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C O N F I D E N T I A L
Maternal Congenital Heart Disease in
PregnancyMartha Monson, MDMaternal Fetal Medicine Fellow
April 20, 2018
Project ECHO Pregnancy Care
C O N F I D E N T I A L
C O N F I D E N T I A L
OBJECTIVES
• MULTIDISCIPLINARY CARE • Maternal cardiac risk stratification • Fetal risk associated with maternal CHD• Antepartum and delivery management
considerations in the CHD patient• Resources
C O N F I D E N T I A L
ADDITIONAL REFERENCES
https://physicians.utah.edu/echo/pdfs/pregnancy-care-didactics/2017-08-25-Cardiac-Disease-in-Pregnancy.pdf
Please refer to Dr. Sullivan’sProject Echo Pregnancy Care Lecture for more information on:
• Hemodynamic changes in pregnancy
• Pathophysiology of specific cardiac lesions
C O N F I D E N T I A L
MATERNAL CARDIAC RISK PREDICTION
• MULTIDISCIPLINARY APPROACH• Step 1 Cardiology Assessment
– Adult Congenital Heart Disease– Cardiologists with expertise in pregnancy
and maternal congenital heart disease• Step 2 Maternal Fetal Medicine (MFM)
Assessment• Step 3 NICU Consultation (if applicable)• Step 4 Anesthesia Consultation for
complex CHD
C O N F I D E N T I A L
MATERNAL CARDIAC RISK PREDICTION
Cardiology AssessmentAdult Congenital Heart Disease Program
• Ideally BEFORE conception or as early as possible in the antepartum period
• Medical/surgical optimization
• +/- ongoing assessment throughout pregnancy (depends on patient risk)
• Continued care postpartum (Ideally Life-long!)
C O N F I D E N T I A L
ACHD EVALUATIONClinic Visit
• Detailed information on type of cardiac lesion, cardiac history
• Symptoms and physical examWork Up:
• EKG or Ziopatch• Transthoracic Echocardiogram• Exercise stress test• Additional imaging if necessary (e.g. Cardiac MRI)
Recommendations• Medication or Intervention• Referral for Genetic Counseling • Plan for ACHD follow up during and after
pregnancy• Intrapartum and postpartum care• Contraception Counseling
C O N F I D E N T I A L
MATERNAL CARDIAC RISK PREDICTION
• CARPREG• Canadian Multi-Center Prospective Study
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104: 515-521.
• Zahara• Multi-Center Retrospective Study
(Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31: 2124.)
• WHO Classification • ESC 2011 Guidelines (Consensus – Regitz-Zagrosek, EHJ 2011)
(Eur Heart J. 2011 Dec;32(24):3147-97.)
C O N F I D E N T I A L
MATERNAL CARDIAC RISK PREDICTION
• CARPREG• Canadian Multi-Center Prospective Study (Siu, Circ
2001)
• Zahara• Multi-Center Retrospective Study (Drenthen, Eur
Heart J 2010)
• WHO Classification • ESC 2011 Guidelines (Consensus – Regitz-Zagrosek,
EHJ 2011)
Risk for Maternal Cardiac Event in PregnancyPulmonary Edema
ArrhythmiaStroke Death
C O N F I D E N T I A L
CARPREG
• Prior cardiac event or arrhythmia• NYHA Class 3 or 4 (or cyanosis)• Systemic Ventricular Systolic Dysfunction
(EF <40%)• Left Heart Obstruction
– Aortic Valve Area <1.5cm2
– Peak LVOT gradient >30 mmHg– Mitral Valve Area <2.0cm2
C O N F I D E N T I A L
ZAHARA
• History of arrhythmia• Symptomatic Heart failure before pregnancy
NYHA ≥ 2• Severe left heart obstruction
• Mean pressure gradient >50mmHg or AV area <1cm2
• History of cardiac medication before pregnancy
• Mod to Severe pulmonary or systemic AV valve regurgitation
• Mechanical Heart Valve
C O N F I D E N T I A L
WHO CLASSIFICATION
4 Risk Categories Class I
Cardiology f/u 1-2x in pregnancy
(Eur Heart J. 2011 Dec;32(24):3147-97.)
C O N F I D E N T I A L
WHO CLASSIFICATION
Class II or II-III
Cardiology f/u every trimester
(Eur Heart J. 2011 Dec;32(24):3147-97.)
C O N F I D E N T I A L
WHO CLASSIFICATION
Class III
Cardiology f/u q4-8 weeks
(Eur Heart J. 2011 Dec;32(24):3147-97.)
C O N F I D E N T I A L
WHO CLASSIFICATION
Class IV
(Eur Heart J. 2011 Dec;32(24):3147-97.)
Pregnancy Contraindicated
Termination should be considered
Cardiology follow up q4-8 weeks in continuing pregnancies
C O N F I D E N T I A L
PREDICTING MATERNAL CARDIAC COMPLICATIONSAPPLICATION OF CARPREG SCORING SYSTEM
• NYHA >II• Obstructive Left Heart
• MV <2cm; AV <1.5cm; Peak Gradient >30mmHg
• Prior cardiac event (before pregnancy)• Heart Failure, Arrhythmia, TIA or Stroke
• Ejection Fraction <40%
# of Predictors0 = 5% % Risk of Cardiac Event 1 = 27% During Pregnancy
>1 = 75% (Eur Heart J. 2011 Dec;32(24):3147-97.)
