OAA 2011 Valvular heart disease in pregnancy: the role of the · PDF file ·...
Transcript of OAA 2011 Valvular heart disease in pregnancy: the role of the · PDF file ·...
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OAA 2011
Valvular heart disease in pregnancy: the role of the multidisciplinary team.
Jason Waugh
Consultant Obstetrics and Maternal Medicine
Royal Victoria Infirmary
Newcastle upon Tyne.
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Hb
Karamermer et al „07
Cardiovascular Changes In Pregnancy
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CEMACH REPORT (Confidential Enquiry) “Saving Mothers Lives” 2003-2005
• Cardiac disease is now the leading cause.
• Substandard care : Cardiac 46%
0
5
10
15
20
25
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Cardiac Causes of Death Developed vs Developing World
UK 2003-5
(early & late deaths) MMR 14/100 000
Commonest cause death
IHD
LV failure Other
AS
Ao dissection
Rh MVD
PAH
Sri Lanka 2004
(early deaths) MMR 38/100 000
IHD
Other
Rh MVD
PAH LV failure
− Saving mothers‟ lives CEMACH ‟07 − Haththotuwa et al IJGO „09
2nd commonest cause of death after PPH
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If ventricular function good Regurgitant valves well tolerated
Stenotic valves may not meet
demands of pregnancy
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MDT : general points
• Pre-pregnancy care and advice
• Antenatal Care
• Intrapartum Care
• Postpartum Care
• ? Participation in obstetric networks
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MDT : general points
• There is a need to be aware of the local / regional expertise for advice or referral.
• Not all women with cardiac disease will require delivery in a tertiary centre…..BUT
• Some very clearly do require specialist multidisciplinary input at all stages in their pregnancy.
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Mitral Stenosis.
• Most common left sided lesion
• Causes most morbidity and mortality
• Usually rheumatic
• Usually UNDIAGNOSED pre-pregnancy
– An awareness of the problem is required
– An understanding of the likely presentation will save lives
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MS : ANC
• Most UK cases are “imported” and are 1st generation immigrants.
• “Worst” possible group in terms of accessing ANC due to social disadvantage and communication issues.
• There is a training gap as current obstetricians have not grown up with Rheumatic heart disease and awareness is therefore less.
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Risk of Adverse Event in Pregnancy With Mitral Stenosis
Siversides Am J Cardiol „03
MVA (cm2) Mild >1.5 Moderate 1.1-1.5 Severe <1.0
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MS: ANC
• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.
• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.
• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate
advice from those with the most experience. • Bed rest; beta blockade; diuretics; oxygen.
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MS: ANC
• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.
• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.
• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate
advice from those with the most experience. • Bed rest; beta blockade; diuretics; oxygen.
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CEMACH : „Saving mothers lives‟
• All clinical staff must undertake regular, written, documented and audited training for:
• The identification, initial management and referral for serious
medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers
• The early recognition and management of severely ill pregnant
women and impending maternal collapse • The improvement of basic, immediate and advanced life support
skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies.
• There is also a need for staff to recognise their limitations and to
know when, how and whom to call for assistance.
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MS: ANC
• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.
• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.
• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate advice from
those with the most experience. • Bed rest; beta blockade; diuretics; oxygen. • Cardiovert for AF • Anticoagulate if LA dilated or AF
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Deliver? If gestational age allows Intervention? Balloon mitral valvuloplasty if no Ca2+ & no MR 95% success rate, safe Diminishing UK experience – need experienced operator Minimal fetal radiation exposure (<0.2 rads)
What Next When Medical Management Fails?
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MS (and AS) : Fetus
• Pre-term delivery rate up to 48%
• FGR up to 21%
• Low APGAR 8%
• All proportional to Cardiac Output deficit.
• Uterine artery dopplers : screen all mod‟ and severe MS – influence USS frequency.
• Umbilical artery and Ductus Venosus dopplers identify the “sick fetus”.
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MS (and AS) : Fetus
• Generally:
• UAD AEDF : OR Perinatal death 4
• UAD REDF : OR Perinatal death 11
• Reversed flow in DV with atrial contractions – poor perinatal outcome
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MS : ANC - remember
• If MS diagnosed pre-preg‟ 40% will get significantly worse.
• Presentation will determine management. • Fetal problems are directly proportional to the
severity of the MS. • ECHO will assess valve for valvuloplasty BUT
gestation need not determine the timing of interventions.
• Seek regional / national advice to avoid delay. • Cardiac surgical support WILL BE NEEDED if
valvuloplasty is contemplated.
