Ma. Socorro C. Bernardino, M.D. FPOGS

Ma. Socorro C. Bernardino, M.D. FPOGS
PREGNANT RHEUMATIC: Pre-natal and Post-natal Care Valvular heart disease in young women is most commonly due to rheumatic heart disease, congenital abnormalities, or previous endocarditis and may increase the maternal and fetal risks associated with pregnancy. Ma. Socorro C. Bernardino, M.D. FPOGS 1

“The management of cardiac disease during pregnancy poses a double challenge.....”
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“...To ensure maternal survival but at the same time promote fetal well-being and to allow a gestational period sufficient for adequate fetal maturity.” (

Management should be MULTIDISCIPLINARY
OB Cardiologist Anesthesiologist

Assessment of the severity Degree of impairment
Accurate diagnosis Assessment of the severity Degree of impairment Evaluation of concomitant therapy Optimizing management Pregnancy Labor and Delivery 5

Preconceptional counseling Hemodynamic changes during pregnancy
Effects of Pregnancy on maternal cardiac disease Effect of Maternal cardiac disease on pregnancy General Measures for the care of pregnant patients with heart disease 6

HEMODYNAMIC CHANGES IN NORMAL PREGNANCY
Non-pregnant Pregnant Cardiac output (L/min) Heart rate (beats/min) Systemic vascular resistance (dyne.cm.sec) Pulmonary vascular resistance Colloid oncotic pressure (mmHg)

HEMODYNAMIC CHANGES IN NORMAL PREGNANCY
Non-pregnant Pregnant Mean arterial pressure Pulmonary capillary wedge pressure (mmHg) Central venous pressure Left ventricular stroke volume Clark et al, 1989

EFFECT OF PREGNANCY ON MATERNAL CARDIAC DISEASE
Periods during pregnancy when the danger of cardiac decompensation is great: 1. 12 – 16 weeks – start of hemodynamic changes in pregnancy 2. 28 – 32 weeks – hemodynamic changes of pregnancy peak and cardiac demands are at a maximum

DURING LABOR sympathetic response to pain + uterine contractions
ml blood injected into general circulation/contraction 2. Increase in systemic vascular resistance increase stroke volume by 50% Stress in CVS

DURING LABOR During the second stage of labor, maternal pushing
decreases the venous return to the heart decrease in cardiac output

Large and abrupt increase in blood volume
AFTER DELIVERY AND PLACENTAL SEPARATION Sudden transfusion of blood from the lower extremities and the uteroplacental vascular tree to the systemic circulation Large and abrupt increase in blood volume

EARLY SIGNS OF CARDIAC COMPROMISE
Starts at first trimester Peak at weeks CO reaches maximum Beyond 24 weeks CO maintained at high levels Post-partum CO only begins to decline

“Intensive monitoring should be continued for at least 72 hours after delivery, preferably in a high care or intensive care environment” (Mulder BJM et al. Valvular heart disease in pregnancy. New England Journal of Medicine 2003)

When an underlying valvular disease is present , its not surprising that signs and symptoms of cardiac failure do occur “Following delivery the cardiovascular status of patient will normalize at 6-8 weeks post delivery” (Van Oppen ACA et al. A longitudinal study of the maternal hemodynamics during normal pregnancy. Obstetrics and Gynecology 1996; 88:40-6)

EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY
Pregnancy outcome is compromised by the presence of cardiac disease. Fetal Death – usually secondary to chronic severe or acute maternal deterioration Fetal morbidity – secondary to preterm delivery and fetal growth restriction > relative inability to maintain an adequate uteroplacental circulation

EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY
Fetal morbidity – secondary to preterm delivery and fetal growth restriction Frequency of effects is related to severity of functional impairment of the heart and severity of chronic tissue hypoxia

GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS
THE LEVEL OF ANTEPARTUM CARE REQUIRED BY A PREGNANT WOMAN DEPENDS ON THEIR RISK CLASSIFICATION:

NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION
FUNCTIONAL CLASS DESCRIPTION I No limitations of activities No symptoms from ordinary activity II Mild limitation of activity Comfortable with rest or mild exertion III Marked limitation of activity Comfortable only at rest IV Should be at complete rest, confined to bed or chair Any physical activity brings discomfort Symptoms occur at rest

