Women’s Health: Cardiovascular Issues in Pregnancy Pregnancy & Heart Disease Final.pdf1. Left...
Transcript of Women’s Health: Cardiovascular Issues in Pregnancy Pregnancy & Heart Disease Final.pdf1. Left...
Women’s Health: Cardiovascular Issues in PregnancyS O N I A T O L A N I , M D
C O L U M B I A U N I V E R S I T Y I R V I N G M E D I C A L C E N T E R
D I V I S I O N O F C A R D I O L O G Y
C 0 - D I R E C T O R O F T H E W O M E N ’ S H E A R T C E N T E R
Objectives1. Understand the cardiovascular physiology of
pregnancy
2. Learn management of common aortopathy & valvular disease
3. Learn management of common arrhythmia
4. Review of peripartum cardiomyopathy
5. Learn how to manage hypertensive disorders of pregnancy
6. Know when to refer pregnant patients to high risk center
Pregnancy CVD Physiology
Increased cardiac output• Sharpest rise in 1st trimester
• Up to 45% increase higher with multiples
• Early increase due to increase SV
• Late increase due to increase HR by 10-20 bpm (20-25% increase)
• Increased blood volume• Activation of Renin-Angiotensin-Aldosterone
• Maintains BP and helps retain salt and water
Monika Sanghavi. Circulation. Cardiovascular Physiology of Pregnancy, Volume: 130, Issue: 12, Pages: 1003-
1008, DOI: (10.1161/CIRCULATIONAHA.114.009029)
Reduced SVR & BP• 35-40% decrease in SVR
• BP lowest in 2nd trimester by up to 5-10 mmHg
• BP increased back to normal postpartum
• Hormonal changes: • Increased estrogen and progesterone
• Relaxin→released after conception works on small arteries
• Increased nitric oxide
Mahendru et al. J Hypertens. 2014
Normal Changes in CV Functionduring Pregnancy
Pre-
pregnancy
1st
Trimester
2nd
Trimester
3rd
Trimester
~16 weeks
Postpartum
SBP (mmHg) 108 ± 9 104 ± 7 103 ± 7 105 ± 8 104 ± 8
DBP (mmHg) 71 ± 7 65 ± 6 63 ± 5 68 ± 6 69 ± 6
HR (bpm) 68 ± 10 71 ± 10 76 ± 5 80 ± 10 68 ± 8
CO (L/min) 5.6 ± 1.0 5.8 ± 1.2 6.2 ± 1.0 6.1 ± 1.0 5.6 ± 1.0
Valve Disease
Preconception Assessment•Preconception counseling by a cardiologist who has expertise in pregnancy and valve disease
• Echocardiogram
• 12-lead ECG
• Detailed history with review of high risk medications: ACEI, blood thinners
• Exercise testing: Stress or cardiopulmonary ET
•Preconception counseling by a maternal fetal medicine (MFM) OB
•Team based approach to assess overall risk and develop appropriate plan for management though pregnancy & delivery
Risk Stratify
CARPREG Score (1 point each)
1. Left heart obstruction (mitral stenosis, aortic stenosis, LVOT obstruction)
2. History of prior CVD event (CHF, TIA/CVA, arrhythmia)
3. NYHA Class 3 or 4 or cyanosis
4. Ejection fraction <40 %
Prospective Multicenter Study of Pregnancy Outcomes in Women with Heart Disease. Circulation Jul 31, 2001. CARPREG investigators.
Risk Stratification
Prognosis (total 599)
1. Score 0= 5% events
2. Score=1 27% events
3. Score >1= 62% events
Prospective Multicenter Study of Pregnancy Outcomes in Women with Heart Disease. Circulation Jul 31, 2001. CARPREG investigators.
