Cardiovascular diseases during pregnancy, european guidlines 2011


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Cardiovascular diseases during pregnancy, european guidlines 2011

  1. 1. ==Normal cardiac signs and symptoms of pregnancy: & Hyperventilation (as a result of increased minute ventilation) & Edema (from volume retention and compressed inferior vena cava [IVC] by the uterus) & Dizziness/lightheadedness (from reduced SVR and venal caval compression) & Palpitations (normal HR increases by 10–15 beats/min) ==Pathologic cardiac signs and symptoms of pregnancy: & Anasarca, or generalized edema, and paroxysmal nocturnal dyspnea (PND) are not components of normal pregnancy and warrant workup. & Syncope should be evaluated for hypotension, obstructive valvular pathology (aortic, mitral or pulmonic stenosis), pulmonary hypertension, pulmonary embolism, or tachybradyarrhythmias. & Chest pain may be due to aortic dissection, pulmonary embolism, angina, or even myocardial infarction. Women are delaying their child-bearing years, with a higher incidence of preexisting cardiac risk factors in the older pregnant woman. & Hemoptysis may be a harbinger of occult mitral stenosis, although rheumatic heart disease is becoming less common in developed countries.
  2. 2. ==Blood pressure (BP) will decline and HR will increase. The point of maximum impulse (PMI) will be displaced laterally as the uterus enlarges. S3 is common because of increased rapid filling of the left ventricle (LV) in early diastole. S4 is unusual and may reflect underlying hypertension. A physiologic pulmonic flow murmur is common because of elevated stroke volume passing through a normal valve. Systolic murmurs of 1/6–2/6 can be explained by these physiologic changes. A mammary souffle and venous hum are two continuous, superficial murmurs that can be obliterated by compressing the site with the diaphragm of the stethoscope. If the murmur does not change, consider patent ductus arteriosus or coronary atrioventricular (AV) fistula. ==Abnormal cardiac findings during pregnancy: & Clubbing and cyanosis are not a part of normal pregnancy; desatuaration for any reason is abnormal and warrants investigation. & Elevated jugular venous pressure is abnormal, reflecting elevated right atrial pressure; it is important to evaluate neck veins in any pregnant woman who has peripheral edema. & Pulmonary hypertension (right ventricular heave, loud P2, JVP elevation) evidence should be investigated early. Women with pulmonary hypertension (pulmonary pressure greater than 75% of systemic pressure) should be counseled in general as to the risks of pregnancy. & Systolic murmur 3/6 or louder and any diastolic murmur audible in pregnancy are considered abnormal and warrant evaluation.
  3. 3. --Obstruction to venous return by the enlarging uterus causes stasis, and a further rise in risk of thrombo-embolism. --Increased intravascular blood volume partly explains the higher dosages of drugs required to achieve therapeutic plasma concentrations, and the dose adaptations needed during treatment. Moreover, the raised renal perfusion and the higher hepatic metabolism increase drug clearance. --BP, CO, and HR normalize over the next 5 to 6 weeks as hormonal changes return to the pregravid state.
  4. 4. Genetic testing and counselling † In cardiomyopathies and channelopathies, such as long QT syndromes † When other family members are affected † When the patient has dysmorphic features, developmental delay/ mental retardation, or when other non-cardiac congenital abnormalities are present, in syndromes such as in Marfan, 22q11 deletion, Williams–Beuren, Alagille, Noonan, and Holt–Oram syndrome. ==If a pregnant woman suffers a cardiac arrest, the viable baby should be delivered after 15 minutes if there is no return of spontaneous maternal circulation.
  5. 5. --TEE safe but take care from sedation. -- Dobutamine stress should be avoided. -- Nuclear scintigraphy should be avoided during pregnancy because of radiation exposure. -- MRI is probably safe, especially after the first trimester. Gadolinium can be assumed to cross the fetal blood–placental barrier, but data are limited.