“A New York Heart Association functional class III or IV has been estimated to carry a > 7% risk of mortality and a 30% risk of morbidity” “ Although women in these functional classes should be counselled against childbearing, it is not infrequent that they are encountered in the prenatal clinic (or even in labor ward, or at the theater door!” (Joubert IA and Dyer RA. Anaesthesia for the pregnant patient with acquired valvular heart disease.Update in Anesthesia. Issue Article 9)

FIVE RISK FACTORS PREDICATIVE OF POOR MATERNAL AND OR NEONATAL OUTCOME
1. Prior cardiac event heart failure, transient ischemic attack or stroke 2. Prior arrythmia symptomatic brady or tachy arrhytmia requiring therapy 3. New York functional > class II or the prescence of cyanosis 4. Valvular or outflow tract obstruction Aortic valve area < 1.5 cm2 or mitral valve area < 2 cm2 Left ventricular outflow tract pressure gradient > 30 mmHg 5. Myocardial dysfunction Left ventricular EF < 40% Restrictive or hypertrophic cardiomyopathy (Siu SC et al. Rik and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96: )

COMPLICATIONS ASCRIBED TO VALVULAR HEART DISEASE
1. Increased incidence of maternal cardiac failure and mortality 2. Increased risk of premature delivery 3. Lower APGAR scores and low birth weight 4. Higher incidence of interventional and assisted deliveries (Malhotra M et al. Maternal and fetal outcome in valvular heart disease. International Journal of Gynecology and Obstetrics 2004;84:11-6)

LOW Maternal and Fetal Risk HIGH Maternal and Fetal Risk
Maternal Risk Neonatal Risk Asymptomatic aortic stenosis low mean outflow gradient (<50mmHg) with normal left ventricular function Severe aortic stenosis with or without symptoms Reduced left ventricular systolic function (LVEF <40%) Maternal age <20 yr or >35 yr Aortic regurgitation of NYHA class I or II with normal left ventricular syustolic function Aortic regurgitation with NYHA class III or IV symptoms Previous heart failure Use of anticoagulant therapy throught pregnancy Mitral regurgitation of NYHA class I or II with normal left vertricular systolic function Mitral regurgitation with NYHA class III or IV symptoms Previous stroke or transient ischemic attack Smoking during pregnancy Mild to moderate mitral stenosis (valve area >1.5cm2, gradient <5mmHg) without severe pulmonary hypertesion Mitral stenosis with NYHA class II, III or IV symptoms Multiple gestations Mitral valve prolapse with no mitral regurgitation or with mild to moderate mitral regurgitation and with normal left ventricular systolic function Aortic valve disease, mitral valve disease, or both, resulting in severe pulmonary hypertension (pulmonary pressure > 75% of systemic pressures) Mild to moderate pulmonary valve stenosis Aortic valve disease, mitral valve disease, or both, with left ventricular systolic dysunction (EF <40%) Maternal cyanosis NYHA class III and IV

MULTIDISCIPLINARY TEAM APPROACH: I. Primary care physician/high-risk pregnancy specialist - monitor fetal condition and maternal cardiac function at frequent intervals in order to determine if the physiological changes elicited by pregnancy are exceeding the functional capacity of the heart - use medications to limit the extent of changes and improve outcome.

MULTIDISCIPLINARY TEAM APPROACH: II. Anesthesiologist - consulted early in pregnancy to assess anesthetic risk of the patient - discuss pain control during labor and delivery

MULTIDISCIPLINARY TEAM APPROACH: III. Cardiologist - consult on a regular basis and be available if primary care physicians sees signs of compromise IV. Neonatologist - if fetus is affected by a congenital heart disease

Patients who are otherwise healthy
require little or no specific treatment usual obstetric recommendations and monitoring. NYHA Class I or II may need to limit strenuous exercise adequate rest, supplementation of iron and vitamins low-salt diet regular cardiac and obstetric evaluations NYHA Class III or IV may need hospital admission for bed rest and close monitoring may require early delivery if there is maternal hemodynamic compromise. Medical Therapy Patients who are otherwise healthy may require little or no specific treatment other than the usual obstetric recommendations and monitoring. Patients who are NYHA Class I or II may need to limit strenuous exercise and get adequate rest, supplementation of iron and vitamins to minimize the anemia of pregnancy, a low-salt diet if there is concern about ventricular dysfunction, and regular cardiac and obstetric evaluations, the frequency of which must be individualized. 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. 28

