APPROACH TO HEART DISEASE IN PREGNANCY

Dr Abdul Hadi bin Jaafar Head and Consultant Cardiology Cardiology Department, Tengku Ampuan Afzan Hospital Kuantan

HEART DISEASE IN PREGNANCY

Introduction
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 mortality accounting for 10% of all deaths Early detection and appropriate management improves maternal and fetal outcomes

PHYSIOLOGICAL CHANGES IN THE CARDIOVASCULAR SYSTEM IN PREGNANCY

Parameter
Blood volume Cardiac output Stroke volume Heart rate Systolic blood pressure Diastolic blood pressure Pulse pressure Systemic vascular resistance 1st Trimester
to to or to

2nd Trimester

3rd Trimester

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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 permanent contraception, if the defect is not correctable

HEART DISEASE IN PREGNANCY

Preconception Planning
1. 2. 3. 4. Dilated cardiomyopathy 15-60% MMR Primary pulmonary HTN 50% MMR Eisenmenger Syndrome 15-30% MMR Marfan Syndrome with aortic root dilatation 25-50% MMR 5. Coarctation of aorta 5% 6. Tetralogy of Fallot 12%

HEART DISEASE IN PREGNANCY

Preconceptual Counselling
High 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 <40%) Marfans Syndrome with aortic root diameter >40mm

HEART DISEASE IN PREGNANCY

Preconceptual Counselling
Wherever possible, significant cardiac lesions should be corrected before pregnancy Congenital Defects Mitral Stenosis ( MVA <1.0 cm2 ) Severe Aortic Stenosis (AVA <1.0 cm2) with impaired exercise tolerance and reduced LVEF

HEART DISEASE IN PREGNANCY

Detection of Cardiac Disease In Pregnancy
History Physical Examination Investigations ECG Echocardiogram The echocardiogram is sometimes the only reliable method of excluding a cardiac murmur as being non significant in a pregnant patient. Thus the threshold for an echocardiogram should be LOW

NEW YORK FUNCTIONAL CLASSIFICATION

CLASS I No limitation. Ordinary physical activity does not cause undue fatigue, dyspnoea or palpitations Slight limitation of physical activity. Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitations, dyspnoea or angina Marked limitation of physical activity.Although patients are comfortable at rest, less than ordinary activity will lead to symptoms Inability to carry on any physical activity without discomfort. Symptoms of congestive failure are present at rest.With any physical activity, increased discomfort is experienced CLASS II

CLASS III

CLASS IV

HEART DISEASE IN PREGNANCY

Risk Stratification
Risk 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

HEART DISEASE IN PREGNANCY

Risk Stratification
Low Risk generally tolerate pregnancy well Moderate Risk High maternal and fetal Risk

HEART DISEASE IN PREGNANCY

Risk Stratification LOW RISK
Uncomplicated septal defects Pulmonary stenosis Aortic and mitral regurgitation Hypertrophic Cardiomyopathy Acyanotic Ebsteins Anomaly Corrected transposition without other defects

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

Risk Stratification HIGH RISK
Pulmonary Hypertension ( PAP >75% of systemic Pressures) Eisenmengers Syndrome Uncorrected Cyanotic Heart Disease Severe Aortic Stenosis Severe mitral stenosis Poor LV function ( LVEF<40%) Poor NYHA due to heart disease Marfans Syndrome ( aortic root diameter >40mm) Pregnancy in patients with heart disease also imposes a high risk to the fetus esp: impaired maternal functional class and presence of cyanosis

HEART DISEASE IN PREGNANCY

Specialist Referral
Low Risk patients can be managed by Primary Care Doctors Moderate Risk Patients can be managed in hospitals where Specialists are available High Risk Patients should ideally be managed in tertiary Hospitals with a multi disciplinary team

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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.

