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APPROACH TO HEART DISEASEIN PREGNANCY
Dr Abdul Hadi bin Jaafar
Head and Consultant Cardiology
Cardiology Department,Tengku Ampuan Afzan Hospital Kuantan
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Heart disease is present in 0.5-4% of pregnancies Common causes of heart disease in Malaysia:
Rheumatic Heart Disease 55%
Congenital Heart Disease 40%
Others: 5%
Commonest non obstetric cause of maternal mortalityaccounting for 10% of all deaths
Early detection and appropriate management improves
maternal and fetal outcomes
Introduction
HEART DISEASE IN
PREGNANCY
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PHYSIOLOGICAL CHANGES IN THE
CARDIOVASCULAR SYSTEM IN
PREGNANCYParameter 1st
Trimester 2nd
Trimester 3rd
TrimesterBlood volume Cardiac output to toStroke volume orHeart rate toSystolic blood pressure Diastolic blood pressure Pulse pressure Systemic vascular
resistance
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Management Principles Preconceptual Counselling
Detection of Cardiac Disease in pregnancy Risk Stratification
Specialist Referral
General Principles of Management and
Follow Up
Labor and Delivery
Post Partum
Breast Feeding
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Preconceptual Counselling
Women with heart disease should be :
Encouraged to complete their family early
Discouraged from multiple pregnancies
High Risk patients should be advised on permanentcontraception, if the defect is not correctable
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Preconception Planning
1. Dilated cardiomyopathy 15-60% MMR
2. Primary pulmonary HTN 50% MMR3. Eisenmenger Syndrome 15-30% MMR
4. Marfan Syndrome with aortic root dilatation 25-50%MMR
5. Coarctation of aorta 5%6. Tetralogy of Fallot 12%
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Preconceptual CounsellingHigh Risk Patients:
Pregnancy should be strongly discouraged.If pregnant, consider for early T.O.P
Pulmonary Hypertension (PAP >75% of syst Pressures)
Eisenmengers Syndrome Cyanotic Heart Disease
Poor LV function ( LVEF 40mm
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Preconceptual CounsellingWherever possible, significant cardiac lesions shouldbe corrected before pregnancy
Congenital Defects
Mitral Stenosis ( MVA
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Detection of Cardiac Disease In Pregnancy History
Physical Examination Investigations
ECG
Echocardiogram
The echocardiogram is sometimes the only reliable methodof excluding a cardiac murmur as being non significant in
a pregnant patient.Thus the threshold fo r an echo cardiogram
shou ld be LOW
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Risk StratificationRisk Stratification of the mother and fetus depends on
the following cardiac conditions: New York Functional Class
Presence of Cyanosis
Left and Right Ventricular Function
Severity of Pulmonary Hypertension Presence of valve/conduit stenosis
Presence of conduction defects
Presence of arrhythmias
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Risk Stratification
Low Risk generally tolerate pregnancy well
Moderate Risk
High maternal and fetal Risk
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Risk Stratification LOW RISK Uncomplicated septal defects
Pulmonary stenosis
Aortic and mitral regurgitation
Hypertrophic Cardiomyopathy Acyanotic Ebsteins Anomaly
Corrected transposition without other defects
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Risk Stratification MODERATE RISK
Coarctation of the Aorta
Univentricular circulation after Fontan Operation
Prosthetic Valves on anti-coagulants
Severe Mitral Regurgitation with NYHA class 1
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Risk Stratification HIGH RISKPulmonary Hypertension ( PAP >75% of systemic Pressures)
Eisenmengers Syndrome
Uncorrected Cyanotic Heart DiseaseSevere Aortic Stenosis
Severe mitral stenosis
Poor LV function ( LVEF40mm)
Pregnancy in patients with heart disease also imposes
a high risk to the fetus esp: impaired maternal functional
class and presence of cyanosis
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Specialist Referral
Low Risk patientscan be managed by Primary CareDoctors
Moderate Risk Patientscan be managed in hospitals
where Specialists are available
High Risk Patients should ideally be managed in
tertiary Hospitals with a multi disciplinary team
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Specialist Referral
The following patients should be considered for early
specialist referral:
Known heart disease who have not been
assessed or risk stratified prior to pregnancy
Moderate and at High Risk Worsening symptoms due to heart disease
Suspected to have heart disease - confirm or refute the diagnosis
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General Principles Of Management
and Follow Up
At the First Visit :
Assessment of maternal and fetal health
Assessment of Maternal NYHA Functional Class
Confirmation of clinical diagnosis
Establishment of baseline hemodynamics
High Risk Patients should be considered for
T.O.P.