  6. 6. If an intervention is absolutely necessary: --Best time to intervene is considered to be after the fourth month in the second trimester. By this time organogenesis is complete, the fetal thyroid is still inactive, and the volume of the uterus is still small, so there is a greater distance between the fetus and the chest than in later months. --Fluoroscopy and cineangiography times should be as brief as possible and the gravid uterus should be shielded from direct radiation. --Heparin has to be given at 40–70 U/kg, targeting an activated clotting time of at least 200 s, but not exceeding 300 s.
  7. 7. Cardiac surgery with cardiopulmonary bypass -- Maternal mortality during cardiopulmonary bypass is now similar to that in non-pregnant women. -- significant morbidity including late neurological impairment in 3–6% of children, and fetal mortality remains high. -- The best period for surgery is between the 13th and 28th week {first trimester  higher risk of fetal malformations, third trimester  higher incidence of pre-term delivery and maternal complications}.
  8. 8. Fetal cardiac anomaly is suspected (1) A full fetal echocardiography to evaluate cardiac structure and function, arterial and venous flow, and rhythm. (2) Detailed scanning of the fetal anatomy to look for associated anomalies (particularly the digits and bones). (3) Family history to search for familial syndromes. (4) Maternal medical history to identify chronic medical disorders, viral illnesses, or teratogenic medications. (5) Fetal karyotype (with screening for deletion in 22q11.2 when conotruncal anomalies are present). (6) Referral to a maternal–fetal medicine specialist, paediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetric, and neonatal management, and options. (7) Delivery at an institution that can provide neonatal cardiac care, if needed.
  9. 9. *Antibiotics that can be given during all trimesters of pregnancy: -- penicillin, ampicillin, amoxicillin, erythromycin, mezlocilli n, and cephalosporins. {group B} --Vancomycin, imipenem, rifampicin, and teicoplanin are all group C, which means risk cannot be excluded and their risk–benefit ratio must be carefully considered. --There is a definite risk to the fetus in all trimesters of pregnancy with group D drugs (aminoglycosides, quinolones, and tetracyclines) and they should therefore only be used for vital indications
  10. 10. NB. Warfarin+ pregnancy --Teratogenic effects: -Potentially teratogenic (low MW, cross placenta) Embryopathy , spontaneous abortion and stillbirth. -The teratogenic effect appears to be dose related, with doses less than 5 mg/day providing the highest margin of safety {regardless of INR} -most common bone and cartilage nasal and limb hypoplasia --CNS abnormalities (including optic atrophy, microcephaly, mental retardation, spasticity, and hypotonia) -Immaturity of fetal enzyme systems and the relatively low concentration of vitamin K-dependent clotting factors render the fetus more sensitive than the mother to the anticoagulant effects of warfarin  risk of hemorrhagic fetal death during vaginal delivery warfarin should be discontinued after 34 to 36 weeks of gestation -Preterm cesarean delivery may prevent hemorrhagic fetal death, and fresh frozen plasma should be administered to the neonate, mother
  11. 11. --UFH (c): -Relative difficulty of maintaining a stable therapeutic response, the inconvenience of parenteral administration, and the complications of heparin-induced thrombocytopenia and bone demineralization in patients treated for more than seven weeks -Guided by APTT --LMW heparin (B): -Sustained, stable therapeutic response -Reduce the inconvenience of parenteral administration -Laboratory monitoring of the anticoagulant effect of LMW heparin is generally not performed in nonpregnant patients, but some authors recommend measuring anti- factor Xa levels four hours after injection in pregnant patients -Less likely to precipitate heparin-associated thrombocytopenia, unclear whether bone loss may be significantly reduced -American College of Obstetricians and Gynecologists has stated that LMW heparin can be considered in women who are candidates for prophylactic or therapeutic anticoagulation during pregnancy - Patients should be switched to subcutaneous unfractionated heparin about two weeks prior to the expected delivery; this will permit regional anesthesia for labor {epidural haematoma}
