Presentation on theme: "Pregnancy & Cardiovascular diseases"— Presentation transcript:
1Pregnancy & Cardiovascular diseases ByMohammad H. soliman(MSc. Cardiology)
2Expected cardiovascular changes in pregnancy MeasurementNormal valueChange in pregnancy (%)Heart ratebpm+ 10%–20%Stroke volumemL+ 30%Cardiac outputL/min+ 30%–50%Blood volume5 L+ 20%–50%Systemic vascular resistance1, dyne/cm/sec- 20%Mean arterial pressuremm HgNot significantOxygen consumption250 mL/min+ 20%–30%Source: Clark SL, et al.1 and Elkayam U, Gleicher N. Hemodynamics and cardiac function during normal pregnancy and the puerperium. In: Elkayam U, Gleicher N, eds. Cardiac Problems in Pregnancy. 3rd ed. New York, NY: Wiley-Liss, Inc; 1998:3-19.
3Figure 1 Physiological changes in pregnancy.8 Systemic and pulmonary vascular resistance fall during pregnancy. Blood pressuremay fall in the second trimester, rising slightly in late pregnancy. Notethat cardiac output and stroke volume peak by 16 weeks gestation.
4PRE-PREGNANCY COUNSELLING To estimate maternal mortality as well as morbidityJoin antenatal care with a high risk pregnancy obstetric team.Minimising maternal risk: e,gif necessary by catheter or surgical intervention before conceptionEstimation and minimising fetal risk e,gmaternal drug treatment may need changing before conception or once pregnant
5Signs and symptoms of normal pregnancy versus heart failure
6A risk index to predict complications 1. A prior cardiac event (including stroke, transient ischemic attack, or arrhythmia). 2. Cyanosis or poor functional class. 3. Left heart obstruction. 4. Systemic ventricular dysfunction.One point was assigned for each risk factor present. No pregnancy received more than 3 points. Women with 0 points had an estimated risk of a cardiac event of 5% (low risk), those with 1 point had a risk of 27% (intermediate risk), and those with more than 1 point had a 75% risk of having a cardiac event (high risk). All three deaths in the study of 562 women occurred in pregnancies with more than one point.
7Maternal mortality risk associated with pregnancy Group I: Minimal risk of complications (mortality <1%)-Pulmonic/tricuspid disease, ASD ,VSD ,PDA-Bioprosthetic valve ,mild AR, mild PS-Mitral stenosis, NYHA Class I or IIGroup II: Moderate risk of complications (mortality 5% to 15%)- Mitral stenosis with AF-Artificial valve-Mitral stenosis, NYHA Classes III or IV-mild to mod AS,sever PS-Previous myocardial infarctionGroup III: Major risk of complications or death (mortality >25%)- Sever Pulmonary hypertension- Eisenmenger syndrome- Complex cyanotic heart disease- Sever AS or NYHA class III IV with any valvular disease
8Valvular heart disease and pregnancy 1- mitral stenosis The most common rheumatic valvular lesion in pregnancyWhen the valve area falls below 1.5 cm2 filling of the left ventricle during diastole is severely limited, resulting in a fixed cardiac outputThe pressure gradient across narrowed valve may increase greatly seconadry to increase in HR and blood volumeIncreased left atrial pressure can result in arrhythmiaDecrease serum coloid osmotic pressure and excessive peripartum fluid administration predispose to pulm edema
9Changes in NYHA class between 1st visit and follow up during pregnancy
10Theraputic approach Aiming to: reduce heart rate Decrease left atrial pressure1- restriction of physical activity2- drugs as B blockers and digoxin used to control HR3- cautious use of diureticsVaginal delivery is permitted in most patients with MSIn symptomatic patients with moderate to sever MS continuous monitoring and use of IV dugs like diuretics digoxine BB and nitrates