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General Principles Of Management
and Follow Up
At Follow Up :
routine antenatal care (mother and fetus)
correct anemia
treat infections
Identify and treat complications of heart disease
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General Principles Of Management
and Follow Up
Heart Failure: - diuretics, digoxin, nitrates and/or hydrallazine Worsening Right to Left Shunt: nasal oxygen, adequate
volume replacement
Thromboembolism
Arrhythmias
Patients with these complications,should be admitted
and kept in hospital till delivery.
All High Risk Patients should be hospitalized in the third
trimester
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SAFETY PROFILE OF CVS
DRUGS IN PREGNANCYDRUG PROFILE ADVERSE EFFECTS
Digoxin Safe Low Birth Weight
Diuretics Safe Impairment of uterine blood flow,
hyponatremia, thrombocytopenia,
jaundice, bradycardia
ACE I Use judiciously Skull ossification, IUGR, low birth
weight, oligohydramnios, neonatal
renal failure, limb contractures
Nitrates Unsafe
Calcium Antagonists Use judiciously Fetal Bradycardia
Sodium Nitrprusside Use judiciously Fetal Distress due to maternal
hypotension
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DRUGS PROFILE ADVERSE EFFECTS
Beta Blockers Safe IUGR, bradycardia, apnea at birth,
hypoglycaemia, hyperbilirubinaemia;may initiate uterine contraction
Adenosine Safe None reported
Propafenone Safe None reported
Lignocaine Safe High blood levels may cause fetal
acidosis and CNS depression
Amiodarone Unsafe IUGR, prematurity, hypothyroidsm
Procainamide Safe None reported
Quinidine Safe Toxic dose may induce premature
labor and damage to 8th cranial
nerve
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Labour and Delivery
The timing and mode of Delivery Hemodynamic Monitoring
Analgesia
Antibiotic Prophylaxis
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Labour and Delivery
1) Timing and Mode of Delivery
This should be individualised
High Risk patients should be delivered at a tertiary
center
Spontaneous Labor is preferred to induction The second stage of labor should not be allowed to
be prolonged
Vaginal delivery vs. caesarian section
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Labour and Delivery
3) Analgesia
This is important to control the stress of labor
An epidural is the technique of choice
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Labour and Delivery
4) Antibiotic Prophylaxis
Routine antibiotic prophylaxis in all susceptiblepatients
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Antibiotic Prophylaxis for Labour and Delivery
Standard Regimen:
Ampicillin/Amoxycillin IV or IM 2.0 gm +
Gentamycin IV or IM 1.5 mg/kg ( not to exceed
80mg) 30 mins before procedure
Followed By,
Ampicillin/Amoxycillin 1.5 gm orally 6 hours after initial
dose or repeat parenteral dose
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Antibiotic Prophylaxis for Labour and Delivery
Penicillin Allergy:
Vancomycin IV or IM 1.0 gm over 1 hr +
Gentamycin IV or IM 1.5 mg/kg (not to exceed 80mg)
30 mins before procedure
Followed By,
repeat parenteral dose of Vancomycin
and gentamycin
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Antibiotic Prophylaxis for Labour and Delivery
Alternative Low Risk Regime:
Amoxycillin oral 3gm 1 hour before procedure
Followed By,1.5gm amoxycillin 6 hours later
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Post Partum Most patients have an uncomplicate delivery and peurperium
Increase in venous return following delivery may
result in worsening heart failure in patients with stenoticvalves and impaired LV function
Patients with Eisenmengers syndrome decompensate
in the early post partum period due to increase right to leftshunting
These patients should be monitored for about 48-72 hours
and remain in hospital for about a week.
