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Cardiac Disease and PregnancyCardiac Disease and Pregnancy
Catherine Nelson-Piercy
Guy’s & St Thomas’ Hospitals
& Queen Charlotte’s Hospital
London, UK
Physiological changes in pregnancy
• Cardiac Output (CO) increases by 40%
• Further increases peripartum
• Stroke Volume and Heart Rate increase
• Peripheral vasodilation and decrease SVR
• PCWP and CVP unaltered
• Colloid osmotic pressure reduced
• Supine position = 25% fall in CO
Early peak in HR (17%) SV (17%) CO (45%)
Plasma volume (40-50%)
Heart rate
Cardiac output &
Stroke volume
Non pregnant Post delivery weeks gestation
4 8 12 16 20 24 28 32 36 40
Physiological Changes in Pregnancy
Slide courtesy of Sara Thorne
Saving Mothers’ Lives 2006-2008, National launch - March 2011
Leading causes of maternal deaths
2006-08, UK
0.00
0.50
1.00
1.50
2.00
2.50
Ca
rdia
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ise
ase
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ca
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ct
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al
co
nd
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ns*
Se
psis
Pre
-ecla
mp
sia
and
ecla
mp
sia
Th
rom
bosis
and
thro
mb
oe
mb
olis
m
Am
nio
tic flu
id
em
bolis
m
Psych
iatr
ic c
ause
s
Ea
rly p
reg
nan
cy
dea
ths
Ha
em
orr
hag
e
An
ae
sth
esia
Oth
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*
Indire
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an
cie
s
Ra
te p
er
100
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ate
rnit
ies DIRECT
INDIRECT
Saving Mothers’ Lives 2006-2008, National launch - March 2011
Cardiac Deaths Rates per million maternities
0
0.5
1
1.5
2
2.5
1985
-87
1988
-90
1991
-93
1994
-96
1997
-99
2000
-02
2003
-05
2006
-08
Saving Mothers’ Lives 2006-2008, National launch - March 2011
Cardiac deaths; UK 2000-2008
Type and cause of death 2000-02 2003-05 2006-08 Acquired
Aortic dissection 7 9 7
Myocardial infarction (MI) 8 12 6
Ischaemic heart disease (No MI) 0 4 5
Sudden Adult Death Syndrome (SADS) 4 3 10
Peripartum cardiomyopathy 4 0* 9**
Other Cardiomyopathy 4 1 4
Myocarditis or myocardial fibrosis 3 5 4
Mitral stenosis or valve disease 3 3 0
Thrombosed aortic or tricuspid valve 0 0 2
Infective endocarditis 1 2 2
Right or Left ventricular hypertrophy or
hypertensive heart disease 2 2 1
Congenital
Pulmonary hypertension (PHT) 4 3 2
Congenital heart disease (not PHT or
thrombosed aortic valve) 2 3 1
Other 2 0 0
Total 44 48*** 53
*12 Late cases reported in 2003-05
**2 late cases reported in 2006-08
***includes one women for whom little information on cause was available
Saving Mothers’ Lives 2006-2008, National launch - March 2011
MI / Ischaemic heart disease
(2003-8)
2003-2005 2006-2008 Total UKOSS*
MI 12 6 18 23 (14 angio)
Atheroma 8 3 11 (61%) 7 (50%)
Dissection 1 1 2 (11%) 3 (21%)
Embolus/thrombosis 1 1 2
Normal Coronaries 2
Undetermined 2 2 4
IHD without MI 4 5 9
Total IHD 12 8 20
Total MI / IHD 16 11** 27
*antenatal MI, 2005-2010
** 9 died postnatally
Risk factors for IHD
2003-5
• Aged 27-40 (av 35 years)
– 6 35 yrs old
• 11 parous
• 6 obese, (4 BMI > 40)
• 7 smoked
• 2 hypertension
• 1 FH +ve
• 2 type 2 diabetes
• 3 asian
2006-8
• Aged 28 to 46 (av 36 years)
– 8/11 ≥ 35 yrs old (5 ≥ 40)
• All were parous, (7 ≥ para 4)
• 3 were obese
• 6 smoked
• 4 hypertension
• 2 FH +ve
• 1 GDM
• 1 hypercholesterolaemia
• 1 sickle cell disease
Deaths in women in UK from Acute Myocardial
Infarction
0
10
20
30
40
50
60
70
15 -19 20 - 24 25 - 29 30 -34 35 - 39 40 - 44
AGE in years
2003
2004
2005
Age
15-24 25-34 35-44
2000-
02 0.11 0.44 2.43
2003-
05 0.05 0.38 1.98
Death rates per 100,000 population from myocardial
infarction among women of childbearing age, UK,
2000-05
ONS, General Register Office Scotland, General
Register Office, Northern Ireland
percentage of maternities in the Upercentage of maternities in the UKK
35-39 40
1997-
1999 12.3 2.1
2003-
2005 15.9 3.2
IHD in pregnancy: messages
• High index of suspicion in those with risk factors
• May not present with typical angina
– Myocardial infarction and acute coronary syndrome can present with atypical features in pregnancy such as abdominal or epigastric pain and vomiting or dizziness.