11Mitral valve repair or replacement Should be considered only in sever cases of MS refractory to optimal medical therapyOr when close follow up during pregnancy and labour is not possibleRisk of foetal death during surgery is % VS 2-12% in PBMVEpidural anesthesia is the most apprpriate form of analgesia for both vaginal and abdominal delivery
132-Mitral regurgitation Most common causes is rheumatic and myxomatous degenerationMR is well tolerated during pregnancyNew AF or sever hypertension can precipitate homodynamic deteriorationWomen with sever MR are advised to under go surgical repair before conception
154-Aortic stenosisAS is far less frequent than MS and most cases are congenitalDelivery is safe in patients whose functional tolerance is goodValve repair or termination of pregnancy considered only after Appearance of symptoms like dyspnea, syncope or pulm. Oedema resistant to medical treatment
175-Aortic regurgitation It may be due to bicuspid aortic valve, rheumatic,or infective endocarditiesIt is well tolerated during pregnancyIn symptomatic patients diuretics,digoxine and hydralazine can be safely used
186-Prothetic valves and pregnant woman The risk of PV. related to increase in heamodynamic burden and increase incidence of thromboembolismSelection of type of prosthesis should be individualized asThe bileaflet mechanical valves more durable, excellent hemodynamic profile, and relatively small risk of thromboembolic and bleeding complications with careful anticoagulation
19In women who are not interested in anticoagulation or for whom close follow-up is not possible, a tissue valve is preferredIn the aortic position, homografts, pericardial valves, and stentless porcine xenografts have not been extensively used in pregnancyThe pulmonary autograft (Ross procedure) is an excellent elternative but associated more with structural valve deterioration
20Thromboembolic complications Valve thrombosis (%) Emboli (%) Outcome of pregnancy in women with mechanical or biological prosthesesStudyNo. of pregnanciesLive births (%)Thromboembolic complicationsValve thrombosis (%)Emboli (%)Mechanical valvesHanania9553119Sbarouni151735Born356383Bioprosthetic valves60808325100Adapted from Baughman (7).
21Conditions warranting anticoagulation during pregnancy Mechanical prosthetic valveHistory of venous thromboembolismAcute deep venous thrombosisAntiphospholipid antibody syndromeInherited deficiency of naturally occuring anticoagulantChronic AFEisenmger’s syndrome
22ACC/AHA Recommendation for Anticoagulation During Pregnancy in Patients With Mechanical Prosthetic Valves1. The decision whether to use heparin during the first trimester or to continue oral anticoagulation throughout pregnancy should be made after full discussion with the patient and her partner.2. High-risk women who choose not to take warfarin during the first trimester should receive continuous unfractionated heparin intravenously in a dose to prolong the mid-interval (6 h after dosing) activated PTT time to 2 to 3 × control value. Transition to warfarin can occur thereafter.3. In patients receiving warfarin, the INR should be maintained between 2.0 and 3.0 with the lowest possible dose of warfarin, and low-dose aspirin should be added.4. Women at low risk might be managed with adjusted-dose SC heparin (17,500 to 20,000 U twice daily to prolong the mid-interval (6 h after dosing) activated PTT time to 2 to 3 × control value.5. Warfarin should be stopped no later than week 36 and heparin substituted in anticipation of labor.6. If labor begins during treatment with warfarin, a cesarean section should be performed.7. In the absence of significant bleeding, heparin can be resumed 4–6 h after delivery, and warfarin begun orally.
