estimated radiation exposure

15 Valvular Heart Disease Severity Risk Stenotic lesions > Regurgitant lesion Left sided diseases> Right sided disease

16 MS Poorly tolerated [ moderate & severe MS]- Tachycardia, increased plasma volume PHT, Trans valvular gradients, PAP measurements are less reliable marker of severity Maternal Risks- HF symptoms, Pulmonary edema in II & III trimester. AF [increases risk of T.Emb, pulmonary edema] ( El Kayam etal, 2005 JACC) Moderate & severe MS counseled against pregnancy without prior intervention Fetal risks- prematurity 20-30%; IUGR 5-20% ( El Kayam & Hameed 2001) & Silversides JACC 2001: 37:

17 MS INTERVENTIONS NYHA III or IV patients or valve area less than 1 cm 2, BMV or MVR before pregnancy. BMV - second trimester in NYHA III/ IV or with PAP above 50 mm Hg despite optimal medical therapy. MVR during pregnancy- high fetal loss (30%) hence reserved till all measures fail and mother`s life is in danger. Anticoagulation in AF OR in bed rest.

18 BMV OUTCOMES BMV in pregnancy KEM study (Gupta et al) – successful outcomes of 40 pregnancies. Ribeiro et al (1992)study on maternal outcomes in 78 patients-8 patients developed mod MR, No evidence of PE De Souza et al(2001) compared the outcomes of PBMV v/s OMC in 21 pts with severe MS -38% fetal death in OMC Current consensus –PBMV to symptomatic patients with severe MS with OMT/ MVA cm2 Complications- CT, AF,MR,emboli, uterine contractions & labor

19 PERIPARTUM MANAGEMENT Vaginal delivery is the usual approach. Avoidance of volume overload and tachycardia is the main hemodynamic goal. In unstable patients, monitoring with arterial line and PCWP aids in optimum hemodynamic management.

20 PERIPARTUM MANAGEMENT Epidural analgesia. Assisted-delivery devices during the second stage of delivery eliminate hemodynamic effects of valsalva maneuver during “pushing”. Caesarean section for obstetrical indications.

21 Pharmacological management of symptoms MS with symptoms or PAH, restricted activities and β1- selective blockers are recommended. Diuretics are recommended when congestive symptoms persist despite β- blockers. Pharmacological management of symptoms MS with symptoms or PAH, restricted activities and β1- selective blockers are recommended. Diuretics are recommended when congestive symptoms persist despite β- blockers. BMV NYHA class III/IV or sys PAP > 50mm Hg, preferably after 20 weeks POG. [CI in asymptomatic women] BMV NYHA class III/IV or sys PAP > 50mm Hg, preferably after 20 weeks POG. [CI in asymptomatic women] Anticoagulation Paroxysmal or Permanent AF, LA thrombus, prior embolism Considered in mod/sev MS with spontaneous echo contrast, LA > 40ml/m2, low CO, CCF Anticoagulation Paroxysmal or Permanent AF, LA thrombus, prior embolism Considered in mod/sev MS with spontaneous echo contrast, LA > 40ml/m2, low CO, CCF

22 MITRAL REGURGITATION Well tolerated due to reduction in SVR. Women with symptomatic MR may benefit from mitral-valve surgery (preferably repair))before becoming pregnant. Diuretics may be indicated. Outcome data that would help to guide clinical decision making in this area are lacking.

23 AORTIC STENOSIS Congenital valvular abnormalities are usually the cause of AS in young women in the US. Severe AS is poorly tolerated during pregnancy. Maternal and perinatal mortality of 17% and 32% respectively have been reported. (Pieper et al 2008)

24 AORTIC STENOSIS  Symptomatic patients - peak outflow gradient > 50 mm Hg are advised to delay conception until after surgical correction.  Termination of pregnancy- if patient is symptomatic before the end of the 1 st trimester.  Even severe AS may be asymptomatic  Aortic-valve replacement and palliative aortic balloon valvuloplasty have been performed during pregnancy with associated maternal and fetal risk.

25 CONTD….. Maternal risk  HF 10%, Arrhythmias 3- 25%(Pieper et al 2008) Fetal risk- Preterm Labour, IUGR, LBW

26 PERIPARTUM MANAGEMENT Vaginal delivery is the usual approach. Oxytocin may decrease the SVR and increase PAP. Epidural analgesia may be given. Avoid sudden decrease in SVR. Cesarean section GA has traditionally being advocated to avoid sudden decreases of SVR. Case reports of regional anesthesia with positive outcomes.