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MS : Intrapartum
• Mode of delivery
• Timing of Delivery (?IOL –may be necessary)
• Analgesia / anaesthesia
• Meticulous volume homeostasis
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MS – intrapartum - CS
• Who really needs this?
– Severe “life threatening” MS (and AS)
– Would an Em CS be “worse” ?
– Clear Obstetric indications
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MS : Intrapartum - IOL
• Little data (Oron et al BJOG 2004 n=121)
– Usually reserved for NYHA III-IV or deterioration in pregnancy
– Balance of fetal immaturity vs maternal risk
– About 50% deliver between 08.00 and 18.00
– May increase the risk of Em CS
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MS : intrapartum – “short 2nd stage” ?
• Consider (given the lack of direct evidence)
– A contraction increases CO by 15-30%
– Valsalva causes CO to fall and then overshoot
– Anxiety (and pain) increase CO
– Supine positions drop CO
– Progress in labour is the critical determinant of benefit.
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MS : postpartum
• Meticulous volume homeostasis
• ITU / HDU support
• In-patient observations for 3-5 days.
• Contraception
• Pre-pregnancy counselling and follow-up.
• Don‟t take your eye off the ball……….
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Blood volume Stroke volume
LV pressure & work Pressure gradient across AV
Coronary blood flow requirement
Symptoms
Sudden death
Usually congenital, bicuspid valve Usually diagnosed pre pregnancy
Opportunity for pre-pregnancy assessment & counselling
Aortic Stenosis in Pregnancy
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Pregnancy ok if asymptomatic AND • Normal ECG: no ST changes • Normal ETT : normal BP response
target HR no ST changes
• Good LV • DPG <80mmHg, mean <50mmHg, valve area >1cm2
Aortic Stenosis : Pre Pregnancy Assessment
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Risk of Adverse Event in Pregnancy With Aortic Stenosis
Siversides Am J Cardiol „03
AVA (cm2) Mild 2.0±0.2 Moderate 1.3 ±0.2 Severe 0.8 ±0.2
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Aortic Stenosis : ANC – similar to MS • Usually secondary to a congenital bicuspid valve –
therefore pre-pregnancy planning should occur
• If first presentation consider a coarctation
• Mild and moderate disease will probably be well tolerated
• Moderate disease can become symptomatic for the first time during pregnancy
• Discuss termination of pregnancy for Severe disease or deteriorating disease.
• Bed rest; beta blockade; diuretics; oxygen.
• Balloon valvuloplasty ; more risk ; fewer cases
• CP Bypass : Maternal Death 15%; Fetal Death up to 30%
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AS : Intrapartum – as for severe MS but even more caution
• Mode of delivery
• Timing of Delivery
• Place of delivery
• Monitoring in Labour
• Meticulous volume control
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AS : Postpartum
• Meticulous volume homeostasis
• ITU / HDU support
• In-patient observations for 3-5 days.
• Contraception
• Pre-pregnancy counselling and follow-up.
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Coarctation
• Hypertension resistant to medical management.
• Can be difficult in Pregnancy as almost no experience of common interventions.
• If repaired hypertension may still persist (L arm is poor reflection of BP)
• Aneurysms are the worst sequelae
• Fetal risk of coarc‟ is 10%
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Cardiac Surgery During Pregnancy
• Risk maternal death 5-13% 2-4 fold ↑cf non pregnant
• Risk fetal death 15-33% ↓risk - normothermic perfusion
- pulsatile flow - pump flow rate >2.5l/min/m2
- perfusion pressure >70mmHg - haematocrit >28% - a-stat pH management
Weiss Am J Obst Gyn ‟98 Chandrasekhar Anesth Analg „09
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Whatever next ?
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• Community MW booking
• Indian ITU nurse; Mild asthma; 2 Prev CS : Refer Cons clinic.
• 12/40: Nuchal normal : Cons review. No treatment for asthma since last pregnancy. Well. 2 Prev CS book for elective at 39/40 Cons to operate.
• 20/40: Normal anomaly USS
Case : A low risk multip……
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Admission.
• 21/40: Acute admission via GP with ↑ SOB over 3/7.
• Obs team: Hx exam. Nothing new. Widespread crackles and wheeze. Sa02 89%. Call Med Reg. Oxygen.
• Med Reg: Hx Exam. Nothing new. Systolic murmer ?flow. Widespread crackles. Continue oxygen. CxR
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Admission
• Cardiology team:
• ECG/ECHO.
• Severe mitral stenosis. Valve area 0.8 cm2
• Pulmonary pressure 100 mmHg
• LV, RV, ok.
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Management.
• Diuretics : excellent response. (SaO2)
• ECHO repeated: confirmed.