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Breast Feeding
Patients with heart disease and an uncomplicated
pregnancy should be encouraged to breast feed
HEART DISEASE IN
PREGNANCY
SAFETY PROFILE OF CVS
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SAFETY PROFILE OF CVS
DRUGS IN LACTATIONDRUG PROFILE COMMENTS
Digoxin Safe Amount ingested far < the pediatric dose
Quinidine Safe Amount ingested far < the pediatric dose
Procainamide Safe Amount ingested far < the pediatric dose
Amiodarone Not safe Excreted in significant amounts in milk
Verapamil Safe Amount ingested far < the pediatric dose
Propanolol Safe No adverse effect
Metaprolol Safe Amount ingested far < the pediatric dose
Atenolol Safe No adverse effect
ACE-I Not safe
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1.4. Management of Specific Conditions
1.4.1 Valvular heart disease including prosthetic
Valves1.4.2 Congenital Heart Disease
1.4.3 Pulmonary Hypertension and Eisenmengers
Syndrome
1.4.4 Depressed LV function1.4.5 Hypertrophic Cardiomyopathy
1.4.6 Marfans Syndrome
1.4.7 Arrhythmias
1.4.8 Anticoagulation in pregnancy
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HEART DISEASE
IN
PREGNANCY
Specif icCondi t ions
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Valvular Heart Disease
Mitral stenosis Patients with mild to moderate
Mitral Stenosis (MVA>1.0 cm2)
usually tolerate pregnancy well
In severe Mitral stenosis
and/or pulmonary hypertension,
consider percutaneous mitralvalvotomy during 2nd trimester
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Valvular Heart Disease
Aortic Stenosis
Patients with mild to moderate ASAVA>1.0 cm2, normal resting ECG
& absence of LVH on voltages,
good LV function &normal exercise
tolerance) usually tolerate pregnancy well
In severe Aortic stenosis use diuretics and/or digoxin
Failure of medical therapy may require termination of
pregnancy or palliative percutanous aortic valvuloplasty
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Valvular Heart Disease
Pulmonary stenosis Generally well tolerated even in the presence of severely
elevated RV pressures
Prosthetic Valves Most patients with a normally functioning valve tolerate
pregnancy well.
Maternal Mortality 1-4% in those with mechanical heart
valves
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Pulmonary Hypertension
Pulmonary Hypertension is present when the systolic
pulmonary pressures are >30 mmHg and the mean pressure>20mmHg respectively
Pulmonary Hypertension may be due to:
Primary Pulmonary Hypertension
Eisenmengers Syndrome
Secondary Vascular Pulmonary hypertension
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Pulmonary Hypertension
Patients with PHT usually die at the time of delivery or
in the early post partum period This is due to shunt reversal with increased right to left
shunting and resultant hypoxia and acidosis
These patients should be admitted in the second trimester
and the following considered:
An t icoagulat ion t i l l term and ear ly post partum
Contin uous oxygen therapy, aiming at SaO2 > 90%
Adequate hydrat ion
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Anticoagulation in Pregnancy
Anticoagulants are indicated in the following situations:
Mechanical Heart valves
Deep venous thrombosis & thromboembolism
Atrial fibrillation associated with structural heart disease
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Anticoagulation in Pregnancy
The anticoagulants available are:
Oral anticoagulants
Warfarin is associated with embryopathy in
4-10% of newborns
Unfract ionated Heparin
Low dose heparin is inadequate for thromboprophylaxisduring pregnancy
Its usage requires monitoring of the APTT
Low m olecular weight Hepar in
Does not require APTT monitoring
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Anticoagulation in Pregnancy
Patients on long term anticoagulants must be counselled prior
to conception
3 options for anticoagulation:I. Combined heparin and oral anticoagulants
First trimester: unfractionated heparin/LMWH
Second trimester till 36 weeks: warfarin
From 36th week: unfractionated heparin/LMWHII. Full dose heparin throughout pregnancy
III. Continuous warfarin therapy:
First trimester till 36 weeks: warfarin
From 36th week: Unfractionated heparin/LMWH
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Anticoagulation in Pregnancy
In High risk Patients with Mechanical Heart
valves we advocate Option III.
