Transcript Cardiac Disease in Pregnancy

Cardiac Disease in
Pregnancy
Dr Jason Reidy
Cardiac Disease in Pregnancy
Why the interest?


Women consistently die form cardiac disease
associated with pregnancy
CEMACH Reports Cardiac Deaths
Congenital heart disease
 Acquired heart disease

Cardiovascular Changes in
Pregnancy
Cardiovascular Changes in
Pregnancy

Pregnancy

SVR


Diastolic BP
Cardiac output
20% by 8/40
 40% by 20-28/40


SV
Circulating volume
 Physiological LVH


HR
Cardiovascular Changes in
Pregnancy

Labour

Cardiac output




1st stage ~15%
2nd stage ~50%
Sympathetic output
Uterine contractions

Autotransfusion
Cardiovascular Changes in
Pregnancy

Immediately Post-partum
 Cardiac
output
 60-80%
 Rapid
decline to pre-labour levels
 ~2h

2 weeks post-partum
 Back
to pre-pregnancy
Cardiovascular Changes in
Pregnancy

Cardiovascular disease can manifest or
worsen in pregnancy due to the
dynamic physiological demands placed
on the cardiovascular system
Maternal Deaths due to
Cardiac Disease
CEMACH 2003-2005
Cardiac Deaths

Commonest indirect and overall cause
 48

deaths
Upward trend in deaths from IHD and
myocardial infarction
CEMACH 2003-2005
Cardiac Deaths
Triennium
Congenital
n(%)
Acquired
n(%)
Acquired
n(%)
Ischaemic
Other
Total
Rate
Per 100,00
Maternities
1985-1987
10 (43)
9 (39)
4 (17)
23
1.01
1988-1990
9 (50)
5 (28)
4 (22)
18
0.76
1991-1993
9 (24)
8 (22)
20 (54)
37
1.60
1994-1996
10 (26)
6 (15)
23 (59)
39
1.77
1997-1999
10 (29)
5 (14)
20 (57)
35
1.65
2000-2002
9 (20)
8 (18)
27 (61)
44
2.20
2003-2005
4 (8)
16 (33)
28 (58)
48
2.27
CEMACH 2003-2005
Cardiac Deaths
Triennium
Congenital
n(%)
Acquired
n(%)
Acquired
n(%)
Ischaemic
Other
Total
Rate
Per 100,00
Maternities
1985-1987
10 (43)
9 (39)
4 (17)
23
1.01
1988-1990
9 (50)
5 (28)
4 (22)
18
0.76
1991-1993
9 (24)
8 (22)
20 (54)
37
1.60
1994-1996
10 (26)
6 (15)
23 (59)
39
1.77
1997-1999
10 (29)
5 (14)
20 (57)
35
1.65
2000-2002
9 (20)
8 (18)
27 (61)
44
2.20
2003-2005
4 (8)
16 (33)
28 (58)
48
2.27
CEMACH 2003-2005
Cardiac Deaths
Triennium
Congenital
n(%)
Acquired
n(%)
Acquired
n(%)
Ischaemic
Other
Total
Rate
Per 100,00
Maternities
1985-1987
10 (43)
9 (39)
4 (17)
23
1.01
1988-1990
9 (50)
5 (28)
4 (22)
18
0.76
1991-1993
9 (24)
8 (22)
20 (54)
37
1.60
1994-1996
10 (26)
6 (15)
23 (59)
39
1.77
1997-1999
10 (29)
5 (14)
20 (57)
35
1.65
2000-2002
9 (20)
8 (18)
27 (61)
44
2.20
2003-2005
4 (8)
16 (33)
28 (58)
48
2.27
CEMACH 2003-2005
Cardiac Deaths
Triennium
Congenital
n(%)
Acquired
n(%)
Acquired
n(%)
Ischaemic
Other
Total
Rate
Per 100,00
Maternities
1985-1987
10 (43)
9 (39)
4 (17)
23
1.01
1988-1990
9 (50)
5 (28)
4 (22)
18
0.76
1991-1993
9 (24)
8 (22)
20 (54)
37
1.60
1994-1996
10 (26)
6 (15)
23 (59)
39
1.77
1997-1999
10 (29)
5 (14)
20 (57)
35
1.65
2000-2002
9 (20)
8 (18)
27 (61)
44
2.20
2003-2005
4 (8)
16 (33)
28 (58)
48
2.27
CEMACH 2003-2005
Cardiac Deaths
Indirect
Late
Aortic dissection
9
0
Myocardial infarction
12
4
Ischaemic heart disease
4
0
Sudden Adult Death Syndrome (SADS)
3
9
Peri-partum cardiomyopathy
0
12
Cardiomyopathy
1
4
Myocarditis or myocardial fibrosis
5
0
Mitral stenosis or valve disease
3
0
Infectious endocarditis
2
2
Right or left ventricular hypertrophy or hypertensive heart
failure
2
1
Pulmonary Hypertension
3
0
Congenital Heart Disease
3
2
47
34
Acquired
Congenital
Totals
CEMACH 2003-2005
Cardiac Deaths
Indirect
Late
9
0
12
4
Ischaemic heart disease
4
0
Sudden Adult Death Syndrome (SADS)
3
9
Peri-partum cardiomyopathy
0
12
Cardiomyopathy
1
4
Myocarditis or myocardial fibrosis
5
0
Mitral stenosis or valve disease
3
0
Infectious endocarditis
2
2
Right or left ventricular hypertrophy or hypertensive heart
failure
2
1
Pulmonary Hypertension
3
0
Congenital Heart Disease
3
2
47
34
Acquired
Aortic dissection
Myocardial infarction
Congenital
Totals
Trends in Cardiac Deaths