27 Pharmacological management of symptoms HF- treat with diuretics AF-  -blockers, CCB to control HR, Digoxin also may be used Pharmacological management of symptoms HF- treat with diuretics AF-  -blockers, CCB to control HR, Digoxin also may be used Pre- pregnancy intervention Symptomatic severe AS LVEF 15mm) TMT- symptoms or falling BP Recent progression of AS Asc. Aorta> 50 MM (27.5mm/m2) During Pregnancy Severe symptomatic AS + refractory to medical therapy/ life threatening symptoms  Non calcified valve may be subjected to BAV/ emergency AVR Pre- pregnancy intervention Symptomatic severe AS LVEF 15mm) TMT- symptoms or falling BP Recent progression of AS Asc. Aorta> 50 MM (27.5mm/m2) During Pregnancy Severe symptomatic AS + refractory to medical therapy/ life threatening symptoms  Non calcified valve may be subjected to BAV/ emergency AVR Delivery Vaginal delivery + regional anesthesia in non-sev AS LSCS in Sev AS Delivery Vaginal delivery + regional anesthesia in non-sev AS LSCS in Sev AS

28 Aortic Regurgitation Root dilatation (Marfan syndrome ),Bicuspid Aortic valve, and RHD are the commonest causes. – The reduced SVR of pregnancy reduces the volume of regurgitated blood – Women with an abnormal functional capacity or left ventricular dysfunction are predicted to have a high risk of abnormal maternal outcomes, but few data concerning this population are available

29 Tricuspid valve lesions Better tolerated Maternal risk- HF, Arrhytmias, Progressive worsening of regurgitations Moderate to severe Regurgitant lesions may undergo exercise testing to decide pre pregnancy intervention Severe lesions + symptoms/ impaired LV function/ Ventricular dilatation  treated surgically, if possible repair TV repair if moderate Secondary TR with annular dilatation >40mm, usually during left sided valve surgeries

30 PS & PR PS is generally well tolerated – Complications of sev PS- RV failure & Arrhythmias – Pre pregnancy balloon valvuloplasty in severe stenosis (peak Doppler gradient > 64 mmHg) – LSCS is considered in patients with severe PS and in NYHA class III/IV despite medical therapy and bed rest, in whom percutaneous pulmonary valvotomy cannot be performed or has failed. Hameed et al ( JACC 2003 )

31 Severe PR with impaired RV function – Pre-pregnancy pulmonary valve replacement (preferably bioprosthesis) should be considered

32 Prosthetic valves Mechanical valves Excellent H.D. Performances Long term durability Thrombogenic Bioprosthetic valves Good H.D Performances Much less thrombogenic High risk of valve degeneration [~50% women <30yrs at 10 yr post implant] – M> A,T position – Reoperation mortality risk addl 5%

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34 Management of valve thrombosis in pregnancy Presents as embolism or dyspnoea TTE and then TEE is required. If still not confirmed a fluoroscopy is done Fibrinolysis is recommended ESC 2010 guidelines - anticoagulation optimisation for small clots Thrombolysis has shown little negative effects on fetus Streptokinase bolus of IU followed by iu/hr for 72hrs

35 General Management Percutaneous intervention- – After 4 th month in the second trimester [ organogenesis complete, fetal thyroid still inactive, volume of uterus small] – ACT b/w s CPBypass- – 13 th & 28 th week [Fetal malformation - I trim & maternal complication - III trim] – 3-6% late neurological impairment in children, high fetal mortality hence Sx only when refractory to medical therapy, interventional procedures fail, mother’s life threatened

36 Peripartum cardiomyopathy Eur J Heart Fail 2010;12:767–778.

37 Etiology Cathepsin D in response to oxidative stress cleaves Prolactin into angiostatic & proapoptotic fragment 16 kDa Prolactin Fas/Apo-1, C-reactiveprotein, IFN-  and IL-6 Fas/Apo-1, C-reactiveprotein, IFN-  and IL-6 Viruses Autoimmune

38 Differential diagnosis Eur J Heart Fail 2010;12:767–778.

39 Natural history Am J Obstet Gynecol 2008;199:415.e1-415.e5..

40 PRESENTATION First 4 months after delivery- most of them(78%) Last month of pregnancy- 9% > than 4months after delivery or before 1month of pregnancy 13% CLINICAL FEATURES Features of right heart or left heart failure or both Can present as ventricular arrythmia 92% heard a third heart sound (2005 South African study) LV thrombosis is seen

41 INVESTIGATIONS Diagnosis of exclusion ECG – 66% LVH, 96% ST-T changes Elevated BNP and NT pro BNP Echo – Not all have LV dilatation and LVEDD>60 predicts poor recovery MRI is a better predictor of LV functions and assesses the chamber volumes better.( Late gadolinium enhancement)

