Approach to cardiac diseases in pregnancy

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  • 1. Approach to Cardiac Disease in Pregnancy Mehul Bhatt, MD Athens Heart Center March 13, 2009
  • 2. Approach to Cardiac Disease in Pregnancy Physiological changes in pregnancy Systematic approach to cardiac lesions Principal of monitoring and treatment Individualizing treatment to each patient
  • 3. Normal Physiological Changes in Pregnancy
    • Framework to understand effects of cardiac pathology
    • Tremendous cardiocirculatory changes in normal pregnancy:
        • SV (increase 40-50%)
        • CO (increase 30-50%)
    • Examine changes at various points of pregnancy
    • Normal changes in physical exam, EKG, CXR, Echo, PA catheter
  • 4. Normal Physiological Changes in Pregnancy Braunwald E et al. Heart Disease. 2001. pg. 2173.
  • 5. Normal Physiological Changes in Pregnancy Braunwald E et al. Heart Disease. 2001. pg. 2173.
  • 6. Normal Physiological Changes in Pregnancy
    • Changes in blood volume start by 6 weeks
    • Most hemodynamic changes completed by 22-25 weeks
    • (major underlying cardiac disease should present by this point)
    • Mechanisms of cardiovascular hyperactivity:
      • Estrogen levels
      • Elevated renin-aldosterone levels
      • Elevated chorionic somatomammotropin
      • Elevated prolactin
      • Fetus not necessary for changes to occur
      • (as evidenced from hydatidiform moles)
  • 7. Normal Physiological Changes in Pregnancy Braunwald E et al. Heart Disease. 2001. pg. 2172.
  • 8. Normal Physiological Changes in Pregnancy
    • Symptoms:
      • Decreased exercise tolerance / Tiredness – increased body weight and physiological anemia
      • Orthopnea – pressure of uterus on diaphragm
      • Palpitations – usually sinus tachycardia
      • Lightheadness / Syncope – compression IVC, decrease CO
      • Dyspnea – 76% of women at 34 th week
    • Physical Exam: Hyperventilation, peripheral edema, capillary pulsations, brisk PMI, palpable RV + PA impulse, bibasilar rales (from atelectasis), distended neck veins (promient a,v waves, brisk x,y descents)
    • May be similar changes from cardiac pathology in pregnancy
  • 9. Normal Physiological Changes in Pregnancy
    • 3 rd heart sound in upto 90%
    • Systolic ejection murmur – from hyperkinetic flow
    • Most auscultatory changes resolved 1-2 weeks postpartum
    Cutforth R et al. Heart sounds and mumurs in pregnancy. Am Heart J. 1966;71:741-747.
  • 10. Normal Physiological Changes in Pregnancy
    • EKG changes
      • QRS axis deviation
      • Small Q wave and inverted P wave in lead III
      • Sinus tachycardia
      • Increase R/S ratio in V 1 and V 2
    • CXR changes
      • Straightening of left upper cardiac border
      • Horizontal positioning of heart
      • Increased lung marking
      • Small pleural effusion at early postpartum
    • Echocardiogram
      • Slightly increased EDdV and ESdV
      • Slightly improved LV function
      • Enlargment of ventricular dimensions
      • Slight enlargement of left atrial size
      • Small pericardial effusion
      • Increased tricuspid annulus diameter
      • Functional tricuspid regurgiation
    Elkayam U et al. Cardiac Problems in Pregnancy. 1990.34-7.
  • 11. Normal Physiological Changes in Pregnancy
    • Effect of position on IVC return
    • Positioning in cardiac pathology may be beneficial or detrimental
    Braunwald E et al. Heart Disease. 2001. pg. 2172.