  12. 12. Mechanical prosthetic heart valves: --FDA  LMWH is not recommended for thromboprophylaxis in pregnant women with prosthetic heart valves. --However, other expert panels disagree, and the American College of Chest Physicians recommended that LMWH remain a therapeutic option in this setting
  13. 13. 2008 ACCP Guidelines One of three approaches for anticoagulation during pregnancy: --Aggressive adjusted-dose unfractionated heparin throughout the pregnancy; heparin is administered subcutaneously every 12 hours in doses adjusted to keep the mid-interval aPTT at least twice control or to attain an anti-Xa level of 0.35 to 0.70 U/mL. After a stable dose is achieved, the aPTT should be measured at least weekly. --Adjusted-dose subcutaneous LMW heparin therapy throughout the pregnancy in doses adjusted according to weight to achieve the manufacturer's recommended anti-Xa level four hours after subcutaneous injection. --Unfractionated or LMW heparin therapy (as above) until the thirteenth week, a change to warfarin until the middle of the third trimester, and then restarting unfractionated or low molecular weight heparin until delivery Heparin can be restarted 12 hours post-cesarean delivery and 6 hours post- vaginal birth, if no significant bleeding has occurred replaced with warfarin (stopping the heparin when the INR is therapeutic)
  14. 14. Other indications for AC in pregnancy Venous thromboembolism Atrial fibrillation associated with significant underlying heart disease Antiphospholipid antibody syndrome Heart failure, particularly in the presence of a ventricular thrombus Eisenmenger syndrome Paroxysmal nocturnal hemoglobinuria
  15. 15. --Monthly injectables that contain medroxyprogesterone acetate are inappropriate for patients with heart failure because of the tendency for fluid retention. Low dose oral contraceptives containing 20 mg of ethinyl estradiol are safe in women with a low thrombogenic potential, but not in women with complex valvular disease. --Barrier methods (condom), the levonorgest relreleasing intrauterine device is the safest and most effective contraceptive that can be used in women with cyanotic congenital heart disease and pulmonary vascular disease. --IUD- Antibiotic prophylaxis is not recommended at the time of insertion or removal since the risk of pelvic infection is not increased. If excessive bleeding occurs at the time of menses, the device should be removed. It is contraindicated in cyanotic women with haematocrit levels >55% because intrinsic haemostatic defects increase the risk of excessive menstrual bleeding.
  16. 16. --IVF Thrombo-embolism may complicate in vitro fertilization when high oestradiol levels may precipitate a prothrombotic state.
  17. 17. -Repaired atrial septal defects (ASD) and ventricular septal defects (VSD) confer no increased cardiac risk. -Unrepaired left-to-right intracardiac shunts (ASD and VSD) are well tolerated because of the reduction in SVR, which decreases left to-right shunting during pregnancy. Patients are at an increased risk for paradoxical embolization if they develop deep venous thrombosis. -Right-to-left (cyanotic) shunting is poorly tolerated in pregnancy because of reduction of SVR. -Women with Eisenmenger’s syndrome risk a 30% to 50% maternal mortality with pregnancy. Such high-risk women are counseled to avoid pregnancy or undergo therapeutic termination.
  18. 18. PAH, Eisenmenger syndrome --Every effort should be made to maintain circulating volume, and to avoid systemic hypotension, hypoxia, and acidosis which may precipitate refractory heart failure. Supplemental oxygen therapy should be given if there is hypoxaemia. --I.v. prostacyclin or aerosolized iloprost have been occasionally used antenatally and peripartum to improve haemodynamics during delivery in PAH,,, in Eisenmenger  systemic vasodilatation increases the right-to-left shunt and decreases pulmonary flow, leading to increased cyanosis and eventually to a low output state. --Teratogenic effects of some therapies, such as bosentan. --In PAH associated with connective tissue disorders, anticoagulant treatment should be considered on an individual basis. In PAH associated with portal hypertension, anticoagulation is not recommended in patients with increased risk of bleeding. In Eisenmenger with cyanosis, AC is indicated. --In patients with Eisenmenger syndrome+ heart failure, diuretics must be used judiciously and at the lowest effective dose to avoid haemoconcentration and intravascular volume depletion.