Pulmonary edema, arrhythmia, stroke, TIA
C O N F I D E N T I A L
PREDICTING MATERNAL CARDIAC COMPLICATIONS
Complicated process!Takes into account:
– Maternal cardiac lesion (risk index score)– Prior obstetric and medical history– Multidisciplinary approach with Adult
Congenital Heart Disease, Anesthesia and Maternal Fetal Medicine Consultation in pregnancy
• Low Cardiac Risk ≠ No Cardiac Risk
C O N F I D E N T I A L
FETAL RISK
Increased risk of:• Spontaneous abortion• Intrauterine growth restriction• Stillbirth• Fetal heart disease (5-10%)
– Advocate for formal fetal echocardiography at 22-24 weeks’ gestation
C O N F I D E N T I A L
FETAL RISK
MFM Recommendations• OB Ultrasound• Antenatal testing• Referral for fetal echocardiogram• Referral for genetic counseling• Referral for NICU consultation• Pregnancy specific medications • Delivery timing, mode & location (in
conjunction with ACHD, Anesthesia)
C O N F I D E N T I A L
INTRAPARTUM & POSTPARTUM MANAGEMENT
All complex CHD patients should have a delivery plan detailing intrapartum and postpartum care plans in the medical chart prior to delivery.
C O N F I D E N T I A L
INTRAPARTUM DELIVERY MANAGEMENT
• Delivery Location• Appropriate Level of Maternal Care
– Critical Care Services, blood bank, telemetry capabilities, in house 24 hour OB, anesthesia, ECMO, catheterization lab, NICU, CT surgery, etc.
• Delivery Mode– Cesarean vs. Assisted 2nd Stage vs.
Spontaneous Vaginal Delivery• Most patients can undergo vaginal delivery with
adequate pain control and cesarean delivery for obstetrical indications
C O N F I D E N T I A L
INTRAPARTUM DELIVERY MANAGEMENT
Delivery ModeCesarean vs. Assisted 2nd Stage vs. Spontaneous Vaginal Delivery
• Critical maternal illness• Aortic dilation/aneurysm >45mm• Critical/symptomatic AS• Current maternal warfarin use
• Aortic dilation 40-45mm or any aortopathy
• Maternal critical illness• Eisenmenger physiology,
pulmonary hypertension, mitral stenosis if no significant HF
Consideration of assisted 2nd stageContraindications to Vaginal Delivery
C O N F I D E N T I A L
INTRAPARTUM DELIVERY MANAGEMENT
Anesthesia ConsultationPre-delivery multidisciplinary planning is key!
• Anticoagulation plan• Monitoring
• Telemetry, A-Line• Labor Analgesia
• Early epidural • combined, low dose, spinal-epidural
• Surgical Anesthesia• Emergency cesarean delivery
• Hemorrhage
C O N F I D E N T I A L
OTHER DELIVERY CONSIDERATIONS
Lesion dependent considerations• Fluid Balance• BP parameters• HR Parameters• Air filters on IV lines (prevent paradoxical embolism)
Medication considerations (lesion specific)• E.g. avoid pitocin in PAH (↑ PVR, ↓ 𝑆𝑆𝑆𝑆𝑆𝑆), avoid
methergine in aortopathy, PGEs may ↓ 𝑆𝑆𝑆𝑆𝑆𝑆.
Endocarditis Prophylaxis• Prosthetic Valves• Cyanotic Heart Disease
C O N F I D E N T I A L
POSTPARTUM CARE
All ACHD patients should be flagged as high risk – for many CHD patients, the postpartum period is THE MOST dangerous time.
Postpartum Care Plan• ICU vs. routine postpartum floor• Telemetry• Strict I/Os• BP and HR parameters• Medication management• CONTRACEPTION COUNSELING
C O N F I D E N T I A L
POSTPARTUM CARE
CONTRACEPTION COUNSELING• Risk of thrombosis • Risk of procedure• Method efficacy in context of maternal
cardiac risk in pregnancy and fetal risk in future pregnancy
• Bleeding profile• Consider your cyanotic patient (avoid anemia!)• Consider your chronically anticoagulated patient
C O N F I D E N T I A L
C O N F I D E N T I A L
UNIVERSITY MATERNAL ACHD CARE RESOURCE LISTHEART DISEASE & PREGNANCY
Women with heart disease during pregnancy need additional medical care and oversight to stay healthy. Our adult congenital heart disease providers
work closely with doctors in maternal fetal medicine and anesthesia to improve communication, identify problems early, and
help women prepare for labor and delivery.
Maternal Fetal Medicinehttps://healthcare.utah.edu/womenshealth/pregnancy-birth/high-risk-pregnancy.php
Adult Congenital Heart Diseasehttps://healthcare.utah.edu/cardiovascular/conditions/adult-congenital-heart-disease.php
Anesthesia Preoperative ClinicUniversity of Utah Health Care Anesthesia Preoperative Clinic Scheduling Line 801-585-1449
C O N F I D E N T I A L
QUESTIONS