Pregnancy in ACHD
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Pregnancy in ACHD

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Pregnancy in ACHD Pregnancy in ACHD Presentation Transcript

  • Massimo Chessa Department of Pediatric Cardiology & Adult with Congenital Heart Disease IRCCS- Policlinico San Donato San Donato Milanese – Milano massimo.chessa@grupposandonato.it PREGNANCY IN ADULT WITHCONGENITAL HEART DISEASE
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Congenital Heart Disease Is a continuum From Fetal Life Until AdulthoodCHILDHOOD TRANSITION ADULTHOOD0 12 16 Pediatricians Pediatricians GUCH Cardiologist GUCH Cardiologist Community Cardiologist Nursing Primary Caregivers
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease AdvancesDiagnosis Therapy Survival
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease The first cause of suchincreasing number of patients is SURGERY
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Extraordinary Management Advances Improved Survival RateYear of birth Complex Moderate Simple CHD CHD CHD1940-1959 10% 55% 90%1960-1979 50% 65% 95%1980-1989 80% 90% 95%
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease More than 75.000 – 100.000 ACHD in Italy 1200-1600 adolescents enter adulthood every year and require life-long care More than 85% of infants are expected to reach adulthoodChessa M, Cullen S, Deanfield J The care of adult patients with congenital heartdefects: a new challenge. Ital Heart J. 2004 Mar;5(3):178-82.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease It is important to outline thatmost pts with CHD who havehad their lives transformed by surgical intervention, hadreparative and not corrective surgery
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Surgery is corrective, if…. …..ventricular function is normal …..life expetancy is normal!…..there is no need for tharapeutic measures during f-up
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseCorrective Surgery……. Atrial Septal defect Ventricular Septal Defect Patent Ductus Arteriosus…..if treated during childhood!!!
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseResiduae Sequelae Mechanical Electrophysiological Functional
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GUCH-PROBLEMS Verheugt C L, Heart 2010;96:872-878.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Hospitalization• Cardiovascular issues: 2-3 times more than general population in subjects over 30 yrs Verheugt C L, Heart 2010;96:872-878.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease 1966 first successful pregnancy in a pt With a Starr-Edward mitral valve ……..what about pregnancy in ACHD more than 40 yrs after ?
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseAt present, 0.2–4% of all pregnancies in westernindustrialized countries are complicated by cardiovasculardiseases. The spectrum of CVD in pregnancy is changing and differs between countries. In western countries maternal heart disease is now the major cause of maternal death during pregnancy
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseThis study has shown the possibility thatchronic heart disease among women ospitalisedduring pregnancy has increased in severity from1995–1997 to 2004–2006 in the USA, and alsoprovided evidence that chronic heart disease inpregnant women is one of the majorcontributors to severe obstetric complications.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease J Perinat Med. 2011 May;39(3):251-6Spectrum of cardiovascular findings during pregnancy and parturition at a tertiary referral center. Merz WM, Keyver-Paik MD, Baumgarten G, Lewalter T, Gembruch U. Cardiac lesions were congenital in 53.1% Overall cardiac complications: 22 Congestive Heart Failure (n=5),
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseAdditional insult to thecirculatory physiology byother factors coexistingtogether with congenitalheart disease can furtherreduce the cardiac reserve inpregnancy and precipitateheart failure
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease From: Abbas Amr E, Lester Steven J, Connolly H: Pregnancy and the cardiovascular system. International Journal of Cardiology, 2005; 98: 11
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease HEMODYNAMIC CHANGES DURING LABOR AND DELIVERYin blood flow and cardiac outputof blood pressure UTERINE CONTRACTIONof O2 consumption (up to 100%)Hemodynamic changes are influenced by the CESAREAN SECTIONtype of anaesthesia
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease HEMODYNAMIC CHANGES IN POST-PARTUMof blood volumeof cardiac output (immediate, secondary to the shift of the blood from the uterus to the systemic circulation and to the decreased caval compression with increase of the venous return, subsequent rapid decrease of cardiac outputin heart rateof vascular peripheral resistances
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseasePre-pregnancy counselling : risk estimationDisease-specific series are usually retrospective and too small toidentify predictors of poor outcome.Therefore, risk estimation canbe further refined by taking into accountpredictors that have been identified instudies that included larger populationswith various diseases.Several risk scores have been developedbased on these predictors, of which theCARPREG risk score is most widely known andused.
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseasePre-pregnancy counselling : risk estimationThe Task Force recommends that maternal risk assessment iscarried out according to the modified World Health Organization(WHO) risk classification.This risk classification integrates allknown maternal cardiovascular risk factorsincluding the underlyingheart disease and any other co-morbidity.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Pregnancy contraindicated
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GENERAL RECOMMENDATIONS Infective Endocarditis Infective endocarditis during pregnancy is rare, 0.006% (1 per 100 000 pregnancies)Patients with the highest risk for infective endocarditis are those with aprosthetic valve or prosthetic materialused for cardiac valve repair, a history ofprevious infective endocarditis, and somespecial patients with congenital heartdisease.