  19. 19. Cyanotic heart disease without pulmonary hypertension --Restriction of physical activity and supplemental oxygen. --Prevention of venous stasis (use of compression stockings and avoiding the supine position) is important. For prolonged bed rest, prophylactic heparin administration should be considered.
  20. 20. --Risk of paradoxical embolism, in women with a residual shunt {ASD, AVSD}, prevention of venous stasis (use of compression stockings and avoiding the supine position) is important, as is early ambulation after delivery.
  21. 21. Coarctation of the aorta --Hypertension should be treated, although aggressive treatment in women with residual coarctation must be avoided to prevent placental hypoperfusion. --Percutaneous intervention for re-CoA is possible during pregnancy, but it is associated with a higher risk of aortic dissection than outside pregnancy and should only be performed if severe hypertension persists despite maximal medical therapy and there is maternal or fetal compromise. --The use of covered stents may lower the risk of dissection. --Severely symptomatic PS not responding to medical therapy and bed rest, percutaneous valvuloplasty can be undertaken.
  22. 22. Short stature
  23. 23.  BB
  24. 24. -Type A dissection (involving the ascending aorta) should be managed surgically, with delivery of the viable fetus before repair. Type B dissection (descending aortic involvement) can be managed medically with labetalol or nitroprusside..
  25. 25. Medical management if symptomatic severe --No endocarditis prophylaxis --Severe mild physical activity {avoid syncope} --Medical therapy for coronary artery disease, and atrial fibrillation --HTN: -Diuretics reduce preload, on which the patient may depend for maintenance of cardiac outputcaution. -Beta blockers reduce contractility which may pose a risk for the overloaded left ventricleavoided in patients with symptomatic aortic stenosis and heart failure. -Vasodilators (such as hydralazine, nitroglycerin, and nifedipine) in the presence of a fixed valvular stenosis may reduce systemic blood pressure and reduce coronary artery perfusion pressure caution -ACEI small dose , gradual titration --Prevention and treatment of concurrent conditions {eg.influenza, fever, volume status} --+ve inotropic agents such as dobutamine must be used with caution; tachycardia (with reduced cardiac output) and myocardial ischemia(O2 demand) --Nitruprusside: may be if no hypotension, critically ill *Percutaneous valvuloplasty can be undertaken in non-calcified valves with minimal regurgitation, AVR after CS
  26. 26. -Only patients with severe symptomatic regurgitation (New York Heart Association [NYHA] class III–IV or greater) should be considered for valve replacement before pregnancy, and the only indication for valve replacement for regurgitation in the gravid patient is infective endocarditis. -IE prophylaxis is optional in vaginal delivery for patients with prior IE, prosthetic valves, congenital heart disease (CHD) within the first 6 months of repair or after 6 months if there is residual shunting, surgically constructed systemic-pulmonary shunts or conduits, and posttransplantation valvulopathy. -It is not indicated in cesarean section per 2007 American Heart Association (AHA) guidelines, although it is often given.
  27. 27. --Safety of drug-eluting stents in pregnant woman is therefore still unknown. --Data on emergency coronary artery bypass graft surgery during pregnancy are rare. --Safety data regarding glycoprotein IIb/IIIa inhibitors, bivalirudin, clopidogrel, prasugrel, and ticagrelor are lacking. -- Heparin can be used safely; however, there is little data on the use of stents because clopidrogel has not been studied in pregnancy.