Malhotra & Yentis
 IJOA
2006
288 maternal cardiac deaths in 30 year
period from CEMD/CEMACH
 Trends in cardiac deaths with or without
known disease or risk factors

Trends in Cardiac Deaths

Deaths in women with diagnosed
disease
 26%

Deaths in women with documented risk
factors
 22%

De Novo deaths
 52%
Congenital Heart Disease
Congenital Heart Disease

Improved survival with better surgery





Growing population
Good quality of life
Normal fertility
Pregnancy is a challenge for their repaired
CVS
They are not cured!
Estimates of the number of people with congenital heart disease (simple and complex), 2000 and 2010, United Kingdom
Complex congenital heart disease
(Incidence - 1.5/1,000 births)
Simple congenital heart disease
(Incidence - 4.5/1,000 births)
Date of birth
Number of births
in the UK
Number born with
congenital heart disease
First year
survival rate
Survivors at
18 year
12 months survival rate
Survivors at
18 years
1940-1960
16,620,000
24,930
20%
4,986
10%
2,493
1960-1980
17,260,000
25,890
50%
12,945
35%
9,062
11,555 in year 2000
1980-1990
7,550,000
11,325
70%
7,928
50%
5,663
17,218 in year 2010
1940-1960
16,620,000
74,790
90%
67,311
90%
67,311
1960-1980
17,260,000
77,680
90%
69,912
90%
69,912
137,223 in year 2000
1980-1990
7,550,000
33,980
90%
30,582
90%
30,582
167,805 in year 2010
All congenital heart disease
148,778 in the year 2000
185,023 in the year 2010
Congenital Heart Disease

Deaths are decreasing

Unplanned pregnancy
 No
pre-pregnancy counselling
Ischaemic Heart Disease
What do we know?


Upward trends in deaths from IHD and
myocardial infarction
Maternal risk factors
Increasing maternal age
 Obesity

Diabetes
 Pre-existing hypertension

Higher parity
 Smoking
 Family history

Maternal Age
CEMACH

Percentages of maternities by age
<20
20-24
25-29
30-34
35-39
≥40
19971999
7.66
18.04
30.47
29.46
12.26
2.11
20002002
7.58
18.24
26.98
30.04
14.49
2.67
20032005
7.15
18.87
25.25
29.64
15.87
3.22
Maternal Age
CEMACH

Percentages of maternities by age
<20
20-24
25-29
30-34
35-39
≥40
19971999
7.66
18.04
30.47
29.46
12.26
2.11
20002002
7.58
18.24
26.98
30.04
14.49
2.67
20032005
7.15
18.87
25.25
29.64
15.87
3.22
Maternal Age
CEMACH

Death rates per 100,000 maternities by
age
20032005
Age
<20
20-24
25-29
30-34
35-39
≥40
9.9
9.8
12.4
14.5
19.1
29.4
Maternal Age
CEMACH

Death rates per 100,000 maternities by
age
20032005
Age
<20
20-24
25-29
30-34
35-39
≥40
9.9
9.8
12.4
14.5
19.1
29.4
Maternal Obesity
CEMACH

64% of women who died of cardiac
disease were overweight or obese
 31%
had a BMI 25-30
 33% had a BMI >30
 60%
of these >35
 33.3% of these >40
Maternal Obesity
CEMACH
BMI > 25
Direct
Thromboembolism
20(65%)
Pre-eclampsia/Eclampsia
9(50%)
Haemorrhage
7(47%)
AFE
6(43%)
Early Pregnancy
2(33%)
Sepsis
8(73%)
Anaesthetic
2(50%)
Indirect
Total
Cardiac
29(64%)
Other
27(39%)
Psychiatric
6(46%)
Malignancies
3(43%)
119(52%)
Maternal Obesity
CEMACH
BMI > 25
Direct
Thromboembolism
20(65%)
Preeclampsia/Eclampsia
9(50%)
Haemorrhage
7(47%)
AFE
6(43%)
Early Pregnancy
2(33%)
Sepsis
8(73%)
Anaesthetic
2(50%)
Indirect
Total
Cardiac
29(64%)
Other
27(39%)
Psychiatric
6(46%)
Malignancies
3(43%)
119(52%)
Maternal Obesity & Age

