Cardiac Disease in Pregnancy

Cardiac Disease in Pregnancy
Dr Jason Reidy

Cardiac Disease in Pregnancy Why the interest?
Women consistently die form cardiac disease associated with pregnancy CEMACH Reports Cardiac Deaths Congenital heart disease Acquired heart disease

Cardiovascular Changes in Pregnancy

SVR Diastolic BP Cardiac output 20% by 8/40 40% by 20-28/40 SV Circulating volume Physiological LVH HR

Labour Cardiac output 1st stage ~15% 2nd stage ~50% Sympathetic output Uterine contractions Autotransfusion

Immediately Post-partum Cardiac output 60-80% Rapid decline to pre-labour levels ~2h 2 weeks post-partum Back to pre-pregnancy

Cardiovascular disease can manifest or worsen in pregnancy due to the dynamic physiological demands placed on the cardiovascular system

Maternal Deaths due to Cardiac Disease

CEMACH 2003-2005 Cardiac Deaths
Commonest indirect and overall cause 48 deaths Upward trend in deaths from IHD and myocardial infarction

Triennium Congenital n(%) Acquired n(%) Total Rate Per 100,00 Maternities Ischaemic Other 10 (43) 9 (39) 4 (17) 23 1.01 9 (50) 5 (28) 4 (22) 18 0.76 9 (24) 8 (22) 20 (54) 37 1.60 10 (26) 6 (15) 23 (59) 39 1.77 10 (29) 5 (14) 20 (57) 35 1.65 9 (20) 8 (18) 27 (61) 44 2.20 4 (8) 16 (33) 28 (58) 48 2.27

Acquired Indirect Late Aortic dissection 9 Myocardial infarction 12 4 Ischaemic heart disease Sudden Adult Death Syndrome (SADS) 3 Peri-partum cardiomyopathy Cardiomyopathy 1 Myocarditis or myocardial ﬁbrosis 5 Mitral stenosis or valve disease Infectious endocarditis 2 Right or left ventricular hypertrophy or hypertensive heart failure Congenital Pulmonary Hypertension Congenital Heart Disease Totals 47 34

Trends in Cardiac Deaths
Malhotra & Yentis IJOA 2006 288 maternal cardiac deaths in 30 year period from CEMD/CEMACH Trends in cardiac deaths with or without known disease or risk factors

Trends in Cardiac Deaths
Deaths in women with diagnosed disease 26% Deaths in women with documented risk factors 22% De Novo deaths 52%

Congenital Heart Disease

Improved survival with better surgery Growing population Good quality of life Normal fertility Pregnancy is a challenge for their repaired CVS They are not cured!

Deaths are decreasing Unplanned pregnancy No pre-pregnancy counselling

Ischaemic Heart Disease

What do we know? Upward trends in deaths from IHD and myocardial infarction Maternal risk factors Increasing maternal age Obesity Diabetes Pre-existing hypertension Higher parity Smoking Family history

Maternal Age CEMACH Percentages of maternities by age <20 20-24
25-29 30-34 35-39 ≥40 7.66 18.04 30.47 29.46 12.26 2.11 7.58 18.24 26.98 30.04 14.49 2.67 7.15 18.87 25.25 29.64 15.87 3.22

Maternal Age CEMACH Percentages of maternities by age <20 20-24
25-29 30-34 35-39 ≥40 7.66 18.04 30.47 29.46 12.26 2.11 7.58 18.24 26.98 30.04 14.49 2.67 7.15 18.87 25.25 29.64 15.87 3.22

Maternal Age CEMACH Death rates per 100,000 maternities by age Age
<20 20-24 25-29 30-34 35-39 ≥40 9.9 9.8 12.4 14.5 19.1 29.4

Maternal Obesity CEMACH
64% of women who died of cardiac disease were overweight or obese 31% had a BMI 25-30 33% had a BMI >30 60% of these >35 33.3% of these >40

