Pregnancy & Heart DiseasesDonna Kang, MD
Oregon Heart & Vascular InstitutePeaceHealth Sacred Heart Medical Center at RiverBend
Disclosures
● None
Objectives
● Demonstrate the importance of recognizing cardiovascular diseases (CVD) in
pregnancy.
● Define risk factors for increased CVD in pregnancy.
● Define physiologic cardiovascular changes in pregnancy.
● Identify signs and symptoms of CVD in pregnancy, and when to refer.
● Identify important cardiac tests.
● Evaluate CVD using various risk stratification methods.
● Familiarize in pre-existing high risk and acquired CVD in pregnancy.
● Identify commonly used cardiac medications.
● Demonstrate general principles of antepartum, intrapartum, and postpartum
care.
Background
● CVD affects 1-4% of
almost 4 million
pregnancies in US
● CVD is leading cause of
maternal mortality (26%)
● Diagnosis is challenging!
Risk factors for increased CVD
● Race/ethnicity: non-Hispanic black women*
● Age: >40 years old*
● Obesity: 60% of maternal death*
● Hypertension*
● Diabetes
● Obstructive sleep apnea (moderate or severe)
● History of preterm delivery
● Strong family history of heart disease
● Exposure to cardiotoxic drugs
● Social determinants○ Patient, physician, and health systems
○ Education
CV physiologic changes in pregnancy
Hematologic, coagulation, and metabolic changes
● Anemia○ HF, MI
● Hypercoagulability
● Catabolic state○ Insulin resistance -> gestational diabetes
○ Increased serum fatty acids -> fatty liver
Signs and symptoms of CVD and when to refer to specialists
Cardiac tests
● Natriuretic peptides (BNP, NT-proBNP)
● Troponins
● D-dimer
● Electrocardiogram
● Chest x-ray
● Echocardiogram
● Exercise stress test
● Computed tomography
● Magnetic resonance imaging
● Holter monitor or prolonged cardiac monitoring device
Preparing women with known heart disease for pregnancy
● Optimization prior to pregnancy
● Cardiology evaluation prior to pregnancy or early as possible during
pregnancy
● Multidisciplinary Pregnancy Heart Team○ OB, MFM, cardiology, anesthesiology
● Pregnancy is not recommended for women in modified WHO pregnancy risk
category IV○ Pregnancy can worsen cardiac status that may not return to baseline after pregnancy
○ Maternal morbidity and mortality
○ Fetal risk of heart disease, fetal growth restriction, preterm birth, fetal demise, high perinatal
mortality
Risk assessment
● All women○ California Improving Health Care Response to Cardiovascular Disease in Pregnancy and
Postpartum toolkit algorithm
Risk assessment
● Women with known CV disease○ Modified World Health Organization (WHO) classification of maternal CV risk**
○ Canadian Cardiac Disease in Pregnancy risk index (CARPREG II)
○ Zwangerschap bij Aangeboren HARtAfwijkingen (ZARAHA)
Modified WHO Pregnancy risk classification
CARPREG II
Pre-existing
high risk
CVD
Acquired CV diseases in Pregnancy
● Peripartum cardiomyopathy
● Acute coronary syndrome
● Maternal cardiac arrest
Peripartum cardiomyopathy
● 25-100 per 100,000 live births in US
● Non-ischemic cardiomyopathy occurring late in pregnancy or the first few
months of postpartum with LV EF <45%
● Unclear etiology, autoimmune?
● 5-10% death or cardiac transplant rate by 1 year postpartum
● Risk factors: non-Hispanic blacks, increased age, multifetal pregnancies,
gestational hypertension, preeclampsia
● 20% recurrence with subsequent pregnancies
● Heart failure symptoms; echocardiogram
● Cardiology consult, pregnancy heart team, appropriate level of care.
