04/08/23 Dr.Uma Dr.NK Gupta 1

Cardiac Diseases in Pregnancy

• Dr.Uma Gupta MD,FICMCH• Dr.N.K.Gupta MS,MChumankgupta@yahoo.comdrnkgupta2000@yahoo.com

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The incidence and changing pattern of heart disease

• It ranges from 0.1% to 4%.• Hospital statistics - industrialized

countries have shown a decrease in the incidence from 0.9% to 0.3%

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Incidence of heart disease………

Sharp decline in the incidence of chronic rheumatic heart disorders.

Advances in the medical and surgical treatment of patients with congenital heart defects has resulted in an increased survival to reproductive age.

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Maternal mortality from heart disease

• Statistics have demonstrated a decline in maternal mortality from cardiac disease since 1950 from 5.6 to 0.3 per 100 000 births.

• B’s of improved medical care of the pregnant cardiac patient and a sharp decrease in the incidence of rheumatic heart disease.

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Maternal mortality from heart disease

• Confidential enquiry of latest report on maternal deaths in the United Kingdom, has shown that cardiac disease accounted for the greatest number of maternal deaths

• accounting for 35 (16.5%) of all maternal deaths over the period 1997–99*

• (37 of 323) in the 1991 to 1993 triennium• (18) -1988 to 1990 trienniums• (23) -1985 to 1987* de Swiet M. Cardiac disease. In: Lewis G, Drife J, eds. Why Mothers Die 1997–1999. The Confidential Enquiries into Maternal Deaths in the United

Kingdom. London: Royal College of Obstetricians and Gynaecologists, 2001; 153–64

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Maternal mortality from heart disease

Cardiac diseases is also the leading cause of indirect maternal death. Of the cardiac deaths reported to the Confidential enquiry between 2000-2002, 40% were noted to have substandard care.

Deans CL, Uebing A, Steer PJ. Cardiac disease in pregnancy. In Progress in Obstetrics and Gynaecology, Vol 17, Edi Studd J, Tan S L, Chervenak FA.Churchill Livingstone 2007, 164-182.

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Cardiovascular Physiology of Pregnancy

• Normal pregnancy is associated with an increase of 30 to 50 percent in blood volume

• Blood volume increases, starting at the sixth week and rising rapidly until mid pregnancy; the levels peak by 20 to 24 weeks of pregnancy and then are either sustained until term or decrease

An estrogen-mediated stimulation of the renin-angiotensin system results in sodium and water retention appears to be the mechanism underlying the blood volume increase.

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Cardiovascular Physiology of Pregnancy

• Increase in cardiac output is most significant change during pregnancy.

• It begins to rise in first trimester and steadily rises to peak at 32 weeks by 30 to 50%.

• Cardiac output is normally 4.2 L/min., is 6.5 L/min. at 8-10 weeks of pregnancy and remains so till near term.

• Increase in cardiac output is achieved by rise in stroke volume (in early pregnancy) and Heart Rate (in latter part of pregnancy) adjusting together

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• Due to rise in endogenous circulating catecholamine, there is positive inotropic and chronotropic myocardial response.

• Later in pregnancy, the rise is related to an acceleration of heart rate (25%), since stroke volume decreases as a result of vena caval compression.

Cardiovascular Physiology of Pregnancy

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• Blood Pressure remains almost to prepregnant levels except a tendency to fall during pregnancy (particularly during midtrimester) as the systemic vascular/peripheral resistance falls

(due to large arteriovenous shunts at placental bed and physiologic vasodilation secondary to endothelial prostacyclin and circulating progesterone)

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• Colloid oncotic pressure is another important variable

• Both plasma and interstitial colloid oncotic pressure decrease throughout pregnancy

• There is accompanying increase in capillary hydrostatic pressure.

• An increase in hydrostatic pressure or a decrease in colloid oncotic pressure may overcome the delicate balance that favors oedema formation

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Colloid oncotic pressure

• After delivery, decrease in plasma colloid oncotic pressure takes place reaching a peak between 6 to 16 hours and returns towards intrapartum level after 24 hours.

• These changes can lead to dependant oedema complicating diagnosis of cardiac decompensation.

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Simulating cardiac disease

Owing to these normal changes, manyhealthy pregnant women have symptomsmimicking those of cardiac disease,Including:fatigue, dyspnea, and light-headedness, & number of “abnormal” findings on physicalexamination, electrocardiography, and

echocardiography

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Table 1. Normal physiological changes of pregnancythat mimic symptoms and signs of cardiac diseaseSymptomsTirednessDyspnoeaOrthopnoeaSyncopeLight-headednessPhysical signsPeripheral oedemaHyperventilationDistended neck veins with prominent A and VwavesBrisk, diffuse, and displaced left ventricularimpulsePalpable right ventricular impulseIncreased S1 intensityPersistent splitting of S2Early ejection systolic murmurs at lower leftsternal edge or pulmonary areaCervical venous humMammary souffle

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Contd..Table 1. Normal physiological changes of pregnancythat mimic symptoms and signs of cardiac disease

ElectrocardiogramLeft axis deviationST segment and T wave changesSmall Q, inverted P or T wave in lead IIIIncreased R wave amplitude in lead V2Atrial or ventricular ectopicsChest X-rayStraightened left upper cardiac borderHorizontal heart positionIncreased lung markingsEchocardiogramIncreased left/right ventricular dimensionsMild increase in left/right atrial sizeSlightly improved left ventricular systolic functionFunctional tricuspid/pulmonary insufficiencySmall pericardial effusion

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Management areas Areas be considered in the clinical approach to

the woman with heart disease who is pregnant or considering pregnancy:

1) Risk stratification, Pre-conceptional

2) Antepartum management,

3) Peripartum management,

4) Recurrence of congenital lesion in the neonate,

5) Site of antepartum and peripartum care.