Percentage distribution of BMI by age
 Health
Survey for England 2003
Percentage in
each age group
16-24
25-34
35-44
18.5 or under
7.4
1.0
1.0
18.6-25
61.2
51.8
43.5
25.1-30
18.3
28.3
33.3
30.1-40
11.1
15.1
18.6
Over 40
2.0
3.0
3.5
BMI
Maternal Obesity & Age

Percentage distribution of BMI by age
 Health
Survey for England 2003
Percentage in
each age group
16-24
25-34
35-44
18.5 or under
7.4
1.0
1.0
18.6-25
61.2
51.8
43.5
25.1-30
18.3
28.3
33.3
30.1-40
11.1
15.1
18.6
Over 40
2.0
3.0
3.5
BMI
Cardiac Disease in Pregnancy
Who’s Going to Have a Problem?
Who’s going to have a problem?

Risk stratification
 Traditional
assessment for non-cardiac
surgery
 Probably not appropriate
 Extrapolation from a physiologically
different population
Cardiac Disease in Pregnancy
How do we stratify risk in the
pregnant population?
Who’s going to have a
problem?
Siu et al, Circulation 2001
 Prospective study
 562 women with 599 pregnancies in
women with heart disease
 Pregnancy & neonatal outcomes
 Receiving comprehensive prenatal care

Who’s going to have a
problem?

Heart Disease
74% Congenital
 22% Acquired
 4% Arrhythmic


80 Cardiac Events (13%)
Pulmonary oedema
 Arrhythmic
 Stroke
 Cardiac death (3)

Siu et al
Who’s going to have a
problem?
Siu et al

1.
4 Main predictors of adverse maternal
cardiac event
Prior history of



2.
Heart failure
TIA/Stroke
Arrhythmia
NYHA ≥ Class II or Cyanosis
Who’s going to have a
problem?
3.
Left Heart Obstruction



4.
Mitral valve < 2cm2
Aortic valve <1.5cm2
Gradient of >30mmHg
Reduced LV Function

EF<40%
Siu et al
Who’s going to have a
problem?
Siu et al

No RF, then < 5% risk of CVS event

1 RF, then >20% risk of CVS event

2 RF, then >60% risk of CVS event
Who’s going to have a
problem?
Lupton et al, Curr Opin Obst Gyn, 2002
 More geared to congenital lesions


Aimed to stratify risk of mortality
 Low
 Intermediate
 High
Low Risk
Lupton et al

Mortality 0.1-1.0%
 Most
repaired lesions
 Uncomplicated left-to-right shunts
 Regurgitant valve lesions
Intermediate Risk
Lupton et al

Mortality 1-5%
 Metal
valves
 Single ventricles
 Systemic right ventricle
 Switch procedure
 Unrepaired cyanotic lesions
 Stenotic valve lesions
High Risk
Lupton et al

Mortality 5-30%
 NYHA
III or IV
 Severely impaired LV function
 Severe aortic stenosis
 Marfan’s Syndrome with aortic valve lesion
or dilated aortic root
 Pulmonary hypertension
 Mortality
30-50%
Management of Heart Disease in
Pregnancy
Management of Heart Disease in
Pregnancy

Pre-conception
 Counselling
 Start
essential
early
 Discussion
of the effect of pregnancy on
the lesion
 Discussion of risks for cardiac events/death
 Drug regimen optimisation
 CVS optimisation
Management of Heart Disease in
Pregnancy

Antenatally
 Multidisciplinary
approach
 Obstetrics
 Midwifery
 Cardiology/cardiothoracics
 Anaesthesia

Multidisciplinary planning meetings are
helpful in forming plans for delivery
Management of Heart Disease in
Pregnancy

Antenatally
 Regular
review in pregnancy
 Including echocardiography
 Low threshold for admission
 Formal
assessment
 Optimisation
Management of Heart Disease in
Pregnancy

Antenatally
 Major
CVS changes in first 20 weeks
 Cardiac decompensation
 Watch for pre-eclampsia
Management of Heart Disease in
Pregnancy

Antenatal deterioration
 Mother
or foetus
 Optimise mother medically

Consider
 Surgical
intervention
 Termination
 IOL or LSCS
Monitoring
Monitoring
Large CVS changes should be
anticipated perinatally
 Degree of monitoring will depend on
nature and severity of the lesion