• ECG and troponin unchanged by pregnancy
– single normal ECG does not exclude ischaemia, especially if performed when the woman is pain-free.
• Get them to the catheter lab quickly
• Thrombolysis safe
• Use bare metal stents
• Aspirin and Clopidogrel are safe
Heart Failure Association of the European Society of
cardiology Working Group on PPCM 2010
PPCM is an idiopathic cardiomyopathy presenting
with heart failure secondary to LV systolic
dysfunction toward the end of pregnancy or in the
months following delivery, where no other cause of
heart failure is found. It is a diagnosis of exclusion.
The left ventricle may not be dilated but the ejection
fraction is nearly always reduced below 45%.
Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Eur J Heart Fail 2010;12:767-78.
Peripartum CardiomyopathyPeripartum Cardiomyopathy
Risk factors
Multiple pregnancy
Pregnancy complicated by hypertension (pre-existing or pre-eclampsia)
Multiparity
Advanced maternal age
Afro-Carribean race
Diagnosis
Echocardiography. Diagnostic criteria
• Left ventricular ejection fraction < 45% (LVEF at presentation 26-31%)
• Heart enlarged with global dilation of all four chambers and markedly reduced left ventricular function
The STAT3–oxidative stress–cathepsin D–16 kDa cascade.
Yamac H et al. Heart 2010;96:1352-1357
©2010 by BMJ Publishing Group Ltd and British Cardiovascular Society
Management
• Elective delivery if antenatal.
• Thromboprophylaxis.
• Conventional treatment for heart failure
– diuretics, vasodilators (hydrallazine and/or nitrates), digoxin, inotropes
– Selective beta blockers (bisoprolol), carvedilol (vasodilator)
– ACE inhibitors (after delivery)
• Inotropes
• Intraaortic balloon pump
• Left ventricular assist device
• Cardiac transplantation.
Mortality
• Recent series from South Africa, US quote
mortality rates of 11-13%
• US data – 0- 19%
• Predictors of death / poor outcome
– Increased age, African, multiparous
– Reduced LVEF at presentation (<30%)
– increased LV size
– NYHA class
– Postpartum presentation
Blauwet L & Sliwa K. Obstetric Medicine 2011.
Cardiac Events predicted by:
• Prior cardiac event or arrhythmia
• NYHA classification > II or cyanosis
• LV Ejection fraction < 40%
• Left heart obstruction
– Mitral valve area < 2 cm2
– Aortic valve area < 1.5 cm2
– Aortic valve gradient > 30mmHg
Siu et al Circulation 2001;104:515
Predictors of cardiac events in pregnancy:
Toronto study
Predictors of cardiac events in pregnancy:
Toronto study
Score 1 for each risk factor
Score 0: Event risk 5%
Score 1: Event risk 27%
Score>1: Event risk 75%
Drug treatment and method of delivery
were not independent risk factors
Siu et al Circulation 2001;104:515
Congenital Heart
Disease
Modified WHO classification
gives best risk estimation
model for cardiac risk in
pregnancy
Page 22
Balci A, Sollie-Szarynska KM, van der
Bijl AGL, et al.
Heart 2014;100:1373–1381.