  • 12. Normal Physiological Changes in Pregnancy
    • Labor and Delivery:
      • Pain / Anxiety – can increase CO by 50-61%
      • Uterine contraction – 300-500 mL infusion into central venous system
      • Cardiocirculatory effects of uterine contraction:
    Elkayam U et al. Cardiac Problems in Pregnancy. 1990. 16. Parameter Change Comments Blood Volume Increase 300-500 mL Cardiac Output Increase 30-60% increase Heart Rate Increase or Decrease Blood Pressure Increase SBP and DBP Peripheral Resistance Unchanged O 2 Consumption Increase 100% increase
  • 13. Normal Physiological Changes in Pregnancy
    • Labor and Delivery:
      • Hemodynamic changes of pregnancy less dramatic in lateral position
      • Maneuvers in delivery position depending on cardiac pathology
  • 14. Normal Physiological Changes in Pregnancy
    • Labor and Delivery
      • Epidural anesthesia – systemic vasodilation that can reduce SV
        • Poorly tolerated in patient who cannot increase SV, fixed CO
      • Cesarean section – with GETA
        • Reduced maternal metabolic needs and stabilization of blood volumes
  • 15. Normal Physiological Changes in Pregnancy Hemodynamic Changes Postpartum Parameter Change Comment Blood Volume Decrease Blood loss CO Increase 60-80% immediate increase followed by rapid decrease, returns to normal levels in few weeks SV Increase HR Decrease BP Unchanged SVR Increase Loss of low resistance placenta
  • 16. Cardiac Diseases in Pregnancy: Basics
    • Cardiac disease hinders physiological reserves
    • Increasing incidence congenital heart disease
    • Decreasing incidence of rheumatic heart disease
  • 17. Cardiac Disease in Pregnancy: Basics
    • Non-cyanotic cardiac disease
      • NYHA Functional Class
        • Maternal mortality
          • Class I and II: 0.4%
          • Class III and IV: 6.8%
        • Fetal mortality
          • Class I: negligible
          • Class IV: 30%
    • Cyanotic cardiac disease
      • 45% rate of fetal death
      • Low birth weight and immaturity
  • 18. Cardiac Disease in Pregnancy: Congenital Heart Disease
    • Increased CO and blood volume on already stressed hemodynamic system
    Lesions with volume overload Lesions with obstruction
    • Atrial septal defect
    • Ventricular septal defect
    • Patent ductus arteriosus
    • Aortic stenosis
    • Coarctation of the aorta
    • Pulmonary stenosis
    • Tetrology of Fallot
  • 19. Cardiac Disease in Pregnancy: Cardiac Lesions Pregnancy well tolerated (except if progress to Eisenmenger’s syndrome) (able to tolerate increased volume) Pregnancy poorly tolerated
    • Mitral regurgitation
    • Aortic regurgitation
    • Atrial septal defect
    • Patent ductus arteriosis
    • Pulmonary stenosis
    • Hypertrophic obstructive cardiomyopathy (may even benefit from increased preload)
    • Obstructive (Fixed CO)
      • Mitral stenosis
      • Aortic stenosis
      • Coarctation of aorta
    • Cyanotic
      • Any lesion with Eisenmenger’s syndrome
      • Primary pulmonary hypertension
      • Tetralogy of Fallot
    • Volume limited
      • Marfan’s with aortic root involvement
      • Aortic dissection
    • Active rheumatic carditis
    • Any lesion with Class III or IV symptoms
  • 20. Cardiac Disease in Pregnancy: Cardiac Lesions
    • Factors that increase risk of CHF with pregnancy:
      • Age > 30 YO
      • Gestational age > 20 weeks
      • Cardiac enlargement > 55% lung space on CXR
      • Atrial tachycardia
      • Physical effort
      • Toxemia
      • Infection
      • Emboli
  • 21. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • In perfect world:
      • Diagnosis of cardiac disease prior to pregnancy
      • Pre-pregnancy counseling of patient and partner with obstetrics, cardiology, and anesthesia involved
      • Pre-pregnancy treatment
        • Medical therapy
          • CHF treatment
          • Arrhythmia management
        • Surgical therapy
          • Valve replacement
          • Congenital heart disease repair
  • 22. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • General objectives of treatment
      • Shunts: avoid favoring R to L shunting, lower PA pressures, avoid hypoxemia, avoid prolonged Valsalva
      • Obstructive Lesions: β -blockers, avoid volume depletion, maintain preload
      • CHF: diuretics (only with pulmonary edema), reduce afterload
      • Arrhythmias: rate and rhythm control, anticoagulation as necessary, higher dose digoxin
      • Tenuous aorta (Marfan’s, aortic dissection): β -blockers (reduce dp/dt)
  • 23. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • Indications for considering PA catheter:
      • NYHA Functional Class II, III, IV
      • Mitral stenosis
      • Aortic stenosis
      • Pulmonary hypertension
      • Pulmonary edema
      • Hypoxemia
      • Ischemic heart disease
      • Intractable hypertension
      • Oliguria unresponsive to fluids
    • Risk of PA catheter:
      • Increased procedural fear and pain leading to increased CO
  • 24.  