If the patient chooses option I or II, sheshould be made aware of the higher risk
of valve thrombosis and thromboembolism
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Anticoagulation in Pregnancy
The choice of anticoagulation regimen for mechanicalheart valves during pregnancy should be made by
balancing 2 risksmaternal morbidity and mortality
from thromboemboliccomplications versus fetal loss
and embryopathy
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Option I
Combined heparin
+ warfarin
Option IIHeparin throughout
Optio n IIIWarfarin throughout
Frequency of Fetal and Maternal Complications
With various Anticoagulation Options
Spontaneous
abortion
Congenital
anomalies
Thrombo-
embolism
Death
24.8% 3.4% 9.2% 4.2%
23.8% 0%-2.8% 33.3% 15%
24.7% 6.4% 3.9% 1.8%
Fetal
compl icat ions
Maternalcompl icat ions
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Higher Risk
1st generation PHV (e.g., Starr-Edwards,Bjork Shiley) in the mitral position,atrial fibrillation, history of TE onanticoagulation
Warfarin (INR 2.53.5) for 35 weeks,followed by UFH (mid-interval aPTT 2.5) or
LMWH (pre-dose anti-Xa 0.7) and
ASA 80
100 mg q.d.OR
UFH (aPTT 2.53.5) or
LMWH (pre-dose anti-Xa 0.7) for 12 weeks,followed by
warfarin (INR 2.53.5) to 35th week, then
UFH (aPTT 2.5) or
LMWH (pre-dose anti-Xa 0.7) and
ASA 80100 mg q.d.
Lower Risk2nd generation PHV (e.g., St. JudeMedical, Medtronic-Hall) anymechanical PHV in the aortic postion
SC UFH (mid-interval aPTT 2.03.0) or
LMWH (pre-dose anti-Xa 0.6) for 12weeks,
followed bywarfarin (INR 2.53.0) for 35 weeks, then
SC UFH (mid-interval aPTT 2.03.0) or
LMWH (pre-dose anti-Xa level 0.6)OR
SC UFH (mid-interval aPTT 2.03.0) or
LMWH (pre-dose anti-Xa 0.6) throughoutpregnancy
Elkayam U et al . Ant icoagulat ion in pregnant w omen wi th prosthet ic hear t
valve. J Cardiovasc Pharmacol Th er 2004;9:10715.
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Assessing the risk Based on a prospective study of pregnancy
outcomes in women with heart disease in
Canada* Overall rate of primary cardiac event
(pulmonary oedema, stroke, cardiac arrest,
arrhythmias and death) was 13%
*CARPREG Investigators . Circu lat ion
2001 Ju l 31; 104(5):515-521
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Predictors of cardiac events*1. Poor functional class (NYHA > II) or cyanosis
2. Previous cardiac event (eg; heart failure, TIA, stroke) or
arrhythmias
3. Left heart outflow obstruction
MVA < 2cm2
AVA < 1.5 cm2
Peak LVOT gradient > 30mmHg4. LV systolic dysfunction (EF < 40%)
*CARPREGInvest igators.Circulat io n 2001
Ju l 31;104(5):515-21
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The score
Score of 0 5% risk
Score of 1 27% risk
Score of >1 75% risk
Risk of developing primary cardiac event
Mode of delivery and outcome;
VD 3% vs. Caesarean 4% (p= 0.46)
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Summary
All women with heart disease should be counselled on
the maternal and fetal risks, should they become pregnant
Wherever indicated, significant cardiac lesions should
be corrected prior to pregnancy
Pregnant patients with heart disease should be riskstratified
Patients at low risk can be managed by their primary
care doctors
HEART DISEASE IN
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Summary Patients at moderate risk may be managed in hospitals
with specialists
Patients at high risk should ideally be managed in
tertiary care centers
In addition to routine antenatal care, complications of
heart disease should be looked for and treated
accordingly
Patients requiring anticoagulants should be counseled
on the available options
HEART DISEASE IN
PREGNANCY
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Summary
Labour and delivery in patients at moderate and high
risk is best managed by a multidisciplinary team
The timing and mode of delivery should be individualised
Adequate analgesia during labour is important
We recommend antibiotic prophylaxis during delivery
in all susceptible patients
HEART DISEASE IN
PREGNANCY