Advise against pregnancy
Pulmonary arterial hypertension
Systemic ventricular dysfunction
LVEF < 30%,
NYHA III/IV
Previous PPCM with any residual LV impairment
Severe mitral stenosis
Severe symptomatic aortic stenosis
Aorta > 45mm Marfan
Aorta > 50 mm bicuspid
Severe coarctation
Pulmonary hypertensionPulmonary hypertension
• Non-pregnant mean PAP > 25 mmHg rest, > 30 on exercise or PVR > 200dy/sec/cm or >2.5 Woods Units (nb. catheter not echo)
• Danger relates to fixed increased pulmonary vascular resistance
• Inability to increase pulmonary blood flow with refractory hypoxaemia
• Most deaths can be attributed to
– thromboembolism
– hypovolaemia
– pre-eclampsia.
Pulmonary Hypertension
Bedard, Dimopoulus, Gatzoulis Eur HJ 2009; 30:256
• Systematic review 1997-2007
• 73 pregnancies
• Idiopathic PAH (72% on advanced therapies)
• Congenital heart disease associated PAH (52%)
• Other PAH (47%)
• Overall mortality reduced
– 1978-1996 = 38% (Yentis et al. BJOG 1998; 105: 921-922)
– 1997-2007 = 25% Idiopathic PAH 17%
CHD PAH 28%
Other PAH 33%
• Phosphodiesterase inhibitors (sildenafil)
• Endothelin-receptor antagonists (bosentan)
• Inhaled nitric oxide
• Prostacyclin analogues
PAH targeted therapies
Page 26
• Current Literature (limited to case series)
• Reported mortalities 77--17%17%
• Risk probably does relate to degree and
vasoresponsiveness
• Individualized pre pregnancy counselling
is essential
• Thorough assessment in PH centre
Is Pulmonary Hypertension still a contraindication to
pregnancy?
Yes in most cases Yes in most cases
CONTRACEPTION
Aortic Dissection
• More common in pregnancy – 7-9 deaths every 3 yrs
• Risk factors Marfan’s / Ehlers Danlos syndrome (type IV) / Turner’s / bicuspid AoV / Coarctation
• Most are type A (ascending aorta)
• Most present late pregnancy/within a week post partum
• Chest pain often attributed to pulmonary embolism
– Severe and interscapular
• Associated hypertension
– Systolic hypertension ignored
Mitral stenosis
• Asymptomatic
• Sinus Rhythm
• No therapy
• MVA = 0.9cm2
Learning points – mitral stenosis
1. Severe mitral stenosis that is asymptomatic prior to and in
early pregnancy may decompensate later in pregnancy and is
potentially fatal
2. The fact that mitral stenosis is asymptomatic does not mean
that it is mild and that pregnancy will be tolerated
3. Pulmonary oedema may present with wheezing
4. Rheumatic valve disease should always be considered in
pregnant women from developing countries
5. Patients with mitral valve disease should be evaluated pre-
pregnancy when possible
Which Anticoagulant Regimes for
Mechanical Valves?
Which Anticoagulant Regimes for
Mechanical Valves?
• Warfarin throughout
• Heparin until 12/40,
Warfarin until 36/40
Heparin
• Heparin + aspirin throughout Large aortic
Bileaflet
Small mitral
Bjork Shiley
<5mg warfarin
LMWH vs Warfarin
• Aortic valve
• Newer valve
– Carbomedics
• Sinus rhythm
• Warfarin dose > 5mg
• Likely compliance with 2 injections / day
• Give adjunctive aspirin
• Mitral valve
• Older (smaller) valve
– Bjork shiley
• AF/ large LA
• Warfarin dose < 5mg
• > 1 mechanical valve
• Previous CVA / embolus
So… what are the anticoagulation options in pregnant
women with mechanical valves?
Any strategy carries risks
Women should participate in the choice of anticoagulation
Women should be fully informed of risks and benefits of all options
Decision should be individualized and ideally made pre pregnancy
Care should be multidisciplinary
Cyanotic congenital heart disease
• Main risks = fetal
• < 20% chance of live birth if oxygen saturation < 80-85%
• Increased risk of
– Miscarriage
– FGR
• Maternal thromboembolism
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