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15. Risk Of Pregnancy In Women With Congenital Heart

15. Risk Of Pregnancy In Women With Congenital Heart






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    15. Risk Of Pregnancy In Women With Congenital Heart 15. Risk Of Pregnancy In Women With Congenital Heart Presentation Transcript

    • Risk of pregnancy in women with congenital heart disease Ng Soo Khai Med IV
    •  Number of women with congenital heart disease reaching childbearing age is growing owing to advances in medical and surgical treatment  Despite these advances, congenital heart disease remains an important cause of maternal mortality and morbidity during pregnancy  2nd leading cause of maternal mortality (second to suicide)
    • CHD Acyanotic  ASD  VSD  PDA Cyanotic  Tetralogy of Fallot  Tricuspid atresia  Transposition of great vessel  Persistent truncus arteriosus  Others
    • Adaptations in pregnancy  Imposes strain on heart and circulation leading to cardiorespiratory adaptations  Rise in intravascular volume resulting in raise cardiac output by 50% during the 1st and 2nd trimester  Reduction in systemic vascular resistance with fall in blood pressure  Results in deterioration in women with CHD
    •  Hypercoagulable state – increase in Vit K dependent clotting factors and reduction in protein S  Increased in thromboembolic risk from uterus compression on IVC resulting in lower extremity venous stasis
    • Risks to mother Cardiac complications  Symptomatic arrhythmia  Congestive heart failure  Cardiovascular event  Endocarditis Obstetrical complications  Thromboembolic complications  Pre-eclampsia  Postpartum hemorrhage
    •  Arrhythmia - mostly supraventricular origin. Higher risk in TGA, AVSD, Fontan repair  Heart failure - mostly in cyanotic heart disease, Eisenmenger syndrome, and PAVSD  Cardiovascular events such as MI, stroke are seen mostly in those with Eisenmenger  Endocarditis – during labor and delivery. Simple ASD appear to be a greater risk.
    •  Thromboembolic complications – substantially higher than normal population A study of 688 pregnant women with CHD, incidence of thromboembolic events: - 2% in CHD compare to - 0.05-0.10% in normal pregnancy  Preeclampsia - cluster in patients with aortic coarctation, PS, PAVSD, and TGA.
    • Risks to fetus  Spontaneous abortion  Premature birth  Intrauterine growth restriction (IUGR)  Fetal & perinatal mortality  Congenital heart disease
    •  Premature birth – rate of 16%, higher than generally population 10%  Fetal and perinatal mortality - ~4% in CHD compare to <1% in normal. As high as 27% in Eisenmenger  Recurrence of CHD - risk is higher - 5.7% if mother had CHD - 2.2% if the father had CHD
    •  Predictors for maternal and fetal complications : - Pulmonary hypertension - Maternal cyanosis - Preconception history of adverse cardiac events eg MI, arrhythmia, TIA - Left heart obstruction (mitral valve area <2cm, aortic valve <1.5cm)
    •  New data shows no increase risk in maternal mortality in women with CHD uncomplicated by Eisenmenger’s syndrome.  Only mothers with Eisenmenger’s syndrome have substantial mortality during pregnancy of 10-30%
    • Pulmonary Hypertension  most serious risk especially Eisenmenger syndrome Eisenmenger syndrome  reversal of shunt in the setting of initial left-to- right shunt due to development of pulmonary hypertension  drop in systemic resistance that accompanied pregnancy amplify the shunt reversal  body cannot compensate such short term changes  severe and potentially fatal hypoxemia during pregnancy or postpartum period
    •  poorly tolerate the hemodynamic changes associated with pregnancy and susceptible to complications like preeclampsia and postpartum hemorrhage  50% - preterm delivery and fetal growth retardation  Only 15-25% progress to full term  Pregnancy is contraindicated in women with Eisenmenger syndrome
    • Cyanosis  Arterial oxygen saturation before pregnancy – important predictor Data from 104 pregnancies in 74 women with CHD: - 90% with cyanotic CHD - 19% with acyanotic CHD had significant postpartum complications  Arterial O2 saturation below 80% increases the risks  No evidence that high sat O2 administration benefits the mother
    •  Mother with cyanotic CHD without pulmonary hypertension, maternal risk is low but fetal risk is high. 96 pregnancies of cyanotic CHD:  43% live birth, 37% of which were premature  Mean weight of full term infants – 2.5kg compare to normal 3.5kg
    •  One recent study reported a 12% likelihood of a livebirth when the arterial oxygen saturation at rest was < 85%;  Livebirth rate improved to 63% when the oxygen saturation was > 85%.
    •  Review of most retrospective reports from 1985-2006 that described the outcomes of 2491 pregnancies in women with CHD: - Cardiac complications in 11% - 5% - heart failure - 4.5% - arrhythmias - 15% miscarriage - 5% chose to terminate pregnancy - 16% premature birth - 4% small for gestational age - 2.3% perinatal mortality - 1.7% fetal mortality