42 FOLLOW UP Repeat echo after 6weeks, 6months and then annually MRI at 6months and annually for accurate assessment of LV volumes and function

43 MANAGEMENT Similar to HF management O2 administration to reach saturation of>95% NIV and PEEP cm H2O Loop diuretics and NTG Inotropics when required Pts after OMT and IABP,the pt may require assist device or cardiac transplantation LVAD used as bridge to transplantation or destination therapy

44 Management of stable heart failure ACEI and ARB avoided Hydralazine and nitrates combination used safely Beta 1 selective agents are preferred LMWH and UFH used in pregnancy Role of CRT AND ICD- pt with LV dysfunction for 6 months post presentation Bromocriptine- used in acute stage- 2.5mg bd (Denise etal 2007)

45 Delivery need not be done in asymptomatics Encouraged in deteriorating patients Vaginal delivery encouraged but LSCS in critically ill patients Left lateral position encouraged

46 Prognosis No European studies Vary geographically

47 LV func. returns to normal in 23–41% LV func. returns to normal in 23–41% SA- 6m & 2yr mortality rates 10% & 28%. Brazil & Haiti 6m rate 14– 16% Turkey- 4yr rate 30% SA- 6m & 2yr mortality rates 10% & 28%. Brazil & Haiti 6m rate 14– 16% Turkey- 4yr rate 30% Eur J Heart Fail 2010;12:767–778.

48 Counselling LVEF <25% subsequent pregnancies discouraged High risk of relapse in subsequent pregnancies Elkayam et al and Habli et al ( 2 studies)

49 Hypertensive disorders Accounts for 15% of all pregnancies BP recordings in lateral recumbent posture Ambulatory BP monitoring is superior Investigations – LFT, RFT, urine r/e, Uric acid, Hct Proteinuria >2g/d –close monitoring >3g/d – delivery VMA and plasma metanephrine analysis along with USG abdomen Doppler USG for uteroplacental perfusion.

50 Classification Pre existing hypertension Gestational hypertension Pre existing hypertension with superimposed gestational hypertension with proteinuria Antenatally unclassifiable hypertension Hypertension defined as SBP> or = 140 & DBP > or = 90 Mild /90-109, Severe ->or = 160/110mmHg

51 Hypertensive disorders TypeCriteriaComments Pre-existing HTN >140/ 90 mm Hg, either precedes pregnancy or develops <20 weeks gestation Usu. Persists after 42 days PP; 1-5% of pregnancy Gestational HTN >140/ 90 mm Hg, develops >20 weeks gestation Usu resolves within 42 days PP; 6-7% pregnancy Pre-eclampsia Gest HTN + proteinuria[>0.3g/day or >30mg/mmol U. creatinine] Upto 25% of prev HTN Eclampsia Pre-eclampsia + seizuresImmediate termination of pregnancy required Pre-existing HTN + superimposed gestational HTN with proteinuria Pre-existing HTN+ further worsening of BP+ proteinuria [>0.3g/day] after 20 wks Antenatally unclassifiable hypertension BP first recorded after 20 wksRe- assessment after 42 days PP

52 Management Non pharmacological- salt restriction, calcium supplementation Low dose aspirin(75-150mg) at early onset<28 weeks Weight gain- in normal kg Pharmacological management- all drugs can be continued except Renin inhibitors, ACEI and ARBs. Severe hypertension iv Labetalol or metaprolol can be used. CCBs are drugs of second choice. Diuretics are not recommended.

53 Contd… Management of crisis –iv Nitroprusside- caution on cyanide toxicity. Patient with pulmonary edema can be managed with iv Nitroglycerin Methyldopa should be avoided postpartum because it causes depression. Earlier the onset of HT in pregnancy the more the chance of recurrence in next pregnancy

54 Recommendations in hypertension

55 CAD 3-6 / deliveries. Coronary artery dissection is a common cause.(LAD is the common culprit artery). Aortic dissection, pulmonary embolism and pre eclampsia also to be ruled out in pregnant women with chest pain Trop I is a useful investigation. PCI treatment of choice in STEMI. PCI in high risk NSTEMI only

56 Contd… PCI preferred to thrombolysis as it will cover up dissections as well BMS Stents are used CABG carries an extremely high mortality DRUGS- ASA, beta blockers are safe but safety of clopidogrel is not known Vaginal delivery is most appropriate

57 Tachyarrhythmia Premature extra beats / sustained tachyarrhythmias become more frequent and may even manifest for the first time during pregnancy PSVT in 20-44% of pregnancy. ( Am J Cardiol 2006;97(8): ) Immediate electrical cardioversion - a/c Rx of any tachycardia with haemodynamic instability For acute conversion of PSVT- vagal manoeuvre followed by I.V. adenosine is recommended. I.V. metoprolol or propranolol can also be considered For long-term management of SVT -oral digoxin or metoprolol/propranolol is recommended. If not successful oral sotalol or flecainide may be used