Bed rest/Activity restriction
GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Bed rest/Activity restriction Diet Modification – dietary salt restriction (4-6 g daily) - limitation of fluid intake (1-1.5 l/day) 29

Prenatal visits – every 2 weeks until 28 weeks then weekly thereafter
GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – every 2 weeks until 28 weeks then weekly thereafter Emphasis: 1. Pulse rate check 2. Presence of palpitations Lanoxin 0.25 mg tab OD Metoprolol – may cause fetal growth restriction 30

Furosemide 20 mg tab OD - may cause oligohydramnios
GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – 3. Signs of congestion Furosemide 20 mg tab OD may cause oligohydramnios 31

Left lateral decubitus position
GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – Fetal growth monitoring and status of amniotic fluid done with ultrasound Instruction: Left lateral decubitus position 32

Antibiotic prophylaxis:
GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Antibiotic prophylaxis: Pen V 250 mg cap BID or Erythromycin 250 mg cap BID 33

RHEUMATIC HEART DISEASE:
RHEUMATIC FEVER Rheumatic fever seldom occurs for the first time young adults and usually preceeded by an episode during childhood (mean age 13) Uncommon in western countries but still prevalent in developing countries Women with a history of rheumatic fever should take daily penicillin before and throughout pregnancy

RHEUMATIC FEVER Acute rheumatic fever is managed similarly in pregnant and non-pregnant patients Acute streptococcal infection mandates a full bactericidal dose for 10 days Manifestations of pericarditis, symptoms of heart failure, cardiac murmurs and heart enlargement necessitates prompt suppression with prednisone and bed rest

CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - the most common rheumatic heart lesion - one of the most dangerous in pregnant women Pregnancy hemodynamic burdens: 1. Increase cardiac output 2. Increase heart rate 3. Expansion of blood volume 4. Increase demand for oxygen

CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 1. Latepregnancy Increased blood volume, CO and HR near term 2. During labor - further 10-15% increase in CO augmented during uterine contractions resulting in autotransfusion of 300 to 500 ml of blood

CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 3. Immediately after delivery - Increase in preload and blood volume from the contracted uterus and release of aortocaval compression - Elevated CO persists several days postpartum and gradually declines over a 2 week period

mitral stenosis increase in cardiac output with the increase in heart rate shortens the diastolic filling time and exaggerates the mitral valve gradient The most common problem encountered is mitral stenosis, which tends to worsen during pregnancy because of the increase in cardiac output coupled with the increase in heart rate; this shortens the diastolic filling time and exaggerates the mitral valve gradient. Any decrease in stroke volume causes a further reflex tachycardia, all of which contribute to an elevated left atrial pressure. The onset of atrial fibrillation may precipitate acute pulmonary edema. A study of Canadian women has reported no maternal death, but 35 percent of pregnancies were associated with cardiac complications.[20] Patients should have a careful echocardiographic evaluation of their mitral valve gradient, valve area, and pulmonary pressures before proceeding with a pregnancy. An exercise echocardiogram may also be helpful in delineating the hemodynamic response to effort in terms of mitral gradient and the presence or absence of pulmonary hypertension. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 39

added volume load may result in symptoms of dyspnea and heart failure in women with impaired LV function and those with limited cardiac reserve Stenotic valvular lesions are less well tolerated than regurgitant ones increased heart rate associated with pregnancy reduces the time for diastolic filling, which can be extremely troublesome for many patients, especially those with MS

exertional dyspnea and fatigue-1st symptoms of MS
decreased exercise capacity Orthopnea paroxysmal nocturnal dyspnea pulmonary edema atrial fibrillation, or an embolic event Rarely, patients may present with hoarseness, hemoptysis or dysphagia Symptoms usually develop when the valve area decreases below 1.5 cm2 and also below 2.5 cm2, particularly when the heart rate is elevated, as during exercise. There is a significant physiologic increase in the transmitral gradient due to increase in the heart rate, circulating blood volume and cardiac output. Patients who are asymptomatic prior to pregnancy can experience dyspnea,decreased exercise capacity, orthopnea, paroxysmal nocturnal dyspnea and pulmonary edema during pregnancy. 41

