1. Heart disease in pregnancy
Kelly Hansul, Do
metro health
university of Michigan health

2. I have no relevant financial relationships to disclose
I will not discuss any off-label use and/or investigational use in my presentation

3. Why can this cause heart palpitations?

4. Pregnancy and heart disease: on the rise!
Congenital heart disease
Now > 1% of pregnancies and accounts for 20% of non-obstetric maternal deaths
Kuklina, BJOG, 2011

5. hypothetical 3 AM 19 yo immigrant – first pregnancy No prenatal care
History Rheumatic heart disease
Vaginal bleeding/abruption
SOB
Would you know what to do?

7. When you have cardiac disease….
Do you think heart failure?
Do you think too much fluid?
Do you think treatment is fluid restriction?

8. Pregnancy is different
Rule # 1
Pregnancy is different

9. Normal heart physiology

10. Basic physiologic changes in pregnancy
Increased blood volume
Cardiac output fluctuations
Blood volume
Labor
Postpartum volume shifts
Decreased SVR
Decreased colloid osmotic pressure

11. Pregnant heart considerations
All is well if the heart is normal
Not good if there is heart disease present
Right heart disease tends to do well
Left heart disease usually does not do well

12. Maternal mortality associated with pregnancy
Group 1= mortality <1%
Group 2 = mortality 5-15%
ASD
VSD
PDA
Mitral stenosis NYHA I and II
Corrected Tetralogy of Fallot
Bioprosthetic valve
Mitral Stenosis NYHA III and IV
Mitral stenosis with a fib
Aortic Stenosis
Coarctation of aorta without valvular involvement
Uncorrected Tetralogy of Fallot
Previous MI
Marfan syndrome with normal aorta
Mechanical heart valve

13. Maternal mortality associated with pregnancy
Group 3 = mortality 25-50%
Pulmonary HTN
Coarctation of the aorta with valvular involvement
Marfan syndrome with aortic involvement
Peripartum cardiomyopathy with persistent left ventricular dysfunction
Severe systemic ventricular dysfunction
Severe left – sided obstructive lesions
Modified from Foley, et all
Critical Care Obstetrics, 2010

14. Normal changes that mimic heart disease
Dyspnea
Many pregnant women complain prior to 20 weeks and 75% by the third trimester
To differentiate between normal physiologic change and disease process
“Normal” dyspnea occurs early and does not significantly worsen
Heart disease dyspnea usually worsens second half of pregnancy
Physiologic dyspnea does not stop women from performing ADL’s and does not occur at rest
Other symptoms that mimic heart disease
Decreased exercise tolerance, fatigue, occasional orthopnea, syncope, chest discomfort

15. Diagnosis and evaluation of heart disease
Indications for further cardiac testing
History of known cardiac disease
Symptoms in excess of those expected in normal pregnancy
Pathologic murmur
Evidence of heart failure on physical exam
Arterial oxygen desaturation in the absence of known pulmonary disease
Most next appropriate step
Transthoracic echocardiography

16. Labor, delivery and postpartum period
Heart rate, blood pressure and cardiac output all increase with contractions
Immediately after delivery, the uterus auto transfuses
During the first 2 weeks postpartum, extravascular fluid is mobilized and diuresis ensues
Unsuspected cardiac disease may be diagnosed when a woman returns to the ED several days PP with dyspnea and oxygen desaturation

17. Atrial Septal Defect
Most common repaired and unrepaired congenital lesion in pregnant women
In general, it is asymptomatic even with large left to right shunts
Three significant complications seen with ASD
Arrhythmias
Heart failure
Paradoxical embolism

18. ASD management in labor
Avoidance of fluid overload
Oxygen administration
Labor in the lateral recumbent position
Pain relief with epidural
Goal is to reduce cardiac work

19. Ventricular septal defect
May occur as an isolated lesion or in conjunction with other congenital anomalies
Size and location most important predictors during pregnancy
Small are tolerated well
Larger defects or those associated with other anomalies are more complicated
Can lead to heart failure, congestive failure, arrhythmias or pulmonary HTN
Echo or cardiac cath is essential in any adult patient in whom persistent VSD is suspected

20. Watch out for pulmonary edema in mitral stenosis patients, especially
Rule # 2
Watch out for pulmonary edema in
mitral stenosis patients, especially
postpartum

21. Cardiac case studies: mitral stenosis
19 yo, G-1, P-0 at 31 weeks; history class II mitral stenosis; presents with chest pain and SOB
VS: 104/40, 122, 28, 98.4
SaO2 94%
Breath sounds – wet
ABG’s 7.41, 42, 60, 19.3
ECG – sinus tach

22. Classification of mitral stenosis
Recommendations for classification of mitral stenosis severity
Mild
Moderate
Severe
Specific findings
Valve area (cm2)
>1.5
<1.0
Supportive findings
Mean gradient (mmHg)a
<5
5-10
>10
Pulmonary artery pressure (mmHg)
<30
30-50
>50
aAt heart rates between 60 and 80 bpm and in sinus rhythm.