  28. 28. 30-50%
  29. 29. --When ACE inhibitors are needed during breastfeeding, benazepril, captopril, or enalapril should be preferred. --Metoprolol, propranolol, or labetalol should be used instead of atenolol. Newborns should be supervised for 24–48 h after delivery to exclude hypoglycaemia, bradycardia, and respiratory depression. --Aldactone is avoided. --Hydralazine with nitrates should replace ACE inhibitors/ARBs in patients with heart failure. --B-type natriuretic peptide (BNP) levels do not rise with normal pregnancy; levels increase in women with myopathy, preeclampsia, eclampsia, and diabetes.
  30. 30. --Outflow obstruction may improve if the LV can dilate. --Cardioversion should be considered for persistent arrhythmia because AF is poorly tolerated. --Epidural anaesthesia causes systemic vasodilation and hypotension, and therefore must be used with caution in patients with severe LVOTO. -- I.v. fluids must be given judiciously and volume overload must be avoided as it is poorly tolerated in the presence of diastolic dysfunction. --Syntocinon may cause hypotension, arrhythmias, and tachycardia, and should only be given as a slow infusion.
  31. 31. --Symptomatic tachyarrhythmia is treated by catheter ablation prior to pregnancy where possible. --All antiarrhythmic drugs should be regarded as potentially toxic to the fetus. --Bradyarrhythmias and conduction disturbances are rare during pregnancy temporary or permanent pacing according to indication is safe.
  32. 32. --Doppler ultrasound of uterine arteries, performed during the second trimester (>16 weeks), is useful to detect uteroplacental hypoperfusion, which is associated with a higher risk of pre-eclampsia and intrauterine growth retardation. --Gestational hypertension develops after 20 weeks gestation and resolves in most cases within 42 days post-partum. --Pre-eclampsia =de novo appearance of hypertension+ new-onset of significant proteinuria >0.3 g/24 h. Oedema is no longer considered part of the diagnostic criteria. --Pre-eclampsia occurs more frequently during the first pregnancy, in multiple fetuses, hydatidiform mole, or diabetes. It is associated with placental insufficiency, often resulting in fetal growth restriction. --Symptoms and signs of severe pre-eclampsia include: † right upper quadrant/epigastric pain due to liver oedema+ hepatic haemorrhage † headache+visual disturbance (cerebral oedema) † occipital lobe blindness † hyperreflexia+clonus † convulsions (cerebral oedema) † HELLP syndrome: haemolysis, elevated liver enzymes, low platelet count. --Management  delivery of the placenta, which is curative. As proteinuria may be a late manifestation of pre-eclampsia, it should be suspected when de novo hypertension is accompanied by headache, visual disturbances, abdominal pain, or abnormal laboratory tests, specifically low platelet count and abnormal liver enzymes; it is recommended to treat such patients as having pre-eclampsia.
  33. 33. --i.v. labetalol, drug of choice in hypertensive crises is sodium nitroprusside given as an i.v. infusion at 0.25– 5.0 mic/kg/min. Prolonged treatment with sodium nitroprusside is associated with an increased risk of fetal cyanide poisoning. --Drug of choice in pre-eclampsia associated with pulmonary oedema is nitroglycerine (glyceryl trinitrate), given as an i.v. infusion of 5 mic/min, and gradually increased every 3–5 min to a maximum dose of 100 mic/min
  34. 34.  0.5 IU/kg twice/d
  35. 35. --Thrombolytics are considered to be relatively contraindicated during pregnancy and peripartum and should only be used in high risk patients with severe hypotension or shock. --Risk of haemorrhage, fetal loss and pre-term delivery --Mostly streptokinase was used and, more recently, recombinant tissue plasminogen activator. Both thrombolytics do not cross the placenta in significant amounts. --When thrombolysis has been given, the loading dose of UFH should be omitted and an infusion started at a rate of 18 U/kg/h. After stabilization of the patient, UFH can be switched to LMWH for the residual duration of pregnancy. --Vena cava filters indicated as nonpregnant. --Vitamin K antagonists do not enter the breast milk in active forms and are safe for nursing mothers. --Mothers taking warfarin may nurse after delivery.