Cardiovascular Disease in Pregnancy
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Transcript of Cardiovascular Disease in Pregnancy
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Cardiovascular Disease in Pregnancy
Songsak Kiatchoosakun M.D.Cardiology, MedicineKhon Kaen University
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Introduction
Pregnancy, labor and delivery are associated with burdens on the cardiovascular system
The outcome of pregnancy is related to functional class and underlying heart disease
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Hemodynamic Modifications during Pregnancy
Blood volume starts to rise at 5th week Systemic vascular resistance and blood
pressure are decreased Resting heart rate increases by 10-20
beats/min Cardiac output increases by 30-50%
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High Risk Pregnancy Advise avoidance of pregnancy
– Mitral stenosis with functional class II-IV– Mitral and aortic regurgitation with functional class
III, IV– Severe pulmonary hypertension– Left ventricular dysfunction– Marfan’s syndrome with dilated aortic root
(> 40 mm)– Cyanotic heart disease– Severe obstructive lesion (aortic stenosis, pulmonary
stenosis)
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High Risk Pregnancy
Close follow up required– Prosthetic valve– Mild to moderate valvular heart disease– Marfan’s syndrome without aortic root
dilatation
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Signs and Symptoms in Normal Pregnancy
History– Dyspnea– Orthopnea– Palpitation
Physical examination– Edema– Systolic murmur < grade II/VI
– Increased of S1, P2
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Suspicious Symptoms and Signs of Cardiac Disease in Pregnancy
Progressive dyspnea Syncope Chest pain Cyanosis Left parasternal heave A grade III/VI or greater systolic murmur Any diastolic murmurs S4 gallop Fixed split of S2
Opening snap
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Cardiovascular Disease in Pregnancy
Valvular Heart disease– Rheumatic heart disease
Prosthetic heart valves Hypertension Congenital heart disease Peripartum cardiomyopathy Marfan syndrome and aortic regurgitation Arrhythmias
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Valvular Heart Disease and Maternal Outcomes
0
10
20
30
40
CHF Arrhythmia Hospitalization
Control
VHD
%
Hameed A. J Am Coll Cardiol 2001;37:893
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Valvular Heart Disease and Fetal Outcomes
0
5
10
15
20
25
Preterm labor IUGR
Control
VHD
%
Hameed A. J Am Coll Cardiol 2001;37:893
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Mitral Stenosis Most common valve disease in pregnancy Valve area < 1.5 cm2 increases risk of
– Pulmonary edema– Heart failure– Arrhythmias– Intrauterine growth retardation
Closed follow up is necessary– Doppler echo at 3 and 5 month and
monthly thereafter
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Diagnostic Assessment
Echocardiography– Confirm diagnosis– Determine the severity of stenosis– Pulmonary artery pressure and RV function– Mitral valve score to determine the success of
percutaneous mitral balloon valvuloplasty
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Medical Management
Most pregnant woman with mitral stenosis can be managed medically
Limit activity Restrict salt and fluid Diuretic if needed
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Medical Management
Digoxin is useful in atrial fibrillation Rheumatic prophylaxis
– Penicillin V 250 mg X 2
– Benzathine Penicillin IM q 3 weeks Betablocker
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Beta-blocker in Pregnancy
Beta-1 selective agents ;metoprolol and atenolol limits the risk interaction with uterine contraction
Cross placenta and excrete in breast milk No serious adverse effects on neonates Fetal bradycardia and hypoglycemia
have been reported
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Percutaneous Balloon Mitral Valvuloplasty (PBMV)
Should be considered after failure of aggressive medical treatment
Radiation exposure and technical difficulties are major limitations
Transesophageal echocardiography guidance may decrease the fluoroscopy time and maternal complications
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Surgical Intervention
Indicated in patients who failed medical treatment
Should be performed between 24-28 weeks’ gestation
Maternal mortality rate 1.5-5% Fetal mortality rate 20-30 % in open heart
surgery Closed mitral valvotomy is preferable
– safe for mother– fetal mortality of 2-12%
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Regurgitation Valve Disease
Pregnancy is generally well tolerated even in severe valve regurgitation
The decrease in vascular resistance and tachycardia during pregnancy reduces the regurgitation fraction
Medical therapy in patients with heart failure– Nitrate– Dihydropyridine calcium blockers– ACE inhibitors and ARB are contraindicated
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Pregnancy with Heart Valve Prostheses
Problems
– Hypercoagulable state during pregnancy
– Use of oral warfarin is associated with fetal anomalies (nasal hypoplasia, epiphysis stippling, CNS anomalies) » Overall risk is 5%» Dose related; low risk if daily dose < 5 mg
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Regimens of Anticoagulant
Regimen 1-Warfarin sodium through out pregnancy with unfractionated heparin sodium near term
Regimen 2-Substitution or warfarin with unfractionated heparin between 6-12 weeks and near term
Regimen 3-Unfractionated heparin through pregnancy
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Fetal Complications
0
5
10
15
20
25
30
Abortion Anomalies
Regimen 1
Regimen 2
Regimen 3
%
Chan WS. Arch Intern Med 2000;160:191
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Maternal Complications
0
5
10
15
20
25
30
35
Thrombus Death
Regimen 1Regimen 2Regimen 3
%
Chan WS. Arch Intern Med 2000;160:191
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Conclusions
Risk of embryopathy (4-6%) when warfarin is used during 6-12 week of gestation
Subcutaneous heparin does not provide adequate anticoagulation
No advantage in the use of heparin during 6-12 week of gestation to prevent fetal wastage
Heparin in first trimester is associated with high incidence of thromboembolism
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Recommendations Warfarin therapy throughout pregnancy
is the safest therapeutic option for the mother
Patients who choose not to take warfarin should receive unfractionated heparin or low molecular weight heparin (aPTT 2-3 time control, predose anti Xa ~ 0.7)
Warfarin should be replaced by heparin at the 36th week to avoid neonatal intracranial hemorrhage
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Hypertension in Pregnancy
Complicates 6-8 % of all pregnancies Complications
– Cerebral hemorrhage– Hepatic failure– Acute renal failure– Abrutio placenta
Pregnancy outcomes relate with underlying causes of HT
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Pharmacological Treatment Methydopa: first line agent; 750 mg-4 g Betablocker Calcium channel blocker Hydralazine Diuretics:
– Contraindicated in preeclampsia– May reduce uteroplacental flow
ACEI and ARB blocker: renal agenesis
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Cardiovascular Drugs in Pregnancy
Drug Use in pregnancy SafetyDigoxin HF, arrhythmia Safe
Beta-blocker HT,MS, IHD Safe
Nifedipine HT Safe
Hydralazine HT, HF Safe
Nitrate IHD Limited data
Diuretics HF,HT +/-
ACEI HT, HF Unsafe
Amiodarone Arrhythmias Unsafe
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Cardiovascular Evaluation in Pregnancy
History Physical examination Investigations
– ECG– Echocardiography
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Management
Low risk patients– HT stage I without end organ damage– Control of HT before conception– Frequent supervision is essential
High risk patients– Severe HT with end organ damage and
co-morbidity condition– Need frequent assessment
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Hypertensive Disorder
Classification and definition Chronic HT: HT prior or before 20 wks of gestation Preeclampsia-eclampsia: proteinuria with new
HTafter 20 wks of pregnancy Pre-eclampsia superimposed on chronic HT:
increased BP (30/15); change in proteinuria or target organ damage
Gestational HT: new HT after 20 wks of pregnancy without proteinuria
Transient HT: elevated HT during or after pregnancy without sings of preeclampsia