● Vaginal delivery is preferred
Acute coronary syndrome
● 8 of 100,000 hospitalizations for pregnancy and postpartum care
● 5-11% maternal death, 3-4x higher rate than non-pregnant age-matched
women
● Etiologies: dissection*, atherosclerosis, embolism, spasm, arteritis, coronary
artery occlusion from aortic dissection
● Risk factors: non-Hispanic black, increased age, obesity, DM, tobacco use,
gestational hypertension, h/o coronary artery dissection, blood transfusion,
peripartum infection
● Typical and atypical symptoms
● Hemodynamic compromise, arrhythmia, cardiogenic shock
● EKG, troponins, echocardiogram, +/- cardiac catheterization
● Pregnancy heart team
Maternal cardiac arrest
● Hemorrhagic (38%), amniotic fluid
embolism (13%), ACS (10%),
venous thromboembolism (5%)
● Oxygenation, decrease aortocaval
compression, CPR, defibrillation,
fetal delivery
Antepartum management principles
● Comprehensive plan for pregnancy, delivery, and postpartum
● Women with pre-existing high risk cardiovascular disease should be
evaluated and managed by Pregnancy Heart Team
● Control HTN in women with CVD prior to pregnancy
● Regular exercise before and during pregnancy if possible
● Screening fetal echo for congenital heart disease at 18-22 weeks of gestation
● Close monitoring of fetal growth
● Prophylactic aspirin 81 mg daily to be started at 12 weeks (before 20 weeks)
in women with high risk for preeclampsia
● Close monitoring of blood pressure and treatment appropriately
● Delivery in a hospital with appropriate maternal level of care
Intrapartum management principles
● Pre-planned with Pregnancy Heart Team in high risk CVD
● Vaginal delivery delivery at term if possible
● Regional anesthesia
● Anticoagulation
● Pulmonary edema, arrhythmias
● Prophylactic antibiotics for infective endocarditis
Immediate postpartum management principles
● Time of heightened risk of CVD related maternal morbidity and mortality
● High risk for peripartum cardiomyopathy, aortic dissection, and ACS
● Pulmonary edema, arrhythmias
● Prolonged monitoring
● High risk for thromboembolism
Postpartum considerations after hospital discharge
● Follow up with primary care or cardiology within 7-10 days of delivery for
women with hypertensive disorders
● Follow up with cardiology within 7-14 days of delivery for women with CVD
● Breastfeeding is encouraged ○ 10% less likely to develop CVD in the future
● Address contraception
● Regular follow up in cardiology at 3 months, 6 months, and a year after
delivery for high risk CVD
Conclusion
● Education and prevention
● Early recognition and referrals
● Transfer of care to higher level of care facilities for pregnancy heart team
approach
● Continuity of maternal care after delivery
References
● Ashrafi, R., Curtis, S. Heart Disease and Pregnancy. Cardiology and Therapy.
2017. 6 (2) 157-173.
● Elkayem, U. High-risk cardiac disease in Pregnancy, part I. Journal of
American College of Cardiology. 2016. 68 (4) 386-410.
● Hollier et al. Pregnancy and heart disease. ACOG Practice Bulletin. 2019.
133 (5) 320-356.
● Martin, N., Montagne, R. US has the worst maternal death in developed
world. National Public Radio. 2017.
● Silversides, C. et al. Pregnancy outcomes in women with heart disease, the
CARPREG II study. Journal of American College of Cardiology. 2018. 71 (21)
2419-2430.
Thank you!
Gestational hypertension (gHTN)
● New onset hypertension (SBP ≥140 and/or DBP ≥90) at ≥20 weeks of
gestation in the absence of proteinuria or new signs of end organ dysfunction
● Severe gHTN SBP ≥160 and/or DBP ≥110
● Chronic HTN: persistently elevated BP ≥12 weeks postpartum
● Antihypertensives for severe gHTN and/or end organ dysfunction○ Goal SBP 130-150, DBP 80-100
○ Methyldopa, labetalol, metoprolol, propranolol, nifedipine, verapamil, hydralazine,
● Delivery at 37 weeks if severe gHTN
Arrhythmia
● Atrial arrhythmias○ Very common
○ Premature atrial beats
○ Paroxysmal supraventricular tachycardia: AVNRT
○ Atrial fibrillation and flutter: structural heart disease
○ Beta-blockers, calcium channel blockers, digoxin, adenosine, cardioversion
● Ventricular arrhythmias○ Rare
○ Structural heart disease
○ Right ventricular outflow tract VT: catecholamine
○ Long QT syndrome, risk of VT especially in postpartum
○ Beta-blockers (sotalol), verapamil, magnesium, procainamide, cardioversion/defibrillation
○ Pregnancy heart team: antiarrhythmics,