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseGENERAL RECOMMENDATIONS Arrhythmias
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GENERAL RECOMMENDATIONS AnticoagulationHemostatic changes during normal pregnancyConcentration of coagulation factorsConcentration of fibrogenPlatelet adhesiveness INCREASED RISK OF THROMBO-EMBOLIC EVENTS
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseGENERAL RECOMMENDATIONS Anticoagulation INDICATIONS Atrial fibrillation Impaired ventricular function PAH Cyanotic Heart Disease Fontan Circulation Venous Thrombosis Pulmonary emboli Valvular Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GENERAL RECOMMENDATIONS Anticoagulation
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GENERAL RECOMMENDATIONS Drugs and fetus CLASS DRUGS SAFETYINOTROPIC Digoxin +AGENTSDIURETICS Furosemide + (not chronic use)-BLOCKERS Propanolol, atenolol +- Preterm delivery, SGA, neonatal bradycardia and hypovolemiaCALCIUM verapamil +-CHANNEL Uterine bloodBLOCKERS flow
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease CLASS DRUGS SAFETYANTIARRHTHMIC Lidocaina, +AGENTS procainamide, quinidine Amiodarone - Neonatal hypothyroidismVASODILATATORS Nitroglycerin +- Volume depletion, hypotension and fall in uterine blood flowACE INHIBITORS Captopril, enalapril - Oligohydramnios, renal failure, bone malformation
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease GENERAL RECOMMENDATIONS DeliveryVaginal delivery is first choice for most patients- Less blood loss, less infections, lower thromboebolic riskIndications for caesarian delivery-Obstetric indications-Preterm labour in patients on OAC-Marfan and Aortic dilatation (> 40-45 mm)-Acute or chronic aortic dissection-Severe Heart failure-Severe AS/LVOTO-Eisenmenger syndrome
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseOne of the most common cardiac complications that has consistently been found Congestive Heart Failure with an incidence of 16.7%
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease The incidence of acute heart failure was the highest in patients with cardiopathy induced by hypertensive disorders complicating pregnancy (80.0%), followed by patients with PPCM (52.2%), patients with RHD (27.3%), and patients with CHD (6.9%).
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease In addition to previously described risk factors(systemic ventricular EF <40%, baseline NYHA functional class II or cyanosis, left heart obstruction and prior cardiac event by Siu SC. Circulation. 2001;104:515–521),the present study found an increased incidence of adverse cardiac eventsin pregnant women with depressed subpulmonary ventricular ejectionfraction and/or severe pulmonary regurgitation.
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseasePerhaps these risk factors were not previously identified becauseof the strong influence of acquired forms of heart disease onrisk factor identification.
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseThey found an incidence of 9% (7/76 pregnancies) symptomatic RHF. On univariate analysis, twin pregnancy and BPS were significantly associated with RHF
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Pathophysiology RV volume overload? RV compliance? Arrhythmias?Different degrees of chamber enlargement in systemic andpulmonary circulations have been observed. Whereas subaorticventricular size increases by 6%, the right atrium and subpulmonaryventricle increase by 20%.Morphological characteristics of an already compromisedsubpulmonary ventricle may enhance susceptibility to furtherpregnancy-induced volume loading.
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseBased on these findings, the recommendation for prophylacticpulmonary valve replacement in patients with moderate-to-severePR prior to pregnancy should be reconsidered.
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease 25,0 22,6 Giamberti G, Chessa M, et al. Ann Thorac Surg. 2009 20,0 17,1 15,0 11,5 9,8 10,4 10,0 7,9 4,9 4,3 4,2 5,0 3,6 1,8 1,2 0,0 R s VR R an S R SD SD n er n TV PV PV s AV tio t io nt si th M lA lV Fo no ta ta O S/ ua ua rc la te AV oa Di sid id ts es .c Ao ui Re Re Re nd ig co Ao nd y ce ar As on lm PuReoperations in ACHD are very frequent today Chessa M, et al. J Cardiovasc Med (Hagerstown). 2006 Sep;7(9):701-5.and mostly due to right ventricular outflowtract lesions. Ot her 22% RVOT problems 38% RVOT problems Aort a Sept al def ect Sept al def ect Ot her 18% Aort a 22%
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseAn Italian single centre experience
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseAn Italian single centre experience
  • Department of Pediatric Cardiology & Adult with Congenital Heart DiseaseAn Italian single centre experience
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Conclusions Women with simple CHD or without significant hemodynamic or rythm impairment may have uncomplicated courses of pregnancy and no impact on the subsequent cardiac state However some lesions, such as ASD II (even when operated), CoA, D/HCMP and cyanogen defects may present serious problems, due to arrythmias or systemic or pulmonary hypertension
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Conclusions and Advices• Prepregnancy counselling and evaluation is mandatory ( physical examination, assesment of hemodynamic status, functional capacity)• Stratifications into high, medium and low risk• Pulmonary hypertension: marked increase of risk of maternal and fetal mortality
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease Conclusions and Advices• Review of medications to avoid drugs that may be deterious to the fetus• Anticoagulant drugs for mechanical prosthetic valves can be associated with fetal embriopathy• Small but increased risk of congenital heart disease in offspring
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease ConclusionsFetal safety or Maternal safety??........ Avoid just a single point of view!
  • Department of Pediatric Cardiology & Adult with Congenital Heart Disease We must act as a team!! Pediatric cardiologist PatientGUCH/ACHD GynecologistCardiologist Neonatologist
  • Massimo Chessa Department of Pediatric Cardiology & Adult with Congenital Heart Disease IRCCS- Policlinico San Donato San Donato Milanese – Milano massimo.chessa@grupposandonato.itThank you for your attention