26Mode of deliveryVaginal delivery is safe in most cases with PV using epidural anesthesiaInvasive heamodynamic monitoring indicated only in sever valve stenosis or HFHeparin should be withdrawn 4 hours before CS or at onset of labor and resumed 6-12 h afterIn high risk patient with previous endocarditis or heart valve prosthesis prophylactic antibiotics should be given
27Congenital heart diseases 1- high risk patientsAny patient reaches NYHA III,IV is at high riskThe situations carries high risk as follow1- sever pulm. HTN with or without septal defects (maternal mortality 30-50%)2-sever left ventricular outflow obstruction3- cyanotic heart diseases with maternal mortality about 2%and incidence of complications of 30%Such as infective endocardities , arrhythmiasand CHF
28Treatment of high risk patients Pregnancy is not recommendedIf pregnancy occurs termination of pregnancy is advisedPhysical activity is restricted and bed restThe patient should be hospitalized at the end of 2nd trimesterLMWH is given subcutaneous against thromboembolismIn sever aortic stenosis balloon valvotomy can relief symptoms it is done in the 2 nd trimesterIn sever cyanotic heart disease :oxygen sturation,,heamatocrite,and HB monitoring is important
292-Low risk patientsPatients with small or moderate shunts without pulm, HTNPatients who have had cardiac surgery early in life without prothesisPatients with mild , mod valve regurg.With mild or mod LV out flow tract obstructionFollow up done every trimester
30Specific conditions 1- pulm stenosis RVOT obstruction tend to be well tolerated during pregnancyNo deaths and low maternal complications 15% have been reportedIn cases of sever RT ventricular failure balloon valvotomy is the method of choice
312- Tetralogy of FallotPregnancy in non-operated patient carries a risk for mother and fetusThe risk is high when O2 stauration below 85%Close monitoring of BP and gases with avoidance of any further systemic dilatationThe risk in good repaired patient is very lowAll patients with TF should have genetic counseling before conception
323- Coarctation of aorta Should be repaired prior to pregnancy The management of hypertension is difficult in non-operated patientToxemia doesn’t occur but treatment may cause very low pressure in distal segmentThis may result in abortion or foetal deathRupture of aorta is the commonest cause of deathBB should be prescribed with avoidance of volume excess and CO
334-Eisenmenger syndrome associated with a high risk of maternal morbidity and mortalityIt is also associated with a poor fetal outcome, with a high incidence of fetal loss, prematurity, intrauterine growth retardation, and perinatal deathpatients with Eisenmenger syndrome should be advised against pregnancy and early abortion should be recommended
34Because of increased incidence of peripartum thromboembolism, anticoagulant therapy seems indicated in the third trimester of gestation and for 4 weeks post partumSpontaneous labor is preferred to induction and should lower the chance of prematurely or the need for cesarean sectionan attempt should be made to shorten the 2nd stage of labor by the use of forceps or vacuum extraction with good oxygenation
35ANTIBIOTIC PROPHYLAXIS for vaginal delivery in all patients with CHD (except those with an isolated secundum type of ASD or surgical ligation and division of PDA) seems reasonable
36Cardiovascular disorders aquired during pregnancy 1- peripartum cardiomyopathy (modified criteria for diagnosis )1-Development of cardiac failure during pregnancy or within 6 months of delivery2-Absence of a determinable cause for cardiac failure3-Demonstrable impairment in left ventricular systolic function
37ETIOLOGY A distinct etiology of PPCM remains unknown Nutritional deficiencesMyocarditisInfectionsAutoimmuneIdiopathicThe incidence of peripartum cardiomyopathy is greater in multiparous women and in those with preeclampsia and twin pregnancies
40TREATMENT Non-pharmacological Pharmacological Salt restriction (4gm/d) Water restriction (2 L/D)PharmacologicalPre-load reduction (diuretics, nitrates)After-load reduction (hydralazine, nitrates, amlodipine)ACE-I contraindicated during pregnancy+ ionotropes (digoxin, dopamine, dobutamine)Beta-blockers
41Con. TREATMENT Immunosuppressive agents May be initiated in patients with PPCM and biopsy-proven myocarditis, but efficacy is unclearEmpiric immunosuppression, in the absence of evidence of myocarditis, is not currently recommended
42Figure 3 Cardiac causes of maternal deaths in the UK: confidential enquiry into maternal deaths 1997–99 (total maternal deaths = 409, cardiac deaths = 41).