• Beta blocked: no problem.
• Thromboprophylaxis (Tinzaparin)
• Frusemide reduced: Pulm oedema returned.
• Ex tolerance reduced, orthopnoea.
• 23/40 underwent balloon valvuloplasty.
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Valvuloplasty
• Success • Multidisciplinary team;
cardiac theatres • Valve area increased
to 1.2 cm2 • Pulm‟ pressures
reduced to 70mmHg post procedure.
• Discharged. • Serial ECHO with
regional MDT.
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MRI and Placental implantation
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32/40
• Repeat USS : Major placenta Praevia Accreta.
• Plans for delivery : n=40
– Obs anaes‟ (team)
– Cardiac anaes‟ (team)
– Cardiac team/theatre/surgeon.
– Gynaecologist.
– Interventional radiology (team).
– Midwifery team with satellite neonatal cover
– Oh …and an obstetrician.
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Delivery……the best laid plans!!!!! • 37/40 stable and well. Valve area 1.2 pulm‟ pressures
>50 mmHg. LV func ok. Major placenta praevia. • IIA catheters placed 10.30 am • Inv monitoring: CVP,Art line, LITCO CO. • Epidural (sequential) ……..x2. • Surgery: 15.30 • 15.40 Confirmed placenta accreta • Baby delivered, proceed to Hysterectomy. • 15.50 Despite IIA catheters blood loss 1500 mls. • 1 hr 45 min to complete operation. • Total blood loss 3500 mls. (6 units transfused) • LITCO very stable. CO at rest 5-5.5 L/Min and increased
to 6.5-7 with a tachycardia. • Transferred to Cardiac ITU PN. Transferred to Obs unit
36 hours. Home day 5 • Alive and well.
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AccretaCS.wmv
AccretaCS.wmv
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Case 2 : First visit • DS ; referred from the communty October
2010 ; unplanned pregnancy ; 16 years old.
• Age 10 months – viral myocarditis - Heart transplant
Age 13 Renal failure secondary to
immunosuppression and post streptococcal glomerulonephritis - Renal transplant
– Live related (mother) – Post transtplant ureteric stenosis and subsequent
reconstruction – 3 episodes of proven rejection – Baseline creatinine 110
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PMH (continued)
• Age 14 : Post transplant Lymphoproliferative disorder – Radio and chemotherapy
• Needle phobia – Midazolam for bloods – Counselling – Psychology
• Chronic neck pain – Extensively investigated, no cause found
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Meds
• Tacrolimus 4mg OD
• Prednisolone 7.5mg alt days
• Codeine phosphate 60mg QDS
• Morphine (Oral) 10-20mg evening
• Amytripyline 25mg evening
• Cephalexin 250mg nocte
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• Good LV/RV function on ECHO
• BP 126/90 mmHg
• Proteinuria – 3+ proteinuria
• pcr 317 mg/mmol
• Creatinine 119
First trimester
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Discussion
• Effect on transplants inc. rejection, infection • Pharmacology • Preeclampsia • Thromboprophylaxis • Phlebotomy frequency • Prematurity, growth restriction • Long term parenting • Surgical risks • Option for termination • Opportunity to transfer to adult services
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By 20/40 gestation
• 12/40;16/40;19/40 • Normal fetal anatomy • PCR 435 • Tinzaparin declined because of needles • TEDS declined because of fashion concerns • Stopped codeine and morphine
(unsupervised) • Continues to have midazolam for bloods with
paed team
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• 20/40 : – Day Unit admission. – Febrile, tachypnoeic, cough……. – Diagnosis : H1N1 – Self discharged : no anti-virals – (MRSA+ve) – Recovered.
• 26/40 • Increasing PCR – up to 1000 with a stable creatinine • Normal growth and blood pressure
• 29/40 • Slightly increased BP – commenced nifedipine following
cardiac discussions. • ?rejection ?preeclampsia • Steroids for fetal lung maturity
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The week of delivery
• 29+6 • Increasing proteinuria and worsening
hypertension. – Delivery by GA LSCS (maternal request) – Difficult anaesthetic post op pain control – Declined implanon
• Female infant • 1400g • Uncomplicated neonatal course
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Postnatal
• Continued hypertension and proteinuria
• ?Rejection component
• Renal biopsy 1 month postnatal (+implanon)
– Features typical of preeclampsia
– Rejection could not be excluded
• Continued relentless deterioration
– Now on dialysis !!!!
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Thanks for listening…
On behalf of the NUTH GUCH pregnancy service. (Crossland, O‟Sullivan, Choudhary, Griffiths, Murphy, Wight and Waugh)