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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

SAFETY PROFILE OF CVS DRUGS IN PREGNANCY

DRUG
Digoxin Diuretics

PROFILE
Safe Safe

ADVERSE EFFECTS
Low Birth Weight Impairment of uterine blood flow, hyponatremia, thrombocytopenia, jaundice, bradycardia Skull ossification, IUGR, low birth weight, oligohydramnios, neonatal renal failure, limb contractures

ACE I

Use judiciously

Nitrates Calcium Antagonists Sodium Nitrprusside

Unsafe Use judiciously Use judiciously Fetal Bradycardia Fetal Distress due to maternal hypotension

DRUGS
Beta Blockers

PROFILE
Safe

ADVERSE EFFECTS
IUGR, bradycardia, apnea at birth, hypoglycaemia, hyperbilirubinaemia; may initiate uterine contraction None reported None reported High blood levels may cause fetal acidosis and CNS depression IUGR, prematurity, hypothyroidsm None reported Toxic dose may induce premature labor and damage to 8th cranial nerve

Adenosine Propafenone Lignocaine Amiodarone Procainamide Quinidine

Safe Safe Safe Unsafe Safe Safe

HEART DISEASE IN PREGNANCY

Labour and Delivery

The timing and mode of Delivery Hemodynamic Monitoring Analgesia Antibiotic Prophylaxis

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

Labour and Delivery 2) Hemodynamic Monitoring High Risk patients require hemodynamic monitoring throughout labor and for several days post partum

HEART DISEASE IN PREGNANCY

Labour and Delivery 3) Analgesia

This is important to control the stress of labor An epidural is the technique of choice

HEART DISEASE IN PREGNANCY

Labour and Delivery 4) Antibiotic Prophylaxis
Routine antibiotic prophylaxis in all susceptible

patients

HEART DISEASE IN PREGNANCY

Antibiotic Prophylaxis for Labour and Delivery Standard Regimen:
Ampicillin/Amoxycillin Gentamycin IV or IM 2.0 gm + IV or IM 1.5 mg/kg ( not to exceed 80mg) 30 mins before procedure Followed By, 1.5 gm orally 6 hours after initial dose or repeat parenteral dose

Ampicillin/Amoxycillin

HEART DISEASE IN PREGNANCY

Antibiotic Prophylaxis for Labour and Delivery Penicillin Allergy:
Vancomycin Gentamycin IV or IM 1.0 gm over 1 hr + IV or IM 1.5 mg/kg (not to exceed 80mg) 30 mins before procedure

Followed By, repeat parenteral dose of Vancomycin and gentamycin

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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 stenotic valves and impaired LV function
Patients with Eisenmengers syndrome decompensate in the early post partum period due to increase right to left shunting These patients should be monitored for about 48-72 hours and remain in hospital for about a week.

HEART DISEASE IN PREGNANCY

Breast Feeding Patients with heart disease and an uncomplicated pregnancy should be encouraged to breast feed

SAFETY PROFILE OF CVS DRUGS IN LACTATION

DRUG
Digoxin Quinidine

PROFILE
Safe Safe

COMMENTS
Amount ingested far < the pediatric dose Amount ingested far < the pediatric dose

Procainamide Amiodarone Verapamil

Propanolol Metaprolol Atenolol ACE-I

Safe Not safe Safe

Safe Safe Safe Not safe

Amount ingested far < the pediatric dose Excreted in significant amounts in milk Amount ingested far < the pediatric dose
No adverse effect Amount ingested far < the pediatric dose No adverse effect

HEART DISEASE IN PREGNANCY

1.4. Management of Specific Conditions
1.4.1 Valvular heart disease including prosthetic Valves 1.4.2 Congenital Heart Disease 1.4.3 Pulmonary Hypertension and Eisenmengers Syndrome 1.4.4 Depressed LV function 1.4.5 Hypertrophic Cardiomyopathy 1.4.6 Marfans Syndrome 1.4.7 Arrhythmias 1.4.8 Anticoagulation in pregnancy

HEART DISEASE IN PREGNANCY

Specific Conditions

HEART DISEASE IN PREGNANCY

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 mitral valvotomy during 2nd trimester

