Non-Ischemic Cardiac Disease Pregnancy

8/18/2019 Non-Ischemic Cardiac Disease Pregnancy

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Non-ischemic cardiac

disease during pregnancyRuben J. Azocar, MD

Assistant Professor of AnesthesiologyBoston University Medical Center


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Introduction

Although the revalence of clinically

significant !aternal heart disease during

regnancy is robably less than "# its

resence increases the ris$ of adverse!aternal, fetal, and neonatal outco!es


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CV Physiology of Pregnancy

Blood volu!e increases %& to ' Plas!a volu!e increase !ore than RBC !ass

leading to hysiologic ane!ia

An estrogen !ediated sti!ulation of the renin(angiotensin syste! results in retention of )A and

*ater

+R increases "& to & b!


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C- increase u to '# by *$s /hese increases begin during the "st tri!ester

Pea$ by &( *$s and are sustained until ter!

0n early regnancy an increase in 12 3&(% isresonsible to the increase in C-

5ater in regnancy, the increase in +R is resonsible since

12 decreased due to 02C co!ression

Concurrently there is a substantial reduction in 12Rby "# *ith decreases in BP and decreases in P2R

by %#


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1y!to!s and P6 of nor!al regnancy!i!ic cardiac disease 67ertional dysnea and orthonea

8atigue and Presyncoe 5o*er e7tre!ity ede!a

a and v *aves !ay be ronounced in C2P tracing

Ma7i!al aical i!ulse is dislaced

"st +eart sound the ul!onary co!onent of nd

!ight are accentuated

%rd +1 is heard in 9 of regnant *o!en


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Mur!urs fre:uently develo during regnancy 1oft, !id(systolic, and heard along the left sternal border is

heard in ; *o!en

Ane!ia !ight accentuate it

0ntensity !ay increase as C- increases

Cervical venous hu!s and a continuous !ur!ur due to

increased !a!!ary blood flo* !ay also be heard

6chocardiograhy is *arranted if< Diastolic, continuous, or loud systolic !ur!urs 3=>?4

A fi7ed slit nd sound

Associated *ith sy!to!s or an abnor!al 6@


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0n nor!al regnant *o!en, echocardiograhy

de!onstrates< Minor increases in the left and right ventricular

diastolic di!ensions 3*ithin the nor!al range4 A slight decrease in the 5261 di!ension and a

!ini!al increase in the size of the left atriu!

0ncreased transvalvular flo* velocities due to the

increased B2

Minor degrees of atrioventricular valve regurgitation


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During labor< C- increases '# above re(labor values

Uterine contraction boluses the atient 0t !ight increase C- u to ?'# of re(labor values

/he BP increases *ith uterine contractions>ain


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0!!ediately after delivery /he cardiac filling ressure increase dra!atically

due to the deco!ression of the vena cava and

the return of uterine blood into the syste!iccirculation C- !ight increase to 9 of re(labor values

/he cardiovascular adatations associated *ith

regnancy regress by aro7i!ately ? *ee$safter delivery


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Physiology of Pregnancy

Pregnancy is also a hyercoagulable state Decreased in Protein 1 activity

1tasis

2enous hyertension


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The problem

A Canadian analyses of the outco!es of regnancyidentified redictors of adverse !aternal and fetaloutco!es in a grou of *o!en *ith congenital orac:uired heart disease 3'? *o!en and ';;

regnancies4 Aro7i!ately of the *o!en had a ri!ary valvedisorder

Adverse !aternal outco!es included< ul!onary ede!a,sustained brady or tachyarrhyth!ias, stro$e, cardiac arrest,or death

Adverse fetal outco!es included< re!ature birth,intrauterine gro*th retardation, resiratory distresssyndro!e, intraventricular he!orrhage, and death


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Maternal outcomes 0ncidence of adverse !aternal cardiac events

"%# of co!leted regnancies More li$ely if<

68 belo* 5eft heart obstruction 3A1 *ith a valve area of less than ".'

c! or M1 *ith a valve area of less than .& c!4 Previous cardiovascular events 3heart failure, tia, or stro$e4 )+A class 00 or higher

/hese events occurred in< # of the *o!en *ith none of these ris$ factors E # of those *ith one ris$ factor ? # of those *ith t*o or !ore ris$ factors /he % *o!en that died had t*o or !ore ris$ factors


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Fetal outcomes

Abnor!al functional caacity 3)+A class 00 or higher4 and leftheart obstruction *ere also redictors of neonatal co!lications

-ther redictors of adverse fetal outco!es included< /he use of anticoagulant drugs throughout regnancy 1!o$ing during regnancy Multile gestation MotherFs age 3= %' yrs or G & yrs4 8etal !ortality *as<