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Pre-conceptional counselling

• This is an important aspect of management or the cardiac patient planning a pregnancy.

• Ideally, the obstetrician and cardiologist should work together to help the patient make an informed decision.

• Prevent an unwanted pregnancy and avoid the risks associated with pregnancy continuation or termination.

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Risk assessment

• Poor functional status (NYHA class III or

IV) or cyanosis• Left ventricular systolic dysfunction (ejection

fraction < 0.40)• Left heart obstruction (mitral valve area

<2.0 cm2, aortic valve area < 1.5 cm2, or

peak left ventricular outflow tract gradient

> 30 mm Hg)

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Risk assessment

A cardiac event (arrhythmia, stroke, transient ischemic attack, or pulmonary edema) before pregnancy but since a prior cardiac surgical procedure.

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Risk assessment

Siu developed a risk index incorporatingthese factors. In a woman with heart disease and no other risk

factors, the likelihood of a cardiac event during pregnancy is about 5%, increasing to 25% with one risk factor & 75% with more than one risk factor.

Siu SC, Sermer M, Colman JM, et al. Prospective multicenterstudy of pregnancy outcomes in women with heart disease.Circulation 2001; 104:515–521.

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Table 2. Maternal mortality risk and cardiac diseaseGroup Cardiac disease Associated mortality risk I Atrial septal defect* <1% Ventricular septal defect*

Patent ductus arteriosus*Pulmonary/tricuspid valve diseaseCorrected tetralogy of FallotBioprosthetic valveMitral stenosis, NYHA Class I, II

II Coarctation of aorta without valvular involvement 5% - 15%Uncorrected tetralogy of FallotMarfan’s syndrome with normal aortaMechanical prosthetic valveMitral stenosis with atrial fibrillation or NYHA Class III, IVAortic stenosisPrevious myocardial infarction

III Pulmonary hypertension—primary or secondary 25% - 50%Coarctation of aorta with valvular involvementMarfan’s syndrome with aortic involvementPeripartum cardiomyopathy

*Uncomplicated

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• A careful history is obtained to identify previous cardiac complications.

• The patients functional status as per The New York Heart Association(NYHA) is defined

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Table 3.NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE

CLASS I No functional limitation of activity. No symptoms of cardiac decompensation with activity.

CLASS II Mild amount of functional limitation. Patients are asymptomatic at rest. Ordinary physical activity

results in symptoms.

CLASS III Limitation of most physical activity. Asymptomatic at rest Minimal physical activity results in symptoms.

CLASS IV Severe limitation of physical activity results in symptoms. Patients may be symptomatic at rest/heart failure at any point of pregnancy.

CLASS V If patient is on ionotropic support, ventilator, Assisted circulation or having comprised renal or pulmonary

function necessitating dialysis/EMCO to maintain vital signs.

The criteria committee of the New York Heart Association, Nomenclature and criteria for diagnosis of diseases of heart and great vessels, Edi 8, New York Association,1979.

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Antepartum Care

• The chief aim of management of the patient in pregnancy is to keep patient within her cardiac reserve.

• It is preferable to have detailed baseline information prior of pregnancy.

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Antepartum care

• Limiting activity is helpful in severely

affected women with ventricular dysfunction,

• left heart obstruction, or class III or IV symptoms.

• Hospital admission by mid-second

trimester may be advisable for some.

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Antepartum care

• Problems should be identified early and treated aggressively, especially pregnancy induced hypertension, hyperthyroidism, infection, and anemia.

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Table 4. Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures

Category Drug and dosage

High-risk patient Ampicillin, 2 g IM or IV,   plus gentamicin sulfate (Garamycin), 1.5 mg/kg IV 30 min before procedure; ampicillin, 1 g IV, or amoxicillin (Amoxil, Trimox, Wymox), 1 g PO 6 hr after procedure

High-risk patient who has penicillin allergy

Vancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr,   plusgentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

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Antepartum care

Beta-blockers rather than digoxin should be used to control the heart rate for patients with functionally significant mitral stenosis.

Empiric therapy with beta-blockers is offeredto patients with coarctation, Marfan syndrome,and ascending aortopathy for other reasons (eg, a bicuspid aortic valve).

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Arrhythmias should be treated if warranted

Premature atrial or ventricular beats are common in normal pregnancy, and in patients with preexisting arrhythmias,

Pregnancy may exacerbate their frequency and hemodynamic severity.