HEART DISEASE IN PREGNANCY

Valvular Heart Disease Aortic Stenosis
Patients with mild to moderate AS AVA>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

HEART DISEASE IN PREGNANCY

Valvular Heart Disease Mitral and Aortic Regurgitation These are generally well tolerated unless the patients present in NYHA Functional Class III-IV or have poor LV function (LVEF <40%)

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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

HEART DISEASE IN PREGNANCY

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: Anticoagulation till term and early post partum Continuous oxygen therapy, aiming at SaO2 > 90% Adequate hydration

HEART DISEASE IN PREGNANCY

Anticoagulation in Pregnancy
Anticoagulants are indicated in the following situations: Mechanical Heart valves Deep venous thrombosis & thromboembolism Atrial fibrillation associated with structural heart disease

HEART DISEASE IN PREGNANCY

Anticoagulation in Pregnancy
The anticoagulants available are: Oral anticoagulants Warfarin is associated with embryopathy in 4-10% of newborns Unfractionated Heparin Low dose heparin is inadequate for thromboprophylaxis during pregnancy Its usage requires monitoring of the APTT Low molecular weight Heparin Does not require APTT monitoring

HEART DISEASE IN PREGNANCY

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/LMWH II. Full dose heparin throughout pregnancy III. Continuous warfarin therapy: First trimester till 36 weeks: warfarin From 36th week: Unfractionated heparin/LMWH

HEART DISEASE IN PREGNANCY

Anticoagulation in Pregnancy In High risk Patients with Mechanical Heart valves we advocate Option III. If the patient chooses option I or II, she should be made aware of the higher risk of valve thrombosis and thromboembolism

HEART DISEASE IN PREGNANCY

Anticoagulation in Pregnancy The choice of anticoagulation regimen for mechanical heart valves during pregnancy should be made by balancing 2 risks maternal morbidity and mortality from thromboembolic complications versus fetal loss and embryopathy

Frequency of Fetal and Maternal Complications With various Anticoagulation Options

Fetal complications
Spontaneous abortion Option I Combined heparin + warfarin Option II Heparin throughout Option III Warfarin throughout 24.8% Congenital anomalies 3.4%

Maternal complications
Thromboembolism 9.2% Death

4.2%

23.8%

0%-2.8%

33.3%

15%

24.7%

6.4%

3.9%

1.8%

Higher Risk
1st generation PHV (e.g., Starr-Edwards, Bjork Shiley) in the mitral position, atrial fibrillation, history of TE on anticoagulation
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 80100 mg q.d.
OR

Lower Risk
2nd generation PHV (e.g., St. Jude Medical, Medtronic-Hall) any mechanical PHV in the aortic postion

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.

SC UFH (mid-interval aPTT 2.03.0) or LMWH (pre-dose anti-Xa 0.6) for 12 weeks, followed by warfarin (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) throughout pregnancy

Elkayam U et al. Anticoagulation in pregnant women with prosthetic heart valve. J Cardiovasc Pharmacol Ther 2004;9:10715.

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. Circulation 2001 Jul 31; 104(5):515-521

Predictors of cardiac events*

1. 2. Poor functional class (NYHA > II) or cyanosis Previous cardiac event (eg; heart failure, TIA, stroke) or arrhythmias Left heart outflow obstruction
MVA < 2cm2 AVA < 1.5 cm2 Peak LVOT gradient > 30mmHg

3.

4.

LV systolic dysfunction (EF < 40%)

* CARPREG Investigators. Circulation 2001 Jul 31;104(5):515-21

The score
Score of 0 Score of 1 Score of >1 5% risk 27% risk 75% risk

Risk of developing primary cardiac event

Mode of delivery and outcome; VD 3% vs. Caesarean 4% (p= 0.46)

HEART DISEASE IN PREGNANCY

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 risk stratified Patients at low risk can be managed by their primary care doctors

HEART DISEASE IN PREGNANCY

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

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