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  1. 1. Acquired heart disease and pregnancy KHABBAZ J MD Homs 08/02/07
  2. 2. Heart disease is the joint most common maternal death in the UK
  3. 3. Copyright ©2004 BMJ Publishing Group Ltd. Cardiac causes of maternal deaths in the UK : confidential enquiry into maternal deaths 1997-99 (total maternal deaths = 409, cardiac deaths = 41).1
  4. 4. Pre-pregnancy counseling
  5. 5. The goal
  6. 6. To prevent accidental and possibly dangerous pregnancies and to allow patients to come to terms with their future childbearing potential
  7. 8. Estimation of maternal mortality as well as morbidity <ul><li>The likelihood of pregnancy resulting in heart failure requiring hospital admission </li></ul><ul><li>Exacerbation of arrhythmias </li></ul><ul><li>Long term deterioration in ventricular function </li></ul>
  8. 9. Assessment of risk in patients with preexisting cardiac disease
  9. 10. Predictors of Maternal Risk for Cardiac Complications - Prior cardiac events (heart failure, transient ischemic attack, stroke prior to pregnancy) - Prior arrhythmia (symptomatic sustained tachyarrhythmia or bradyarrhythmia requiring treatment) - NYHA functional class > 2 or cyanosis - Valvular and outflow tract obstruction (aortic valve area < 1.5 cm2, mitral valve area < 2 cm2, or left ventricular outflow tract peak gradient > 30 mm Hg) - Myocardial dysfunction (LVEF < 40% or restrictive cardiomyopathy or hypertrophic cardiomyopathy
  10. 11. Return to Pregnancy and Heart Disease Chapter Maternal Cardiac Lesions and Risk of Cardiac Complications During Pregnancy Low Risk Atrial septal defect Ventricular septal defect Patent ductus arteriosus Asymptomatic AS with low mean gradient (<50 mm Hg) and normal LV function (EF>50%) AR with normal LV function and NYHA class I or II MVP (isolated or with mild/moderate MR and normal LV function) MR with normal LV function and NYHA class I or II Mild/moderate MS (MVA >1.5 cm2, mean gradient <5 mm Hg) without severe pulmonary hypertension Mild/moderate PS Repaired acyanotic congenital heart disease without residual cardiac dysfunction Copyright 2003 The Cleveland Clinic Foundation
  11. 12. Return to Pregnancy and Heart Disease Chapter Maternal Cardiac Lesions and Risk of Cardiac Complications During Pregnancy Intermediate risk Large left to right shunt Coarctation of the aorta Marfan's syndrome with a normal aortic root Moderate/severe MS Mild/moderate AS Severe PS History of prior peripartum cardiomyopathy with no residual ventricular dysfunction Copyright 2003 The Cleveland Clinic Foundation
  12. 13. Return to Pregnancy and Heart Disease Chapter Maternal Cardiac Lesions and Risk of Cardiac Complications During Pregnancy High Risk Eisenmenger's syndrome Severe pulmonary hypertension Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, tricuspid atresia) Marfan's syndrome with aortic root or valve involvement Severe AS with or without symptoms Aortic and/or mitral valve disease with moderate/severe LV dysfunction (EF<40%) NYHA class III to IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology History of peripartum cardiomyopathy with persistent LV dysfunction Copyright 2003 The Cleveland Clinic Foundation
  13. 14. Classification of risk The WHO classification
  14. 15. The WHO classification <ul><li>WHO 1 = low risk </li></ul><ul><li>WHO 2+3 = Intermediate risk </li></ul><ul><li>WHO 4 = High risk </li></ul>
  15. 16. Pregnancy contraindications <ul><li>Pulmonary hypertension of any cause </li></ul><ul><li>Severe LV dysfunction: EF<20% </li></ul><ul><li>Severe left sided obstruction </li></ul><ul><li>Marfan with dilated aortic root>4cm diameter </li></ul>
  16. 17. Minimising maternal risk <ul><li>If necessary by catheter or surgical intervention before conception </li></ul><ul><li>Timing of pregnancy : 20s>30s </li></ul>
  17. 18. Estimation and minimising fetal risk <ul><li>Recurrence risk : familial or congenital diseases (HCM) </li></ul><ul><li>Maternal drug treatment may need changing before conception or once pregnant </li></ul><ul><li>Maternal factors which may compromise the fetus: cyanosis, uncontrolled arrhythmia </li></ul>
  18. 19. Joint antenatal care with a high risk pregnancy obstetric team
  19. 20. But ?
  20. 21. Copyright ©2004 BMJ Publishing Group Ltd. Physiological changes in pregnancy Systemic and pulmonary vascular resistance fall during pregnancy. Blood pressure may fall in the second trimester, rising slightly in late pregnancy. Note that cardiac output and stroke volume peak by 16 weeks gestation.
  21. 23. Valve heart disease
  22. 24. Stenotic valvar lesions are generally less well tolerated than regurgitant lesions, especially if severe and left sided
  23. 25. Low risk lesions
  24. 26. Mitral regurgitation
  25. 27. Aortic regurgitation
  26. 28. Moderate/high risk lesions
  27. 29. Mitral stenosis
  28. 31. Aortic stenosis
  29. 35. Percutaneous mitral balloon valvotomy prior to conception or during pregnancy
  30. 36. Percutaneois aortic balloon valvuloplasty
  31. 37. Antibiotic prophylaxis is recommended during vaginal delivery in high risk patients (prosthetic valve)
  32. 38. Mechanical prosthetic heart valves
  33. 39. Heart valve repair
  34. 40. Biological valves
  35. 41. Anticoagulation during pregnancy <ul><li>Aspirin </li></ul><ul><li>Warfarin </li></ul><ul><li>Heparin: UFH, LMWH </li></ul>
  36. 42. Anticoagulation during pregnancy <ul><li>Warfarin (fetus) # Heparin (mother) </li></ul>
  37. 44. Anticoagulation during pregnancy <ul><li>The fetal risk of warfarin is significantly reduced if the woman is adequately anticoagulated on < 5 mg of warfarin </li></ul><ul><li>The safest option for the woman is to remain on warfarin throughout the pregnancy, with an elective section to reduce the time off warfarin </li></ul>
  38. 45. Cardiac diseases complicate 1-4% of pregnancies in women without preexisting cardiac abnormalities
  39. 46. Hypertension in pregnancy
  40. 47. Hypertension is the most commonly occurring complication of pregnancy and remains one of the leading causes of both maternal and perinatal morbidity and mortality
  41. 48. Ischaemic heart disease
  42. 52. Cardiac troponin I is unaffected by normal pregnancy, labour, and delivery
  43. 55. Thrombolysis should be avoided for 10 days post-section and late in pregnancy in case of premature labour: increased maternal hemorrhage by 8%
  44. 56. PCI may be the best option ( > 2d trimester )
  45. 57. Peripartum cardiomyopathy
  46. 74. Arrhythmias in pregnancy
  47. 75. Increased sympathetic drive of pregnancy often worsens arrhythmias
  48. 76. Arrhythmias in pregnancy <ul><li>Rate control can be safely achieved with digoxin and BB </li></ul><ul><li>Adenosine, verapamil, and DC cardioversion are safe for both mother and fetus </li></ul><ul><li>Amiodarone is contraindicated </li></ul>
  49. 77. Radiofrequency ablation ?
  50. 78. &quot;The majority of patients will tolerate pregnancy and contraception well.&quot; But &quot;the failure to give adequate family planning advice to women with heart disease can cause them an unnecessary burden that can have devastating consequences, such as the requirement for a termination.&quot;
  51. 79. Thank you