2018 ESC Guidelines for the management ofcardiovascular diseases during pregnancy

Dr R.Sow CHL

• HTA et grossesse • Pathologies thrombo-emboliques et grossesse • Classification mWHO • Pathologies spécifiques

Hypertension artérielle• L’atteinte cardiovasculaire la plus fréquente

concernant 5-10% des grossesses dans le monde. • Cause majeure de morbi-mortalité maternelle ,

fœtale. • Risque maternel : de décollement placentaire,

AVC, de défaillance multiviscérale, et de coagulation intravasculaire disséminée

Hypertension artérielle• Risque fœtal : retard de croissance intra-utérin

( 25% des cas de pré éclampsie), mort intra-utérine (4% des cas de pré éclampsie).

Hypertension artérielle• Définition : SBP >=140 mmHg et/ou DBP90 mmHg. Modérée: 140-159/90-109 mmHg Sévère : >=160/110 mmHg

Hypertension artérielle• Hypertension préexistante : avant 20 SA, persiste

>42 jours post-partum et peut être associé à une protéinurie

• Hypertension gestationnelle : après 20SA et disparaît dans les 42 jours post-partum

• Pré éclampsie : hypertension gestationnelle + protéinurie (>0.3g/24h ou ACR> 30mg/mmol).

Hypertension artérielle• Hypertension pré existante associé à une

hypertension gestationnelle avec protéinurie . • Hypertension anténatale inclassable.

Hypertension artérielle • Prise en charge non pharmacologique • Traitement pharmacologique

Maladie thrombo-embolique veineuse( TVP et EP)• Représente une cause importante de morbi-

mortalité . • Majoration du risque thrombo-embolique de

0.05-0.20% • En Angleterre EP 1ère cause de mortalité

maternelle

Arythmies

Arythmies

Classification mWHO

Cardiopathies congénitales

Maladie aortique

Maladie aortique

Maladie aortique

Cardiopathie valvulaire

Cardiopathie valvulaire

Cardiopathie valvulaire

Cardiopathie valvulaire

Cardiopathie ischémique

Cardiomyopathie et insuffisance cardiaque

Cardiomyopathie et insuffisance cardiaque

Médicaments et grossesse

Key messages• Risk estimation should be individualized depending on the

underlying cardiac diagnosis, ventricular and valvular function, functional class, presence of cyanosis, PAPs, and other factors.

• Indications for intervention (surgical or catheter) in the majority of patients do not differ in women who consider pregnancy compared with other patients. There are a few exceptions, such as some degree of aortic dilatation and severe asymptomatic MS.

Key messages• the pregnancy heart team : In women with a moderate or high-risk of complications during pregnancy (mWHO II–III, III, and IV), pre-pregnancy counselling and management during pregnancy and around delivery should be performed in an expert centre by a multidisciplinary team. Management of women with a mechanical valve prosthesis are at high-risk of maternal morbidity (especially valve thrombosis and bleeding) and even mortality.

Key messages• Vaginal delivery is the first choice for the majority of patients. • Indications for caesarean section are:

– pre-term labour in patients onOACs – aggressive aortic pathology – acute intratable HF – severe forms of PH (including Eisenmenger’s syndrome)

Key messages• The following patients should be counselled against pregnancy:

– with a Fontan operation and additional comorbidities (ventricular dysfunction, arrhythmias, or valve regurgitation) – with PAH – severe systemic ventricular dysfunction (EF <30% or NYHA class III–IV). – severe (re-)coarctation – systemic right ventricle with moderate or severely decreased ventricular function – with vascular Ehlers-Danlos

Key messages– with severe aortic dilatation or (history of) aortic dissection – with severe MS (even when asymptomatic) – Patients with severe AS who are symptomatic, or asymptomatic patients with impaired LV function or a pathological exercise test – if LVEF does not normalize in women with previous PPCM.

Key messages• Women with HF during pregnancy should be treated according to current guidelines for non-pregnant patients, respecting contraindications for some drugs in pregnancy (see table ‘Recommendations for drug use in pregnancy’). When inotropes or more advanced treatment is necessary, transport to an expert centre is recommended.

Key messages• In women with PPCM and DCM, subsequent pregnancy is not recommended if LVEF does not normalize. • Patients with congenital LQTS and catecholaminergic polymorphic VT are recommended beta-blockers during pregnancy and post-partum. • Methyldopa, labetalol, and calcium antagonists are recommended for the treatment of hypertension in pregnancy. • LMWH is the agent of choice for VTE prophylaxis and treatment.

Merci de votre attention