Tocolytic agents that are positively chronotrophic are contraindicated
PRETERM LABOR: Tocolytic agents that are positively chronotrophic are contraindicated Magnesium sulfate

Both maternal and fetal outcomes are directly related to the severity of MS and the pre-pregnancy NYHA functional class

intrauterine growth retardation low birth weight, prematurity
fetal/neonatal death has been estimated at approximately 33% in severe MS 28 % in moderate MS 14% in Mild MS

Associated with 10% maternal mortality
Mortality rises to >50% in NYHA class III and IV Mortality rises between 5-10% if with concomitant atrial fibrillation

Many px w/ moderate to severe MS can be managed successfully with medical therapy w/c includes strict control of heart rate ,volume status and frequent monitoring

Reduce left atrial pressure
Reduce Heart rate Beta Blockers or calcium Channel Blockers Metoprolol( beta blocker)-preferred beta blocker Atenolol-can cause IUGR,bradycardia and Death Digoxin-used in px w/AF for control of ventricular rate and is generally safe, well tolerated and has fewer side effects Restriction of physical activity Reduce left atrial pressure Diuretics- caution must be exercised to avoiud uteroplacental hypoperfusion associared w/ use of diuretics The cornerstone of therapy for the symptomatic patient is beta blockade. This slows the heart rate, prolongs the diastolic filling time, and can result in marked improvement in symptoms. The judicious use of diuretics is appropriate if there is pulmonary edema. 47

“Severe symptomatic disease, threatening maternal or fetal well-being is an accepted indication for either balloon vulvoplasty or valve replacement” “ Valve replacement is usually undertaken during 2nd trimester. Cardiopulmonary bypass and hypothermia carry substantial risk for the fetus. Fetal bradycardia and death are not uncommon” (Unger F et al . Standards and concepts in valve surgery. Report of the task force: European Heart Institute (EHI) of the European Academy of Sciences and Arts and the International Society of Cardiothoracic Surgeons (ISCTS). Indian Heart Journal 2000;52:237-44)

Patients with severe mitral stenosis who develop decompensation during pregnancy should undergo percutaneous trans-mitral commissurotomy Percutaneous mitral valvuloplasty can be performed with few or no complications to the mother or the fetus and excellent clinical and hemodynamic results

The “optimal time” appears to be between 20 and 28 weeks of gestation
Obstetric monitoring of the fetus during the procedure Maternal functional class is an important predictive factor for maternal death. Surgical Management Cardiac surgery is seldom necessary during pregnancy and should be avoided whenever possible. There is a higher risk of fetal malformation and loss if cardiopulmonary bypass is performed in the first trimester; if performed in the last trimester, there is a higher likelihood of precipitating premature labor. The “optimal time” appears to be between 20 and 28 weeks of gestation and the fetal outcome may be improved by using normothermic rather than hypothermic extracorporeal circulation, higher pump flows, higher pressures (mean blood pressure of 60 mm Hg), and as short a bypass time as possible.[5] Obstetric monitoring of the fetus during the procedure is recommended so that fetal bradycardia may be dealt with promptly and uterine contractions may be controlled. Despite these interventions, the current risk of fetal loss is still at least 10 percent, and is probably higher when the cardiac surgery is emergent. Maternal functional class is an important predictive factor for maternal death. A multidisciplinary approach is preferable to optimize the outcome for both mother and baby. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 50

Anticoagulation with Warfarin or Heparin can be considered for px with severe left atrial dilatation and Severe MS despite the presence of sinus rhythm, because of the hypercoagulable state of pregnancy Anticoagulants should probably be given if the patient is on bed rest and should certainly be administered in the setting of atrial fibrillation. 51

PREGNANT RHEUMATIC: Labor and Delivery

Labor and delivery in lateral decubitus position
GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR: Labor and delivery in lateral decubitus position Continuous monitoring with pulse oximetry Control of rate of IV fluid administration to 75 cc/hr Adequate pain relief (epidural narcotics) 54