Pregnant patients with heart disease
13% total events: pulmonary edema, arrythmia, stroke, cardiac death
Aortic stenosis•Etiology: Bicuspid aortic valve
•Mild and moderate AS tolerate pregnancy ok
•Severe AS:• Fixed outflow obstruction: can’t tolerate
increase in CO and stroke volume• CHF/pulmonary edema• Ventricular arrythmias• High rate of obstetric and fetal/neonatal
complications
•Symptomatic AS→Preconception balloon valvotomy if possible or tissue valve
•Diuretics
Mitral stenosis•Etiology: Rheumatic heart disease
•Mild MS probably ok
•Moderate or severe MS:• Tachycardia and increased CO→increased
LA pressure
• Pulmonary edema
• Atrial arrythmia
•Mitral Stenosis: balloon valvotomy if no concomitant MR
•Beta blockers and diuretics
Aortic regurgitation•Etiology: Bicuspid aortic valve
•Mild to moderate AI will do ok
•Severe AI with preserved EF and normal sized LV probably ok
•Symptomatic severe AI, reduced EF, or pulmonary HTN at high risk for CHF• tissue valve replacement prior to pregnancy
•Important to assess for aortopathy:• Marfan syndrome
• Ehlers Danlos
• Loeys-Dietz
Mitral regurgitation•Etiology: MVP, congenital disease, rheumatic heart disease
•Mild to moderate and asymptomatic severe MR ok
•Severe MR with reduced EF or elevated pulmonary pressures at risk
•MV repair or tissue MVR for high risk MR patients prior to conception
•Diuretics
Delivery plansStenotic lesions:◦ Minimize Valsalva◦ Induced labor with assisted second phase of labor◦ Consider CSX especially for aortopathy and aorta >4.5cm
or pulmonary HTN
Regurgitant lesions: ◦ Careful monitoring of volume status◦ Vaginal delivery generally ok unless there is pulmonary
hypertension
Arrythmias
Common arrythmias10% of palpitations in pregnancy will be an arrythmia
•PVCs
•Idiopathic VT
•PACs
•SVT→AVRT and AVNRT
•AF (less common)
Initial evaluation1. Ensure there is no underlying structural disease
with echocardiogram
2. Check for any underlying drivers such as elevated thyroid, anemia or dehydration
3. Monitoring for highly symptomatic patients
Management•Generally just monitor in absence of high risk features
•Identify high risk features:• Syncope or presyncope
• Long periods of arrythmia
• Structural heart disease→decreased EF
• Concerning family history
•Metoprolol first line for most arrythmias of pregnancy
•Digoxin can be used in AF
Metoprolol in pregnancy•Can decrease fetus weight if used for prolonged period in second and third trimester→atenolol is more implicated
•Can decreased fetal heart rate
•Can further lower blood pressure
Peripartum Cardiomyopathy
Peripartum Cardiomyopathy•Decreased LV function <45% in at end of pregnancy or within 5 months of delivery
•Incidence varies widely by geography→~1:1000 to 1:4000 in US
•Etiology: Unclear→oxidative stress, prolactin, impaired VGEF signaling, genetics, inflammatory response
Risk factors:◦ Age >30
◦ African American
◦ Multiple fetuses
◦ Hypertensive disorders of pregnancy/PEC in the past
◦ Cocaine use
Diagnosis•Recognizing symptoms: Shortness of breath, cough, edema
•TTE: Globally reduced EF, dilated LV
•Exclude other causes of heart failure:• Pre-existing cardiomyopathy: Idiopathic, HIV• Valvular disease• MI→abnormal ECG, wall motion abnormality• Pulmonary embolism• Thyroid disease, alcoholism
Management•Heart failure specialist
•Monitored setting:• Ventricular arrythmias
• Atrial fibrillation
•Standard Heart failure regimen:• BB: Metoprolol
• ACEI: Enalapril→ok to breastfeed
• Diuretics as needed
• O2
•Bromocriptine: Prolactin blocker so cannot breast feed→variablerecommendations
Prognosis•42/100 some recovery
• 23 complete
• 19 partial
•Better prognosis with better baseline EF
JACC. Volume 63, Issue 25, Part A, 1 July 2014.
Hypertensive disorders of pregnancySLIDES COURTESY OF DR. NATALIE BELLO
Peterson et al. MMWR. 2019
DuringPregnancy
Day ofDelivery
1-6 7-42 43-365
Number of days Postpartum
Hypertension
CV
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CV
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Stroke
CV
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CM
Maternal Morbidity by Etiology & Time Relative to Delivery
Maternal mortality high in US
•Office Blood Pressure (measure at every prenatal visit)
•Hypertension:
• Systolic ≥140 mm Hg and/or Diastolic ≥90 mm Hg
•Severe Hypertension:
• Systolic ≥160 mm Hg and/or Diastolic ≥110 mm Hg
Diagnostic cut-offs for elevated out of office blood pressure on ambulatory
or home monitoring have not been established for pregnant women*
Diagnosis of HTN in pregnancy
Bello NA et al. Hypertension 2018
BP Lab
Spacelabs 90207
Welch Allyn QuietTrak
A&D UM-101
Dinamap ProCare 400
Microlife 3AS1-2
Nissei DS-400
Omron HEM-907
Omron MIT
Omron MIT Elite
Terumo ES-H51
Welch Allyn Vital Signs