58 Arrhythmia Immediate electrical cardioversion of VT is recommended for sustained, unstable & stable VT. I.V. Sotalol or Procainamide - a/c conversion of sustained, haemodynamically stable and monomorphic VT. Oral metoprolol, propranolol or verapamil - idiopathic sustained VT (Long-term management). If unsuccessful  oral sotalol, flecainide, propafenone ICD implantation, recommended prior to pregnancy and during pregnancy also. Implantation of PPI or ICDs -considered with echo guidance, especially if the fetus > 8 weeks gestation.

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60 Bradyarrythmia Rare Favourable outcome 30% of congenital AV blocks present during pregnancy Vaginal delivery carries no extra risks Temporary pacing in patients with CHB with symptoms Permanent pacing can be done once fetus is > 8weeks of age. Echo guidance is used.

61 Anticoagulation No results of RCT to guide the choice of anticoagulant therapy during pregnancy. Monitoring to assess whether the antithrombotic effect is adequate. The effective doses of these drugs change during pregnancy because of changes in intravascular volume and body weight. In a series of 976 women with a total of 1234 pregnancies the use of any anticoagulant therapy resulted in major bleeding in 2.5 % of the pregnancies, with bleeding usually occurring at the time of delivery. Arch Intern Med 2000;160:

62 OAC UFH LMWH OAC UFH Anticoagulation Strategies Maternal outcomes- Chan et al(2000) OAC LMWH 3.9 % % 4 15 Valve thrombosisMaternal mort.

63 OAC In women with mechanical valves the use of OAC - G reatest maternal protection.( Risk of thromboembolism- 3.9%, risk of death-1.8%). High rate of fetal loss including spontaneous abortions, stillbirths, and neonatal deaths (30%). Exposure to warfarin between wks - fetal loss twice that associated with the use of UFH Fetopathic effects - (nasal hypoplasia and bone stippling) occurred in approximately 6 % of cases in doses > 5mg Vitale et al - J Am Coll Cardio 1999;33:

64 Heparin If heparin rather than warfarin was used during the 1 st trimester, the risks of maternal thromboembolism and maternal death more than doubled (9.2% and 4.2% respectively). The use of heparin throughout pregnancy was associated with the highest risks of maternal thromboembolism and maternal death (25% and 7 % respectively). Long-term use of heparin - HIT and osteopenia. Arch Intern Med 2000;160:191-6.

65 LMWH Lower risks of thrombocytopenia and osteopenia than UFH There are insufficient data from studies of women with prosthetic heart valves to support the efficacy of this therapy. No data regarding the use in AF with valvular disease. To be monitored with anti X a levels. Target 6 hr post dose 0.8 to 1.2 U/ mL. J CardioPharmacol Ther 2004;9:

66 Anticoagulation Strategies OAC throughout pregnancy best strategy [esp. if warf <5 mg, Acitrom (acenocoumarol) <2 mg] Discontinuation of OAC b/w 6 &12 wks and replacement by UFH (a PTT ≥2× control; infusion in high risk pts) or LMWH twice daily (according to weight and target anti-Xa level 4-6 hours post-dose U/mL in patients with a warfarin dose required of >5 mg/day OAC discontinued and UFH (a PTT ≥2× control) or adjusted-dose LMWH (anti-Xa level 4-6 hours post-dose U/mL) started at the 36th week LMWH replaced by i.v. UFH at least 36 hours before planned delivery. UFH to be continued until 4-6 hours before planned delivery and restarted 4-6 hours after delivery if there are no bleeding complications If delivery starts on OACs, LSCS indicated to prevent fetal bleed OAC UFH/L OAC UFH/L UFH 36 wks 12 wks6 wks 6 hrs H H

67 Differences In strategy

68 BOOK REFERENCES BRAUNWALD`S HEART DISEASE HURST`S THE HEART VALVULAR HEART DISEASE –WANG – VALVULAR HEART DISEASE IN PREGNANCY TOPOL TEXTBOOK OF CARDIOVASCULAR MEDICINE

69 ARTICLES AND REVIEWS CARPREG study (Circulation.2001;104: ) Am J Obstet Gynecol 1998;179:1643–1653 Am J Cardiol 2006;97(8): Am J Obstet Gynecol 2008;199:415 Circulation 2001;104: Eur J Heart Fail 2008;10: Eur J Heart Fail 2010;12:767–778 N Engl J Med 2001;344: Arch Intern Med 2000;160:

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