432-Hypertension in Pregnancy ClassificationChronic hypertensionPreeclampsia-eclampsiaPreeclampsia Superimposed upon chronic hypertension or Renal DiseaseGestational hypertension (only during pregnancy)Transient hypertension (only after pregnancy)
44A.Chronic Hypertension Defined as hypertension diagnosedBefore pregnancyBefore the 20th week of gestationDuring pregnancy and not resolved postpartum
45B.Gestational Hypertension Diagnosis of gestational hypertension:Detected for first time after midpregnancyGestational Hypertension:Systolic >140Diastolic>90No proteinuriaIf preeclampsia does not develop andBP returns to normal by 12 weeks postpartum, diagnosis is transient hypertension.BP remains high postpartum, diagnosis is chronic hypertension.Proteinurea develops Preeclampsia is diagnosed (25% incidence)
46Drug Therapy of Hypertension in Pregnancy ExampleCommentα2-adrenergic blockersMethyldopaMost commonly used. Safety well established. Drug of choice.Beta-blockersAtenolol, MetoprololAppear safe. Case reports of fetal bradycardia, growth retardataion.α, β blockersLabetololAppears effacious. Very scant safety data.Arteriolar vasodilatorsHydralazineEffacacious and safe during pregnancy and lactation.ACE inhibitorsCaptoprilAbsolutely contraindicated during pregnancy due to fetal toxicity.Calcium channel blockersDiltiazemAppear safe, but not as much data to support their use.DiureticsFurosemideAppears safe, but limited efficacy.Sodium nitroprussideAvoid in pregnancy due to potential for fetal thiocyanate toxicityMagnesium sulfateTreatment of choice for prevention of ecclamptic seizures.Adapted from reference 7.
47Treatment of Acute Severe Hypertension in Pregnancy SBP > 160 mm Hg and/or DBP > 105 mm HgParenteral hydralazine is most commonly used.Parenteral labetalol is second-line drug (avoid in women with asthma and CHF.)Oral nifedipine used with caution. (Short-acting nifedipine is not approved by FDA for managing hypertension.)Sodium nitroprusside may be used in rare cases.
48C.Preeclampsia-Eclampsia DiagnosisGestational Hypertension:Systolic >140Diastolic>90Proteinuria is defined as urinary excretion0.3 g protein or greater in a 24-hour+2 or greater on urine dip specimen
49Criteria for Severe Preeclampsia (one or more)Blood Pressure: >160 systolic, >110 diastolicProteinurea: >5gm in 24 hours, over 3+ urine dipOligurea: less than 400ml in 24 hoursCNS: Visual changes, headache, scotomata, mental status changePulmonary EdemaEpigastric or RUQ Pain: Usually indicates liver involvement
50Indications for Delivery in Preeclampsia Gestational age 38 weeksPlatelet count < 100,000 cells/mm3Progressive deterioration in liver and renal functionSuspected abruptio placentaePersistent severe headaches, visual changes, nausea, epigastric pain, or vomiting
52ARRHYTHMIASSerious cardiac arrhythmias are uncommon in pregnancy due to the low prevalence of heart disease in women in the reproductive age groupPre-existing arrhythmias may be aggravated and new arrhythmias appear for the first time in pregnancyArrhythmias occurring in structurally normal hearts are uncommon and usually benign.
53Tachyarrhythmias such as AF, VT and VF tend to be associated with SHD DC cardioversion can be safely performed and should not be withheld if the arrhythmia is associated with haemodynamic instabilityAlthough no drug is completely safe, digoxin, quinidine, procainamide and adenosine are well toleratedBB are useful agents but use of atenolol, specifically during the first trimester may be associated with intrauterine growth retardation
54COMPLETE HEART BLOCK it is usually congenital Patients with CHB may remain asymptomatic during pregnancy and have an uncomplicated labor and delivery without treatmentSymptomatic patients with conduction abnormalities treated during pregnancy with either temporary or permanent pacemakersIt has been done with electrocardiographic and echocardiographic guidance in some cases to avoid ionizing radiation
55Coronary artery disease and pregnancy Familial hyper chlesterolimia, obesity smoking and diabetes is the main factorsAcute myocardial infarction during pregnancy is rare, occurring in 0.01 percent of pregnanciesMost myocardial infarctions occur during the third trimester in women over age 33in situ coronary thrombosis, and coronary dissection occur more frequently than classic obstructive atherosclerosis
56Medical therapy for acute myocardial infarction must be modified in the pregnant patient Thrombolytic agents increase the risk of maternal hemorrhage substantially to 8%Low dose aspirin and nitrates..BB Short-term heparin generally are safe.(ACE) inhibitors and statins are contraindicatedHydralazine and nitrates may be used as substitutes for ACE inhibitors.