These usually are not treated.

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Antepartum careSustained tachyarrhythmias, such asatrial flutter or atrial fibrillation, should betreated promptly.

If possible, all antiarrhythmic drugs shouldbe avoided during the first trimester, and thoseknown to be teratogenic should be avoidedthroughout pregnancy.

Because of their safety profiles, preferred drugs include digoxin, beta-blockers and adenosine.

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Antepartum care

• Anticoagulation therapy. No current

strategy is equally safe for both mother and fetus.

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Anticoagulation therapy

Oral therapy with warfarin is effective and

logistically easy.

However, it can affect embryonic organ development, although some evidence shows that a dosage of 5 mg per day may not be teratogenic.

Fetal intracranial bleeding is a risk throughout pregnancy, particularly during vaginal delivery, unless warfarin is stopped before labor.

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Anticoagulation therapy

* Heparin in adjusted subcutaneous dosesdoes not cross the placenta and so has no

teratogenic effects.

However, it may cause maternalthrombocytopenia and osteoporosis and isless effective in preventing thrombosis inpatients with prosthetic valves.

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Anticoagulation therapy

More recent guidelines recommend either(1) adjusted-dose heparin during the entire pregnancy or (2) adjusted-dose heparin until the 13th week of gestation,

warfarin from the 14th week to the middle of the third trimester, and then restart adjusted-dose heparin.* Low-molecular-weight heparin in adjusteddoses is easier to administer and has beensuggested as an alternative to adjusted-doseunfractionated heparin.

Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy. Chest 2004; 126:627S–644S.

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Anticoagulation therapy

At week 36 #*Discontinue warfarin *Change to UFH titrated to a therapeutic aPTT or anti-

factor Xa level.At Delivery:*Restart heparin therapy 4 to 6 hr after delivery if no

contraindications*Resume warfarin therapy the night after delivery if no

bleeding complications#if labor begins while the woman is receiving warfarin,

anticoagulation should be reversed and caesarean delivery performed

Ginsberg JS, Greer I, Hirsh J. Use of antithrombotic agents during pregnancy. Chest 2001;119:Suppl:122S-131S

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Anticoagulation therapy

Monitoring• With LMWH administered sc. twice daily

maintain anti-Xa level between 0.7 and 1.2 U/ml 4 hours after admn.

• With dose adjusted UFH, the aPTT should be at least twice control.

• those on warfarin, the INR goal should be 3.0(range 2.5 to 3.5)

Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic

review of the literature. Arch Intern Med 2000;160:191-196

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Peripartum management

• Cesarean section is indicated only for the

following conditions:

• Aortic dissection

• Marfan syndrome with dilated aortic root

• Taking warfarin within 2 weeks of labor.

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Peripartum care

Preterm induction is uncommon.However, once fetal lung maturity is assured,

a planned induction and delivery may bewarranted for high-risk patients to ensurethat appropriate staff and equipment areavailable.

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Peripartum care

Antibiotic prophylaxis for endocarditis is

not routine. AHA guidelines do not recommend routine endocarditis prophylaxis for cesarean section delivery or for uncomplicated vaginal delivery without infection.37

However, some centers do administer

endocarditis prophylaxis for vaginal delivery

in women with structural heart disease, as an

uncomplicated delivery cannot always be

anticipated.

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Peripartum care

Positioning the patient on her left sidelessens the hemodynamic fluctuations associated with contractions when the patient is supine.

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Peripartum care

• Forceps or vacuum extraction should be

considered at the end of the second stage of labor to shorten and ease delivery.

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Peripartum care

• Postpartum monitoring

Because hemodynamics do not return to baseline for many days after delivery, patients at intermediate or high risk may require monitoring for at least 72 hours postpartum.

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Peripartum care

• Lactation should be encouraged unless patient is in failure.

• Cardiac output is not compromised during lactation.

• Lactation is a pathway for fluid excretion and diuretic requirement may actually fall.

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Contraception

• Barrier methods – unreliable.• COC contraindicated.• Progesterone only pill have better side effect

profile & long acting slow releasing as Mirena intrauterine system have improved efficacy.

• Sterilization where family completed. (Laparoscopic clip sterilization carries risk).

Deans CL, Uebing A, Steer PJ. Cardiac disease in pregnancy. In Progress in Obstetrics and Gynaecology, Vol 17, Edi Studd J, Tan S

L, Chervenak FA.Churchill Livingstone 2007, 164-182.

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ConclusionPregnancy causes significant haemodynamic

changes and imposes an additional burden on the cardiac patient, especially around the time of labour and in the immediate puerperium.

To achieve a successful pregnancy outcome, a clear understanding of these haemodynamic adaptations as well as meticulous maternal and foetal surveillance for risk factors and complications throughout the pregnancy is essential.

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Conclusion

Appropriate contraceptive and family planning advice as well as pre-conceptional counselling are also important.

The concerted efforts of a team consisting of the

obstetrician, cardiologist, anaesthetist, cardiothoracic surgeon, neonatologist, and paediatric cardiologist are mandatory to ensure optimal results.

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