23. MS therapy

24. X-ray fluoroscopy during balloon mitral valvuloplasty

25. Intrapartum management
Avoid tachycardia
Decreases L-ventricular filling time
B-blockers for pulse >90-100
Avoid hypervolemia, but also hypovolemia !
Keep PCWP approximately 14
Accommodate postpartum volume load
May need diuretics
Individualize PCWP and CO

26. Despite heart disease, diuresis is usually the incorrect strategy
Rule #3
Despite heart disease, diuresis is usually the incorrect strategy

27. Cardiac case Studies Aortic stenosis:
24 yo G-2, P-1 at 36 weeks; admitted with severe chest pain, numbness radiating down left arm; and contractions
Vitals signs: 160/104, 126, 38, 97.8
SaO2 99%
Breath sounds clear
ABG’s 7.46, 28, 140, 18.7
ECG Inverted T-waves, slightly prolonged S-T segment

28. Aortic stenosis Most common etiology is congenital bicuspid valve
Ideally, correction of the valvular abnormality occurs prior to pregnancy
Surgical valve repair
Surgical valve replacement
Or percutaneous balloon valvotomy
If diagnosed during pregnancy, maximal medical therapy is preferred

29. Aortic stenosis Fixed CO in severe disease
Critical stenosis
(valve area , 1-1.5cm2)
LVH
CHF
Fixed CO in severe disease
May not be adequate to perfuse coronary and cerebral systems
Angina, MI, syncope, death

30. Intrapartum management
Spinal and epidural anesthesia are discouraged during labor due to vasodilatory effects
Balloon valvuloplasty can be considered in severe cases that require intervention prior to delivery
Avoid hypotension
Decreased venous return will decrease CO
Avoid hemorrhage
Hypovolemia more dangerous than pulmonary edema
Keep on the “wetter” side

31. Rule # 4
Certain patients should be advised that pregnancy is prohibitively risky

32. Overview 22 yo Gravida 1 Hx: congenital heart disease/single ventricle
Repaired / follow up
Residual problem: pulmonary hypertension

33. Pulmonary hypertension and pregnancy
PHTN=PAP > 30mmhg
Traditionally, 50% mortality
Contraception and early pregnancy risk counseling remain paramount

35. Avoid hypotension Systemic hypotension
Decreased R ventricle filling pressure
Decreases pulmonary perfusion in face of PHTN
Profound hypoxemia
Sudden death

36. Marfan syndrome Autosomal dominant, variable expression
Mutation of the fibrillin gene on 15q21
Generalized connective tissue weakness
Can lead to aneurysms, rupture, dissection
60% also have mitral or aortic regurgitation
RISK IN PREGNANCY SURROUNDS AORTIC ROOT DISSECTION OR RUPTURE

37. AORTIC ROOT RISK IN PREGNANCY
Aortic root diameter
< 4cm
> 4 cm
Risk of dissection or rupture
1% during pregnancy
10% during pregnancy
Risk of maternal mortality
<5%
Up to 50%

38. Prophylactic B-blockade
Reduces hemodynamic stress on ascending aorta
Slows rate of dilation
Reduces pregnancy aortic complication rate 5 fold
Pacini, Int Card, 2009

39. Delivery Route < 4 cm root = vaginal + assisted second stage
> 4 cm root = cesarean

40. Peripartum cardiomyopathy
Cardiomyopathy in the last month of pregnancy or first 5 months postpartum with exclusion of other causes
Peak incidence is within 1 month postpartum
Greater risk with older gravidas, multiparas, African Americans, twins and PIH
Manifests as biventricular failure and dilatation
50% will develop chronic dilated cardiomyopathy

41. Outcome Even today, high risk for adverse outcome despite normal EF
Peripartum cardiomyopathy: prognostic factors for long term maternal outcome
EF > 40% = 29% had worsening cardiac symptoms
EF < 25% = 57% end stage cardiac disease
Habli, AJOG 2008

42. Acute treatment Reduce preload Reduce afterload if hypertension
Lasix 20-40mg daily
Use carefully in the undelivered patient
Reduce afterload if hypertension
Hydralazine mg up to QID
Postpartum = ACE inhibitor
Improve contractility
Digoxin mg daily
Reduce myocardial demand and remodeling
Beta blocker such as metoprolol (Lopressor) 12.5 – 100mg daily

43. In conclusion: a summary
With respect to CHD, patients with any of the following are considered at high risk:
Aortic regurgitation or mitral regurgitation with NYHA class III to IV symptoms
Marfan syndrome, especially with aortic regurgitation
Severe aortic stenosis with valve area< 1.5cm or gradient > 30mmgHg
Severe Mitral stenosis < 2cm
Any condition that results in LV dysfunction (LVEF <40%) or severe pulmonary HTN
Mechanical valves that require chronic antigoagulation
Poor functional class (NYA class III or IV) or cyanosis

44. Summary continued
In comparison, patients with the following conditions are considered at low risk
Asymptomatic aortic stenosis with an LVEF >50% and a mean gradient less than 25mmHg
Aortic regurgitation or mitral regurgitation with no or mild symptoms (NYHA class 1 to II)
Mild to moderate pulmonary valve stenosis