# a!ong regnancies in *o!en *ith one or !ore of

these ris$ factors, # a!ong those *ith none of these ris$ factors


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Evaluation

/he evaluation of a *o!an *ith clinically significantvalvular heart disease should occur before concetionand entail a full cardiac assess!ent

/he history should focus on the atientHs e7ercisecaacity, current or ast evidence of heart failure, and

associated arrhyth!ias Cardiac he!odyna!ics, including PAP and the severityof valve dysfunction, should be assessed by echo

67ercise testing !ay be useful if the history isinade:uate to allo* an assess!ent of functional caacity

During regnancy evaluation each tri!ester and*henever there is a change in sy!to!s, in order toassess any deterioration in !aternal cardiac status is therule


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Mitral tenosis

Rheu!atic M1 is the !ost co!!on valvularabnor!ality in regnant *o!en 3? Associated *ith ul!onary congestion, ede!a, and

atrial arrhyth!ias during regnancy or soon afterdelivery /he increased B2 load and C- associated *ith regnancy

lead to an increase in left atrial volu!e and ressure,elevated ul!onary venous filling ressures, dysnea, anddecreased e7ercise tolerance

0ncreases in the !aternal +R decrease the diastolic fillingeriod, further increasing left atrial ressure anddecreasing C-

/he increased atrial ressure !ay cause arrhyth!ias


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Mitral tenosis

Mortality a!ong regnant *o!en *ith!ini!al sy!to!s is less than "#

Predictors of adverse !aternal outco!es Mitral valve area less than ".' c!

Abnor!al functional class before regnancy

8etal !ortality increases *ith deteriorating

!aternal functional caacity %& # *hen the !other has )+A class 02


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Mitral tenosis

8or *o!en *ith !ild or !oderate sy!to!s Medical theray is directed to the treat!ent of volu!e

overload

Diuretic theray but avoiding hyotension and

tachycardia

)AI restriction

Reduction of hysical activity

Beta(bloc$ers decrease +R and rolong the diastolicfilling eriod *hich rovides sy!to!atic benefit


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Mitral tenosis

Develo!ent of A8 re:uires ro!t treat!ent,

including cardioversion.

Beta(bloc$ers and digo7in for rate control

Procaina!ide and :uinidine are fre:uently used ifsuressive antiarrhyth!ic theray is needed

Due to the increased ris$ of syste!ic e!bolis! in

atients *ith M1 and A8 anticoagulant theray is

indicated


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Mitral tenosis

)+A class 000 > 02 or a valve area of less than ".& c!,

Percutaneous balloon !itral valvulolasty 3PBM24 orvalve surgery B68-R6 conceiving aear to allo*regnancy *ith fe*er co!lications than *o!en treated!edically

PBM2, during the nd

tri!ester, has been associated *ithnor!al deliveries and e7cellent fetal outco!es 8etal ris$s associated *ith e7osure to radiation !ay

be reduced by avoiding e7osure during the first halfof regnancy

/he uterus !ust be shielded and the atient should beinfor!ed about the ossible ris$s Mitral valvulolasty has also been erfor!ed under

/66 guidance


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Mitral tenosis

-en cardiac surgery has been erfor!ed

during regnancy for severe M1

Maternal outco!es are si!ilar to the non(

regnant 8etal loss in "& to %& # of cases


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M! "nesthesia management

Careful clinical evaluation early on inconunction *ith the -B tea! to have a clearlan

0CU consultation

2aginal delivery is the usual aroach +e!odyna!ic goals<

Avoidance of tachycardia and fluid overload

Preservation sinus rhyth! 0ncrease of B2, C- and +R during regnancy

and labor !ay result in ul!onary congestion,tachycardia and atrial fibrillation


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Monitoring< A(50)6 and robably PAC

5abor and delivery is associated *ith an increaseof 9 to "& !! +g in the left atrial and ul!onary*edge ressures

PAC used before and during delivery facilitatesthe !anage!ent of he!odyna!ics in *o!en *ithadvanced disease


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6idural anesthesia to achieve effective ain control A !i7ture of 5A and oioids is ideal

Pain control and !ini!ization of B2>C- increase after

delivery

Assisted(delivery devices during the second stage

of delivery eli!inate he!odyna!ic effects of

valsalva !aneuver during ushing

Cesarean section should be erfor!ed *hen thereare obstetrical indications for it


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Mitral #egurgitation

Most co!!only due to !itral(valve rolase and isusually *ell tolerated during regnancy because ofthe reduction in 12R

Ko!en *ith sy!to!atic MR !ay benefit fro!

!itral(valve surgery 3referably reair 4beforebeco!ing regnant. +o*ever, 52 dysfunction associated *ith MR is unli$ely to

i!rove after surgery and *ill increase !aternal ris$ duringregnancy

Diuretics and vasodilators !ay be indicated -utco!e data that *ould hel to guide clinical

decision !a$ing in this area are lac$ing.