57Drug therapy in pregnancy Balancing actmaternaltreatmentfetaleffectsLittle scientific evidence
58Maternal fetal transfer Placental transferDrugs & metabolites in fetusFetal GI absorptionTransfer via breastmilk
59Drug Use Potential Side Effects Safe Use During Breastfeeding Cardiovascular Drugs In PregnancyDrugUsePotential Side EffectsSafeUse During BreastfeedingAdenosineArrhythmiaNone reportedYesNo dataAmiodaroneIUGR, prematurity, hypothyroidismNoACE inhibitorsHypertensionOligohydramnios, IUGR, PDA, prematurity, neonatal hypotension, renal failure, anemia, death, musculoskeletal abnormalitiesOkBeta-blockersHypertension, arrhythmias, MI, ischemia, HCM, hyperthyroidism, mitral stenosis, Marfan syndrome, cardiomyopathyFetal bradycardia, low birth weight, hypoglycemia, respiratory depression; prolonged laborDigoxinArrhythmia, CHFLow birth weight, PrematurityDiureticsHypertension, CHFReduced utero- placental perfusionUnclearFlecainide? fetal death; limited dataLimited dataLidocaineArrhythmia, anesthesiaNeonatal CNS depressionLow Molecular Weight HeparinMechanical valve, hypercoaguable state, DVT, AF, Eisenmenger syndromeHemorrhage, unclear effects on maternal bone mineral densityNitratesFetal distress with maternal hypotension
61Infective endocarditis although it is rare complication in pregnancy, causes mortality in 10–30% of those affectedThe development of a new cardiac murmur is common in pregnancy and can make the diagnosis of endocarditis difficultpredisposing factors in young women include MVP, CHD and intravenous drug abuseThe use of antibiotic prophylaxis during uncomplicated deliveries remains controversialprophylaxis only for women who are at high risk is recommended
62Antibiotic prophylaxis is recommended for the following: High-risk category Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot) Surgically constructed systemic pulmonary shunts or conduits
63Moderate-risk category Most other congenital cardiac malformations (other than above and below) Acquired valvular dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation and/or thickened leafletsEndocarditis prophylaxis is not recommended for the following: (no greater risk than the general population) Isolated secundum atrial septal defect
64Surgical repair of ASD, VSD, or PDA Previous coronary artery bypass graft surgery MVP without valvular regurgitationPhysiologic, functional, or innocent heart murmurs Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunctionCardiac pacemakers (intravascular and epicardial) and implanted defibrillators
65High-risk patient who has penicillin allergy Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal proceduresCategoryDrug and dosageHigh-risk patientAmpicillin, 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 6 hr after procedureHigh-risk patient who has penicillin allergyVancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr, plus gentamicin sulfate, 1.5 mg/kg IV 30 min before procedure
66Anaesthesia during pregnancy The choice of anesthesia depends on circumstances of the delivery and maternal cardiac statusEpidural anesthesia is well tolerated and provides effective analgesia.-It minimize HR and BP changes associated with inadequate pain relief. With cautious fluid preloading, gradual increments in drug dosages and positioning in the lateral position,-It should still be used with extreme caution in those with restricted cardiac output or right-to-left shunts.
67summaryWomen at low risk are those who have few or no symptoms and good LV functionThose of high risk need to be managed within or from a cardiac centerThe mode and time of delivery should be discussed and vaginal delivery usually advisedAntibiotic prophylaxis is not advised for a normal delivery