Maternal Obesity CEMACH
BMI > 25 Direct Thromboembolism 20(65%) Pre-eclampsia/Eclampsia 9(50%) Haemorrhage 7(47%) AFE 6(43%) Early Pregnancy 2(33%) Sepsis 8(73%) Anaesthetic 2(50%) Indirect Cardiac 29(64%) Other 27(39%) Psychiatric 6(46%) Malignancies 3(43%) Total 119(52%)

Percentage in each age group
Maternal Obesity & Age Percentage distribution of BMI by age Health Survey for England 2003 BMI Percentage in each age group 16-24 25-34 35-44 18.5 or under 7.4 1.0 61.2 51.8 43.5 18.3 28.3 33.3 11.1 15.1 18.6 Over 40 2.0 3.0 3.5

Percentage in each age group
Maternal Obesity & Age Percentage distribution of BMI by age Health Survey for England 2003 BMI Percentage in each age group 16-24 25-34 35-44 18.5 or under 7.4 1.0 61.2 51.8 43.5 18.3 28.3 33.3 11.1 15.1 18.6 Over 40 2.0 3.0 3.5

Cardiac Disease in Pregnancy Who’s Going to Have a Problem?

Who’s going to have a problem?
Risk stratification Traditional assessment for non-cardiac surgery Probably not appropriate Extrapolation from a physiologically different population

Cardiac Disease in Pregnancy How do we stratify risk in the pregnant population?

Siu et al, Circulation 2001 Prospective study 562 women with 599 pregnancies in women with heart disease Pregnancy & neonatal outcomes Receiving comprehensive prenatal care

Who’s going to have a problem? Siu et al
Heart Disease 74% Congenital 22% Acquired 4% Arrhythmic 80 Cardiac Events (13%) Pulmonary oedema Arrhythmic Stroke Cardiac death (3)

4 Main predictors of adverse maternal cardiac event Prior history of Heart failure TIA/Stroke Arrhythmia NYHA ≥ Class II or Cyanosis

3. Left Heart Obstruction Mitral valve < 2cm2 Aortic valve <1.5cm2 Gradient of >30mmHg 4. Reduced LV Function EF<40%

No RF, then < 5% risk of CVS event 1 RF, then >20% risk of CVS event 2 RF, then >60% risk of CVS event

Lupton et al, Curr Opin Obst Gyn, 2002 More geared to congenital lesions Aimed to stratify risk of mortality Low Intermediate High

Low Risk Lupton et al Mortality 0.1-1.0% Most repaired lesions
Uncomplicated left-to-right shunts Regurgitant valve lesions

Intermediate Risk Lupton et al
Mortality 1-5% Metal valves Single ventricles Systemic right ventricle Switch procedure Unrepaired cyanotic lesions Stenotic valve lesions

High Risk Lupton et al Mortality 5-30% NYHA III or IV
Severely impaired LV function Severe aortic stenosis Marfan’s Syndrome with aortic valve lesion or dilated aortic root Pulmonary hypertension Mortality 30-50%

Management of Heart Disease in Pregnancy

Pre-conception Counselling essential Start early Discussion of the effect of pregnancy on the lesion Discussion of risks for cardiac events/death Drug regimen optimisation CVS optimisation

Antenatally Multidisciplinary approach Obstetrics Midwifery Cardiology/cardiothoracics Anaesthesia Multidisciplinary planning meetings are helpful in forming plans for delivery

Antenatally Regular review in pregnancy Including echocardiography Low threshold for admission Formal assessment Optimisation

Antenatally Major CVS changes in first 20 weeks Cardiac decompensation Watch for pre-eclampsia

Antenatal deterioration Mother or foetus Optimise mother medically Consider Surgical intervention Termination IOL or LSCS

Monitoring

Monitoring Large CVS changes should be anticipated perinatally
Degree of monitoring will depend on nature and severity of the lesion

Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Monitoring Continuous ECG Consider for all Continuous SpO2 Especially useful where shunting or pulmonary oedema are a possibility Adapted from Dob & Yentis, IJOA, 2006: 15( )

Monitoring Arterial line Any lesions associated with high risk of mortality Severe symptoms/impairment Pre-eclampsia High risk of haemorrhage Adapted from Dob & Yentis, IJOA, 2006: 15( )