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"ortic tenosis

Congenital valvular abnor!alities are usually thecause of A1 in young *o!en in the U1

1evere A1 is oorly tolerated during regnancy Maternal and erinatal !ortality of "E# and %# have

been reorted

/he ressure gradient is resonsible for the +Dchanges seen in A1 /he increased 521P needed to !aintain syste!ic arterial

blood ressure increases stress in the ventricular *all 5t ventricular hyertrohy develos leading to diastolicdysfunction, fibrosis, di!inish coronary blood flo* reserveand late systolic failure


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"ortic tenosis

Patients *ho are sy!to!atic or *ho have a

ea$ outflo* gradient of !ore than '& !! +g are

advised to delay concetion until after surgical

correction

/er!ination of regnancy should be strongly

considered if the atient is sy!to!atic before

the end of the "st tri!ester

Aortic(valve relace!ent and alliative aorticballoon valvulolasty have been erfor!ed during

regnancy *ith associated !aternal and fetal ris$


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"ortic tenosis

+e!odyna!ic goals< Maintain nor!ovole!ia

)1R /achycardia decrease dyastolic filling ti!e

Atrial $ic$ is resonsible for u to of ventricular

filling in this atients

Baseline 12R


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"ortic tenosis

/he nor!al hysiological changes of regnancy can

reciitate heart failure in atient *ith severe A1

/he further increase of C- and B2 during labor in

face of the fi7ed C- of A1 atients !ay reciitate< /achycardia *hich decreased diastolic ti!e 3and

coronary erfusion ti!e4 and increases -,consu!tion

0ncreases 526DP 0sche!ia !ight result


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"ortic tenosis

2aginal delivery is referred 0nstru!ental delivery to avoid he!odyna!ic

changes of the valsalva !anuver

-7ytocin !ay decrease 12R an increase PAP Monitoring<

A(line

LC2P LPAC


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"ortic tenosis

6idural analgesia Pain control and also !ini!izes B2>C- increase

after delivery

Avoid einehrine test dose Careful titration to avoid sudden decrease of 12R

Dilute 5A *ith oioids to !ini!ize sy!athecto!y


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"ortic tenosis

Cesarean section A has traditionally being advocated to avoid sudden

decreases of 12R

-iod based induction

8etal deression. Pediatric tea! !ust be a*are Case reorts of eidural anesthesia *ith ositive outco!es

Careful titration of 5A and fluid relace!ent>vasoressors

to counteract sy!athecto!y

Phenylehrine ossible a better choice over ehedrine


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"ortic #egurgitation

A0 !ay be due to a dilated Ao annulus 3as inMarfanHs syndro!e4, a bicusid Ao valve, orrevious endocarditis

/he reduced 12R of regnancy reduces thevolu!e of regurgitated blood

Ko!en *ith an abnor!al functional caacity orleft ventricular dysfunction are redicted to have ahigh ris$ of abnor!al !aternal outco!es, but fe*data concerning this oulation are available


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"ortic Insu$iciency

0solated A0 can usually be !anaged *ith vasodilators

and diuretics

AC6 inhibitors should be discontinued during

regnancy, and other agents, such as hydralazine

or nifediine, should be substituted

Clinical and echo assess!ent should be erfor!ed

before concetion in *o!en *ith A0 due to MarfanHs

syndro!e

6ven in the absence of overt cardiac abnor!alities,

this syndro!e redisoses *o!en to

unredictable, but increased, ris$ during regnancy.


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Pulmonary hypertension

P+/) is associated *ith high !aternal !ortality 3%%

to & #4, as *ell as *ith an increased rate of

adverse neonatal events

1econdary P+/) due to valvular disease isassociated *ith an increased rate of adverse

!aternal events, but the absolute ris$ of such

events is unclear.

A systolic ul!onary(artery ressure that is !orethan E' # as high as the syste!ic ressure laces

the *o!an at high ris$.


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+e!odyna!ic obectives Maintain the PAP as lo* as ossible and the

syste!ic ressure *ithin the "'# above and

belo* the basal level 3the syste!ic ressureshould al*ays be higher than ul!onary

ressure4

Avoid dysrhyth!ias and tachycardia, and !aintain

sinus rhyth!


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Pregnancy and labor C2 changes against goals< Uterine contraction after delivery returns a large bolus

of blood to the circulation. /his can be oorly toleratedin atients *ith severe P+/)

/he sudden hyervole!ia can be treated *ithvasodilators, such as nitroglycerine, and diuretics.

A BP cuff inflated bet*een the arterial and venousressures around the thighs, can suddenly and

reversibly decrease R2 filling by reducing venousreturn Air or a!niotic fluid e!bolis! could acutely increase

ul!onary ressure


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Monitoring< a(line and C2P or PAC should be used for !onitoring

or for drug ad!inistration

2aginal delivery Pain control *ith a !i7ture of local anesthetics in a lo*

concentration and oioids via eidural 8orces delivery, *hich decreases atient effort and

he!odyna!ic conse:uences, is the techni:ue of

choice.