Antibiotic prophylaxis
GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR: Antibiotic prophylaxis Short Vaginal delivery with excellent anesthesia Cesarean section per obstetric indications Invasive monitoring if needed Medical therapy optimization of loading conditions Prevention and treatment of pulmonary edema 55

Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures Category Drug and dosage High-risk patient Ampicillin, 2 g IM or IV, plus gentamicin sulfate (Garamycin), 1.5 mg/kg IV 30 min before procedure; ampicillin, 1 g IV, or amoxicillin (Amoxil, Trimox, Wymox), 1 g PO 6 hr after procedure High-risk patient who has penicillin allergy Vancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr, plus gentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

EPIDURAL ANESTHESIA GENERAL ANESTHESIA Desirable for vaginal delivery
Performed using small increments of local anesthetic to achieve T8-T10 level GENERAL ANESTHESIA Best option for NYHA class III and IV Avoid atropine, pancuronium, meperidine, ketamine Epidural anesthesia is recommended to reduce fluctuations in heart rate and cardiac output. 57

Shortening of the second stage of labor and assisted vaginal delivery is strongly recommended
Cesarean section are performed for Obstetrics indications

CARDIOVASCULAR DRUGS IN PREGNANCY:

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
contraindicated in pregnancy abnormal renal development in the fetus oligohydramnios and intrauterine growth retardation Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

BETA-ADRENERGIC RECEPTOR BLOCKERS
been used extensively during pregnancy for treatment of arrhythmias, hypertrophic cardiomyopathy, and hypertension cross the placenta but are not teratogenic demonstrated to cause fetal growth retardation be associated with neonatal bradycardia and hypoglycemia BETA-ADRENERGIC RECEPTOR BLOCKERS These have been used extensively during pregnancy for treatment of arrhythmias, hypertrophic cardiomyopathy, and hypertension. They cross the placenta but are not teratogenic. Concern exists, however, particularly regarding fetal growth, because they have been demonstrated to cause fetal growth retardation. They may also be associated with neonatal bradycardia and hypoglycemia. More concern exists with regard to atenolol than some of the other beta-blocking agents. From a practical perspective, however, although the risk-benefit ratio needs to be considered, beta blockers have been used safely during pregnancy, although it is recommended that fetal growth be monitored more carefully. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 61

CALCIUM CHANNEL BLOCKERS
used to treat both arrhythmias and hypertension limited data regarding use Most experience probably exists with verapamil, and no major adverse fetal effects have been recorded Diltiazem and nifedipine have also been used, but studies are limited. CALCIUM CHANNEL BLOCKERS. These have been used to treat both arrhythmias and hypertension. There are limited data regarding their use. Most experience probably exists with verapamil, and no major adverse fetal effects have been recorded. Diltiazem and nifedipine have also been used, but studies are limited. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 62

used during pregnancy for many decades cross the placenta
DIGOXIN used during pregnancy for many decades cross the placenta no adverse effects with its use have been reported DIGOXIN. This has been used during pregnancy for many decades and, whereas it does cross the placenta, no adverse effects with its use have been reported Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 63

DIURETICS most commonly furosemide
treat congestive heart failure during pregnancy and treatment of hypertension. may cause reduction in placental blood flow and have a detrimental effect on fetal growth. DIURETICS. These agents, most commonly furosemide, may be used to treat congestive heart failure during pregnancy and sometimes are used for the treatment of hypertension. Aggressive use of diuretics, however, may cause reduction in placental blood flow and have a detrimental effect on fetal growth. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 64

WARFARIN contraindicated in the first trimester of pregnancy
crosses the placenta and may cause fetal embryopathy third trimester (about labor and delivery) 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 WARFARIN. This is usually contraindicated in the first trimester of pregnancy, because it crosses the placenta and may cause fetal embryopathy. As noted earlier (see “Mechanical Prostheses and Anticoagulant Treatment”), however, there may be some high-risk situations in which the mother and physician determine that the safer approach is to continue warfarin therapy, particularly when the maternal dose is 5 mg or lower. Concern exists in the third trimester about labor and delivery, because the immature fetal liver does not metabolize warfarin as rapidly as the mother's liver. After discontinuation of warfarin, reversal of anticoagulation occurs more rapidly in the mother, whereas 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. Therefore, switching to an alternative anticoagulant such as heparin must be done well before labor is anticipated. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 65