Monitoring Central Line Useful in Heart failure Patients sensitive to hypovolaemia Vasoactive substances Drawbacks What are you monitoring? Technicality of insertion Complications Adapted from Dob & Yentis, IJOA, 2006: 15( )

Monitoring Trans-oesophageal Echo/Doppler ? Role Not well tolerated at LSCS Adapted from Dob & Yentis, IJOA, 2006: 15( )

Mode of Delivery

Mode of Delivery in Cardiac Disease
Low risk Labour with epidural High risk Elective caesarean Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24,

Labour Epidural analgesia for ALL Including fixed output states Low dose Except Therapeutic anticoagulation Clopidogrel ± Aspirin Minimal pushing in 2nd stage! Adapted from Dob & Yentis, IJOA, 2006: 15( )

LSCS GA or Regional? Either done carefully is acceptable Multifactorial Adapted from Dob & Yentis, IJOA, 2006: 15( )

LSCS Influences Arrhthymias SVR Pulmonary hypertension Anticoagulants/antiplatelets Need for post-op ITU Mortality & maternal attitude Associated airway anomalies Anaesthetist’s preference Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems

Peri-partum Problems Haemorrhage Some lesions tolerate blood loss poorly Aortic stenosis Fontan circulation risk due to anticoagulation risk due to lack of uterotonics Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems Uterotonics
Oxytocin Tachycardia/hypotension SVR, CO Ischaemic changes Bolus Vs. infusion Adapted from Dob & Yentis, IJOA, 2006: 15( )

Ergometrine Hypertension Pulmonary vasoconstriction Pulmonary hypertension Safe i.m in less severe lesions in the absence of hypertension Adapted from Dob & Yentis, IJOA, 2006: 15( )

Carboprost Hypertension CVS collapse Pulmonary oedema Largely unsuitable in cardiac disease Adapted from Dob & Yentis, IJOA, 2006: 15( )

Misoprostol Increasingly used Not evidence in cardiac disease Good side effect profile Uterotonic efficacy Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems Pulmonary Oedema Cardiac Obstetric Iatrogenic Careful fluid balance in labour or at LSCS Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems Arrhythmias Cardiac filling  Cardiac output  Coronary perfusion Avoid precipitants Oxytocin Ephedrine Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems Acute Pulmonary Hypertension Severe/catastrophic Even in mild disease Pulmonary hypertensive changes may be accelerated Adapted from Dob & Yentis, IJOA, 2006: 15( )

Peri-partum Problems Chest Pain Aortic dissection
Acute surgical emergency Bypass has 20% foetal mortality Coronary ischaemia/myocardial infarction Atheromatous changes Coronary artery dissection

European Heart journal (2003) 24, 761-81
Peri-partum Problems Management of AMI Occur mostly peri-partum Coronary dissection > atheroma Thrombolysis contra-indicated in dissection Important to exclude PPCM if heart failure present Rx of choice Immediate angiography +/- coronary stenting Normal coronaries in up to 47% Beyond 2nd trimester safe for foetus Thrombolysis is not contra-indicated in pregnancy Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24,

European Heart journal (2003) 24, 761-81
Peri-partum Problems Management of AMI Ongoing management to be directed jointly by cardiology and obstetrics Nitrates, aspirin, b-blockers, clopidogrel safe ACE-I and statins not safe Mortality Estimated 37% But up to 50% if delivery within 2 weeks of AMI Expert consensus document on management of cardiovascular diseases during pregnancy European Heart journal (2003) 24,

Post-Partum

Post-Partum Fluid balance Post-partum pre-eclampsia Good analgesia
Thromboprophylaxis Close monitoring should continue How long?

Summary Cardiac deaths increasing Maternal risk factors Congenital
Ischaemia Maternal risk factors Age Obesity

Summary What’s important Close supervision High index of suspicion
Especially for ischaemia More attention to risk factors

Summary Management principles Understand the physiology of the lesion
Appropriate monitoring Cardiovascular stability Good epidural analgesia in labour Careful anaesthesia for LSCS Awareness that delivery is not the end of the problem

Thank you

Cardiac Disease in Pregnancy

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