Microlife 3BTO-A
Microlife WatchBP Home
Omron HEM 705 CP
Omron M7
Omron MIT
Omron MIT Elite
Omron T9P
Ambulatory Office or HomeOffice Home
How to Monitor BP
SBP ≥ 140 mm Hg
and/or
DBP ≥ 90 mm Hg
< 20 weeks gestation
or
Persistent >6 weeks postpartum
Chronic Hypertension
≥ 20 weeks gestation
Gestational Hypertension
(no target organ involvement)
Preeclampsia/Eclampsia
(target organ involvement)
~25%
>40%
ACOG Practice Bulletin Nos. 202 and 203. Jan 2019; USPSTF. October 2014
Classifying HTN in Pregnancy
ASA 81mg daily after 12week for those at risk for developing PEC
PEC Risk Factors
ACOG Committee Opinion 743
Blood pressure • SBP 140 mm Hg and/or DBP 90 mm Hg on two occasions at least 4 hours apart after 20 weeks of
gestation in a woman with a previously normal blood pressure
• SBP 160 mm Hg and/or DBP 100 (confirmed over 15 min)
AND
Proteinuria• 300 mg per 24 hour urine collection
• Protein/creatinine ratio 0.3 mg/dL
• Dipstick reading of 2+ (if quantitative methods are not available)
OR
Thrombocytopenia (<100k)
• Renal insufficiency (Cr >1.1 mg/dL or 2x Cr in the absence of other renal disease)
• Impaired liver function (transaminases >2x ULN)
• Pulmonary edema
• New-onset headache or visual symptoms
ACOG Practice Bulletin No. 202. Jan 2019
Severe Features
Diagnosis of Preeclampsia
Whelton PK, et al 2017 High Blood Pressure Clinical Practice Guideline
Management of CHTN
Chronic HTN Gestational HTN Preeclampsia
ACOG* (2013/2015/2019)
*2017 ACC/AHA Guideline
refers to this document
StartSBP ≥ 160 mm Hg
DBP ≥ 110 mm Hg
SBP ≥ 160 mm Hg
DBP ≥ 110 mm Hg
GoalSBP 120-160 mm Hg
DBP 80-110 mm Hg
ESC/ESH (2018)Start
Gestational HTN, chronic HTN superimposed by gestational HTN, HTN
with target organ damage or symptoms: SBP > 140 mm Hg or DBP >90
mm Hg
All others: SBP ≥ 150 mm Hg or DBP ≥ 95 mm Hg
Goal
HTN Canada (2018)Start SBP ≥ 140 mm Hg OR DBP ≥ 90 mm Hg
Goal DBP 85 mm Hg
NICE (2010)
Start SBP ≥ 150 mm Hg OR DBP ≥ 100 mm Hg
Goal
SBP <150 mm Hg
DBP 80-100 mm Hg
If target organ damage:
SBP <140 mm Hg
DBP 80-90 mm Hg
SBP <150 mm Hg
DBP 80-100 mm Hg
Pregnancy HTN Goals
First Line
•Labetalol 100-200mg BID, increase Q2-3d; max 2400 mg/24h
•Nifedipine ER 30-60mg QD, increase Q7-14d; max 120 mg/24h
•Methyldopa 250 mg BID-TID, increase Q2d; max 3000 mg/24h
Second Line
•Hydralazine* 10mg QID, increase Q2-5d; max 200 mg/24h
•Thiazide diuretics
CONTRAINDICATED: ACEI/ARB, Renin Inhibitors, mineralocorticoid receptor antagonists
*Hydralazine should not be used in isolation due to reflex tachycardia
ACOG Practice Bulletin Nos. 202 and 203. Obstet Gynecol, 2019
Medical management
ACOG Practice Bulletin Nos. 202 and 203. Obstet Gynecol, 2019
Avoid Nifedipine with MgSO4 (synergistic hypotension)
Emergent BP Control•Labetalol: 10-20 mg IV, then 20-80mg IV Q 20-30 min to max 300mg or
1-2 mg/min IV gtt
•Nifedipine: 10-20mg PO repeat x1 in 30 min, then 10-20mg Q2-6h
•Hydralazine: 5 mg IV or IM, then 5-10 mg IV Q 20-40min or 0.5-10
mg/h IV gtt
Nitro gtt: can be used for pulmonary edema
Magnesium Sulfate: to prevent eclampsia and treat seizures in
women with severe preeclampsia or eclampsia
Medication Class Preferred Agents
Calcium Channel
Blockers
Nifedipine, Verapamil, Diltiazem
B-blockers Labetalol, Metoprolol, and Propranolol are preferred,
Atenolol may be used but concentrates in breast milk
ACE-I Captopril, Enalapril, Quinipril
Diuretics Safe, can decrease mild production
Methyldopa Caution! May exacerbate postpartum depression
ARBs Insufficient data to recommend their use during breast
feeding
Newton et al. Clin Obstet Gynecol. 2015
Safety for Breastfeeding
•Headache or visual changes in association with hypertension raise suspicion for postpartum preeclampsia
•Pregnancy related hypertension should resolve within 6 weeks.
•Women with gestational HTN and preeclampsia have:
• >2x higher rates of developing chronic HTN in 1-5 years
• 2-3 x increased risk of CVD in their lifetime
Black et al. J Hypertens. 2016; Stuart et al. Ann Int Med. 2018
The Fourth Trimester
2017
ACOG Committee Opinion No. 736, May 2018
Post-partum Care
Columbia’s Mothers Center
Outpatient: 844-MOM-CNTR (844-666-2687).
Inpatient: 800-NYP-STAT
Take Home Points1. Preconception counseling with cardiology and MFM is key for any
preexisting heart disease
2. Severe stenotic or regurgitant valve lesions should be addressed prior to pregnancy
3. Arrythmias of pregnancy in STRUCTURALLY NORMAL hearts is usually benign and does not need treatment
4. Peripartum cardiomyopathy should be on the differential when there is SOB or edema after 36 weeks or in the early post partum period
5. Hypertensive disorders of pregnancy are common and dangerous if not addressed
6. Refer patients with heart disease to specialized centers