POST NATAL CARE: CONTRACEPTION
For women with cardiac disease, appropriate contraceptive advice should be given before they become sexually active. This is particularly true for those with congenital heart disease who, like other adolescents without heart disease, often become sexually active in their early teens; For some, pregnancy may pose a high risk of morbidity and even mortality. Patients need to be given detailed advice about various contraceptive methods and their effectiveness, and each patient should understand the relative risks and benefits of each modality. The approach should be individualized, also bearing in mind the patient's likely compliance 66

Postnatal Care: Counseling on contraception
Permanent sterilization after delivery discussed during prenatal visits Surgical management prior to the next pregnancy BARRIER CONTRACEPTION. Male and female condoms help protect against sexually transmitted disease but must be used correctly and require some dexterity. Even when used appropriately, they have a recognized failure rate of approximately 15 pregnancies/100 woman- years of use. 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. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 67

failure rate of approximately 15 pregnancies/100 woman-years of use
use of a barrier method depends on how critical it is for the woman to avoid pregnancy, compliance and the ability to use a condom correctly. BARRIER CONTRACEPTION. Male and female condoms help protect against sexually transmitted disease but must be used correctly and require some dexterity. Even when used appropriately, they have a recognized failure rate of approximately 15 pregnancies/100 woman- years of use. 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. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 68

Combination estrogen-progesterone oral preparations
increased risk of venous thromboembolism, atherosclerosis, hyperlipidemia, hypertension, and ischemic heart disease congenital heart disease who have cyanosis, atrial fibrillation or flutter, mechanical prosthetic heart valves, or a Fontan circulation should avoid estrogen-containing preparations impaired ventricular function from any cause or with a history of any prior thromboembolic Oral Contraceptives Combination estrogen-progesterone oral preparations are very effective, with an extremely low failure rate and, for this reason, coupled with ease of use, are widely taken. For the woman with heart disease, however, concern exists because of increased risk of venous thromboembolism, atherosclerosis, hyperlipidemia, hypertension, and ischemic heart disease, particularly for those who are older than 40 years and for those who smoke. In addition, 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. Those with impaired ventricular function from any cause (probably an ejection fraction less than 40 percent) or with a history of any prior thromboembolic event should avoid warfarin. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 69

Progesterone-only contraceptives
There is a paucity of data about adverse effects of progesterone agents on the cardiovascular system, but probably these are safe for most women with heart disease Progesterone-only contraceptives are less reliable than combined preparations, with failure rates of 2 to 5 pregnancies/100 woman-years. They require that the woman take the pill at the same time every day for optimum efficacy, and this requires considerable motivation on the part of the patient. There is a paucity of data about adverse effects of progesterone agents on the cardiovascular system, but probably these are safe for most women with heart disease. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 70

fluid retention and irregular menstruation
cardiovascular contraindications are the same as those for progesterone DEPOT PROGESTERONE. Injectable progesterone, given three times monthly, is effective and is an attractive alternative for patients who may have problems with compliance with oral medications. Some patients find fluid retention and irregular menstruation to be problematic, but otherwise cardiovascular contraindications are the same as those for progesterone. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 71

performed laparoscopically or via a laparotomy
tenuous cardiac hemodynamics risk of cardiac instability = cardiac anesthesia may be preferable tubal sterilization has been accomplished with the use of an intrafallopian plug inserted endoscopically Tubal Sterilization This may be performed laparoscopically or via a laparotomy. For patients who have tenuous cardiac hemodynamics, there may be some risk of cardiac instability, and cardiac anesthesia may be preferable. This is particularly important, for example, in patients with primary or secondary pulmonary hypertension when general anesthesia may be hazardous and insufflation of the abdomen may elevate the diaphragm and contribute to unstable cardiorespiratory function. More recently, tubal sterilization has been accomplished with the use of an intrafallopian plug, which is inserted endoscopically. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. 72

Ma. Socorro C. Bernardino, M.D. FPOGS

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