  • 25. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • Labor and Delivery:
      • Epidural anesthesia:
        • Systemic vasodilation
        • Decrease CO 25-45% even in normal patients
        • Well tolerated (often beneficial):
          • AR, MR, L to R shunts
        • Poorly tolerated:
          • Limited ability to increase SV
          • R to L shunts
          • AS, MS
          • Hypertrophic CM
          • Pulmonary hypertension without ASD
  • 26. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • Labor and Delivery
      • Caesarian section recommended:
        • Obstetrical reasons
        • Anticoagulation with coumadin
          • Avoid forceps, use vacuum/suction devices
        • Severe fixed obstructive cardiac lesions
          • Avoid vasodilation (reduced preload) with epidural anesthesia
        • Severe pulmonary HTN
        • Marfan’s with dilated aorta or aortic dissection
          • Avoid increased blood volume, aortic stress with contractions
  • 27. Cardiac Disease in Pregnancy: Monitoring and Treatment
    • Labor and Delivery
      • Shorten stage II labor
        • Prolonged valsalva
          • Increase PA pressures, Increases R to L shunting
          • Shunts: ASD, VSD, Tetralogy of Fallot, Eisenmenger’s
      • Maternal Position:
        • Supine versus lateral decubitus
          • Consider lateral decubitus with obstructive lesions
          • Consider supine with CHF
      • Post-delivery:
        • Continue monitoring
          • Increased CO (returns to normal after several weeks)
          • Increased SVR (with loss of placenta)
          • Hemorrhage risk
  • 28. Cardiac Disease in Pregnancy: Highest-Risk Cardiac Lesions
    • Suprasystemic pulmonary vascular resistance (Eisenmenger’s syndrome)
    • Marfan’s syndrome with dilation of the aortic root
    • Peripartum cardiomyopathy with persistent cardiac enlargement
  • 29. Cardiac Disease in Pregnancy: Peripartum Cardiomyopathy
    • Incidence: 1 in 4000 pregnancies
    • More common after age 30
    • Can result in severe CHF
    • Clinically present by 3 rd trimester
    • Close hemodynamic monitoring and early delivery maybe necessary
    • Cardiomyopathy may persist even after delivery
    • High rate of recurrence so birth control recommended
  • 30. Cardiac Disease in Pregnancy: Acute Myocardial Infarction
    • Rare in pregnancy
      • 1 in 10,000 to 30,000 pregnancies
    • Coronary dissections
    • Thrombolytic therapy relatively contraindicated
    • Primary angioplasty safe after 1 st trimester with lead shielding over fetus
  • 31. Cardiac Disease in Pregnancy: Anticoagulation
    • Increased thrombogenicity in pregnancy
      • Increased fibrinogen
      • Increased factors II, VII-X
      • Increased von Willebrand factor
      • Increased endothelial cell inhibitor of tPA
      • Increased placental inhibitor of tPA
      • Decreased protein S
    • Same indication as in non-pregnant
    • Mechanical valves still particularly challenging
  • 32. Cardiac Disease in Pregnancy: Anticoagulation
    • Anticoagulants:
      • Warfarin
        • 1 st trimester teratogenicity – due to low levels of Vit. K clotting factors in early fetus
          • “ Coumadin embryopathy”: Facial abnormalities, optic atrophy, mental impairment (5-25% risk)
          • Possibly dose related effects (one study)
        • Higher rates of spontaneous abortion
      • Unfractionated Heparin
        • Used during 1 st trimester to avoid coumadin embryopathy
        • Subcutaneous unfractionated heparin still see fatal valve thrombosis
  • 33. Cardiac Disease in Pregnancy: Anticoagulation
    • Anticoagulants
      • Low molecular weight heparin (LMWH)
        • Seemed easy, cost-effective, non-teratogenic
        • Effective in DVT, antiphospholipid syndrome in pregnancy
        • Safe in peri-procedural bridging in non-pregnant patient with mechanical valve replacements
        • Randomized trial of LMWH in prosthetic heart valves terminated after 12 patients enrolled secondary due to 2 deaths from prosthetic valve thrombosis
  • 34. Cardiac Disease in Pregnancy: Prosthetic Valves
    • Treatment dilemma:
      • Warfarin best for prevention of thromboembolic events, but fetal safety issues
      • Heparin reduces fetal complications, but dosing issues increase risk of thromboembolic events
    • Consider bioprosthetic valves in women of childbearing age or planning pregnancy
    • Anticoagulation with mechanical valves
      • Very high risk patients
      • Limited data
      • ACC / AHA Guidelines
  • 35. Cardiac Disease in Pregnancy: Prosthetic Valves Braunwald E et al. Heart Disease. 2001. pg. 2186.
  • 36. Cardiac Disease in Pregnancy
    • Framework for evaluation and treatment
    • Individualized management
    • Anticoagulation with mechanical valves remains challenge