Monitoring

Continuous ECG
 Consider

for all
Continuous SpO2
 Consider
for all
 Especially useful where shunting or
pulmonary oedema are a possibility
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Monitoring

Arterial line
 Any
lesions associated with high risk of
mortality
 Severe symptoms/impairment
 Pre-eclampsia
 High risk of haemorrhage
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Monitoring

Central Line

Useful in
Heart failure
 Patients sensitive to hypovolaemia
 Vasoactive substances


Drawbacks
What are you monitoring?
 Technicality of insertion
 Complications

Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Monitoring

Trans-oesophageal Echo/Doppler
?
Role
 Not well tolerated at LSCS
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Mode of Delivery
Mode of Delivery in Cardiac
Disease

Low risk
 Labour

with epidural
High risk
 Elective
caesarean
Expert consensus document on management of cardiovascular diseases during pregnancy
European Heart journal (2003) 24, 761-81
Labour

Epidural analgesia for ALL
 Including
 Low

fixed output states
dose
Except
 Therapeutic
anticoagulation
 Clopidogrel ± Aspirin

Minimal pushing in 2nd stage!
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
LSCS

GA or Regional?
 Either
done carefully is acceptable
 Multifactorial
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
LSCS

Influences
Arrhthymias
 SVR
 Pulmonary hypertension
 Anticoagulants/antiplatelets
 Need for post-op ITU
 Mortality & maternal attitude
 Associated airway anomalies
 Anaesthetist’s preference

Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems
Peri-partum Problems

Haemorrhage
 Some
lesions tolerate blood loss poorly
 Aortic
stenosis
 Fontan circulation
 risk
due to anticoagulation
 risk due to lack of uterotonics
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems
Uterotonics

Oxytocin
 Tachycardia/hypotension
 SVR,
CO
 Ischaemic changes

Bolus Vs. infusion
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems
Uterotonics

Ergometrine
 Hypertension
 Pulmonary
vasoconstriction
 Pulmonary hypertension

Safe i.m in less severe lesions in the
absence of hypertension
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems
Uterotonics

Carboprost
 Hypertension
 CVS
collapse
 Pulmonary oedema

Largely unsuitable in cardiac disease
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems
Uterotonics

Misoprostol
 Increasingly
used
 Not evidence in cardiac disease
 Good side effect profile
 Uterotonic efficacy
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems

Pulmonary Oedema
 Cardiac
 Obstetric
 Iatrogenic

Careful fluid balance in labour or at
LSCS
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems

Arrhythmias
Cardiac filling
  Cardiac output
  Coronary perfusion


Avoid precipitants
Oxytocin
 Ephedrine

Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems

Acute Pulmonary Hypertension
 Severe/catastrophic
 Even

in mild disease
Pulmonary hypertensive changes may
be accelerated
Adapted from Dob & Yentis, IJOA, 2006: 15(137-144)
Peri-partum Problems

Chest Pain
Aortic dissection
 Acute surgical emergency
 Bypass has 20% foetal mortality


Coronary ischaemia/myocardial infarction
Atheromatous changes
 Coronary artery dissection

Peri-partum Problems

Management of AMI





Occur mostly peri-partum
Coronary dissection > atheroma
Thrombolysis contra-indicated in dissection
Important to exclude PPCM if heart failure present
Rx of choice

Immediate angiography




+/- coronary stenting
Normal coronaries in up to 47%
Beyond 2nd trimester safe for foetus
Thrombolysis is not contra-indicated in pregnancy
Expert consensus document on management of cardiovascular diseases during pregnancy
European Heart journal (2003) 24, 761-81
Peri-partum Problems

Management of AMI




Ongoing management to be directed jointly by cardiology and
obstetrics
Nitrates, aspirin, b-blockers, clopidogrel safe
ACE-I and statins not safe
Mortality


Estimated 37%
But up to 50% if delivery within 2 weeks of AMI
Expert consensus document on management of cardiovascular diseases during pregnancy
European Heart journal (2003) 24, 761-81
Post-Partum
Post-Partum
Fluid balance
 Post-partum pre-eclampsia
 Good analgesia
 Thromboprophylaxis
 Close monitoring should continue

 How
long?
Summary

Cardiac deaths increasing
 Congenital
 Ischaemia

Maternal risk factors
 Age
 Obesity
Summary

What’s important
 Close
supervision
 High index of suspicion
 Especially
 More
for ischaemia
attention to risk factors
Summary

Management principles
 Understand
the physiology of the lesion
 Appropriate monitoring
 Cardiovascular stability
 Good
epidural analgesia in labour
 Careful anaesthesia for LSCS
 Awareness
that delivery is not the end of
the problem
Thank you