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Pulmonary %ypertension

Cesarean Delivery Both general and eidural anesthesia have been

used for cesarean delivery in atients *ith

ul!onary hyertension. /he surgical rocedure can lead to e7cessive

bleeding and hyovole!ia


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0nduction of general anesthesia Based on oioids 5idocaine 3" !g>$g4 reduces ul!onary and

he!odyna!ic reactions during intubation 0nduction can be co!le!ented *ith entothal,

roofol, or eto!idate 1uccinylcholine can be used for intubation Anesthesia could be !aintained *ith use of short

acting narcotic infusion, volatile anestheticsand>or roofol infusion


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Prosthetic %eart Valves

Biorostheses are not as durable as !echanical

rostheses, but eli!inate the need for anticoagulanttheray

Ko!en *ith !echanical valves have a higher rateof thro!boe!bolis! and higher "&(year !ortality,

desite a lo*er rate of valve loss Pregnancy does not aear to increase the rate of failure of

!echanical rostheses or ho!ograft nor accelerates thedeterioration of biorosthetic valves

Pregnancy in a *o!an *ith a !echanical valve is

associated *ith an esti!ated !aternal !ortality of " to #*ith death usually resulting fro! co!lications ofrosthetic(valve thro!bosis.


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"nticoagulation

/here are no results of clinical trials to guide the

choice of anticoagulant theray during regnancy

Monitoring is re:uired in order to assess *hether the

antithro!botic effect is ade:uate

/he effective doses of these drugs change duringregnancy because of changes in intravascular

volu!e and body *eight

0n a series of ;E? *o!en *ith a total of "%

regnancies the use of any anticoagulant therayresulted in !aor bleeding in .' # of the regnancies,

*ith bleeding usually occurring at the ti!e of delivery


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&arfarin

0n *o!en *ith !echanical valves the use of*arfarin throughout regnancy *as associated *iththe greatest !aternal rotection Ris$ of thro!boe!bolis!, %.;#, ris$ of death, ".9# Karfarin crosses the lacenta

8etal defor!ities and C)1 abnor!alities

+igh rate of fetal loss 3% including sontaneousabortions, stillbirths, and neonatal deaths 67osure to *arfarin bet*een ? (" *$s of gestation

*as associated *ith a rate of fetal loss that *as t*icethat associated *ith the use of unfractionated hearin

8etoathic effects of *arfarin use 3nasal hyolasia andbone stiling4 occurred in aro7i!ately ? # of cases,


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%eparin

0f hearin rather than *arfarin *as used during the "st tri!ester,the ris$s of !aternal thro!boe!bolis! and !aternal death !orethan doubled 3;.# and .# resectively4

/he use of adusted(dose hearin 3titrated to a theraeutic

activated P//4 throughout regnancy *as associated *ith thehighest ris$s of !aternal thro!boe!bolis! and !aternal death3'# and E # resectively4

A large roortion of the *o!en had ball(and(cage valves orolder single(tilting(dis$ valves that are $no*n to carry a high ris$

of thro!boe!bolis!

5ong(ter! use of hearin is associated *ith !aternal ris$s of +0/and osteoenia.


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'M&%

5o*(!olecular(*eight hearins have been usedsuccessfully to treat D2/ during regnancy 5o*er ris$s of thro!bocytoenia and osteoenia than

unfractionated hearin Probably safe for the fetus /here are insufficient data fro! studies of *o!en *ith

rosthetic heart valves to suort the efficacy of thistheray or the use of any tye of hearin throughoutregnancy

)or has the use of lo*(!olecular(*eight hearin beenstudied in *o!en *ith A8 associated *ith valvular diseaseduring regnancy.


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"nticoagulation (uidelines

Although definitive data are lac$ing authorsreco!!end 6ncourage education of the rosective arents and their

involve!ent in the decision(!a$ing rocess

Karfarin to achieve a target 0)R of .& to %.& throughout!ost of the regnancy. /he only e7cetions are the eriods bet*een ? and "

*ee$s of regnancy and after %? *ee$s of regnancy,*hen they *ould ot for the closely !onitored use ofunfractionated hearin

/his otion *as suggested because of !edicolegalconcern relating to the off(label use of *arfarin and theris$ of e!bryoathy.


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Peripartum cardiomyopathy

Un$no*n etiology 0ncidence '(E'>"&&&&& in so!e series Diagnosis<

Biventricular dilated cardio!yoathy in %rd tri!ester or in uereriu!

Absence of rior cardiac disease ' good rognosis if early reversion of

sy!to!s but '(' !ortality /reat!ent< 1uortive


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Non-Ischemic Cardiac Disease Pregnancy