OAA 2011

Valvular heart disease in pregnancy: the role of the multidisciplinary team.

Jason Waugh

Consultant Obstetrics and Maternal Medicine

Royal Victoria Infirmary

Newcastle upon Tyne.

Hb

Karamermer et al „07

Cardiovascular Changes In Pregnancy

CEMACH REPORT (Confidential Enquiry) “Saving Mothers Lives” 2003-2005

• Cardiac disease is now the leading cause.

• Substandard care : Cardiac 46%

0

5

10

15

20

25

Cardiac Causes of Death Developed vs Developing World

UK 2003-5

(early & late deaths) MMR 14/100 000

Commonest cause death

IHD

LV failure Other

AS

Ao dissection

Rh MVD

PAH

Sri Lanka 2004

(early deaths) MMR 38/100 000

IHD

Other

Rh MVD

PAH LV failure

− Saving mothers‟ lives CEMACH ‟07 − Haththotuwa et al IJGO „09

2nd commonest cause of death after PPH

If ventricular function good Regurgitant valves well tolerated

Stenotic valves may not meet

demands of pregnancy

MDT : general points

• Pre-pregnancy care and advice

• Antenatal Care

• Intrapartum Care

• Postpartum Care

• ? Participation in obstetric networks

MDT : general points

• There is a need to be aware of the local / regional expertise for advice or referral.

• Not all women with cardiac disease will require delivery in a tertiary centre…..BUT

• Some very clearly do require specialist multidisciplinary input at all stages in their pregnancy.

Mitral Stenosis.

• Most common left sided lesion

• Causes most morbidity and mortality

• Usually rheumatic

• Usually UNDIAGNOSED pre-pregnancy

– An awareness of the problem is required

– An understanding of the likely presentation will save lives

MS : ANC

• Most UK cases are “imported” and are 1st generation immigrants.

• “Worst” possible group in terms of accessing ANC due to social disadvantage and communication issues.

• There is a training gap as current obstetricians have not grown up with Rheumatic heart disease and awareness is therefore less.

Risk of Adverse Event in Pregnancy With Mitral Stenosis

Siversides Am J Cardiol „03

MVA (cm2) Mild >1.5 Moderate 1.1-1.5 Severe <1.0

MS: ANC

• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.

• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.

• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate

advice from those with the most experience. • Bed rest; beta blockade; diuretics; oxygen.

MS: ANC

• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.

• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.

• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate

advice from those with the most experience. • Bed rest; beta blockade; diuretics; oxygen.

CEMACH : „Saving mothers lives‟

• All clinical staff must undertake regular, written, documented and audited training for:

• The identification, initial management and referral for serious

medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers

• The early recognition and management of severely ill pregnant

women and impending maternal collapse • The improvement of basic, immediate and advanced life support

skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies.

• There is also a need for staff to recognise their limitations and to

know when, how and whom to call for assistance.

MS: ANC

• Almost never a history of RF (so an index of suspicion is required). Screen the at risk population with Hx and exam‟.

• Usual presentation is 2nd trimester with “SOB” ; exertional dyspnoea, orthopnoea, PND, and pulm‟ oedema.

• Ix : CxR, ECG, first and then ECHO later. • Inform Cardiologists early : seek appropriate advice from

those with the most experience. • Bed rest; beta blockade; diuretics; oxygen. • Cardiovert for AF • Anticoagulate if LA dilated or AF

Deliver? If gestational age allows Intervention? Balloon mitral valvuloplasty if no Ca2+ & no MR 95% success rate, safe Diminishing UK experience – need experienced operator Minimal fetal radiation exposure (<0.2 rads)

What Next When Medical Management Fails?

MS (and AS) : Fetus

• Pre-term delivery rate up to 48%

• FGR up to 21%

• Low APGAR 8%

• All proportional to Cardiac Output deficit.

• Uterine artery dopplers : screen all mod‟ and severe MS – influence USS frequency.

• Umbilical artery and Ductus Venosus dopplers identify the “sick fetus”.

MS (and AS) : Fetus

• Generally:

• UAD AEDF : OR Perinatal death 4

• UAD REDF : OR Perinatal death 11

• Reversed flow in DV with atrial contractions – poor perinatal outcome

MS : ANC - remember

• If MS diagnosed pre-preg‟ 40% will get significantly worse.

• Presentation will determine management. • Fetal problems are directly proportional to the

severity of the MS. • ECHO will assess valve for valvuloplasty BUT

gestation need not determine the timing of interventions.

• Seek regional / national advice to avoid delay. • Cardiac surgical support WILL BE NEEDED if

valvuloplasty is contemplated.

MS : Intrapartum

• Mode of delivery

• Timing of Delivery (?IOL –may be necessary)

• Analgesia / anaesthesia

• Meticulous volume homeostasis

MS – intrapartum - CS

• Who really needs this?

– Severe “life threatening” MS (and AS)

– Would an Em CS be “worse” ?

– Clear Obstetric indications

MS : Intrapartum - IOL

• Little data (Oron et al BJOG 2004 n=121)

– Usually reserved for NYHA III-IV or deterioration in pregnancy

– Balance of fetal immaturity vs maternal risk

– About 50% deliver between 08.00 and 18.00

– May increase the risk of Em CS

MS : intrapartum – “short 2nd stage” ?

• Consider (given the lack of direct evidence)

– A contraction increases CO by 15-30%

– Valsalva causes CO to fall and then overshoot

– Anxiety (and pain) increase CO

– Supine positions drop CO

– Progress in labour is the critical determinant of benefit.

MS : postpartum

• Meticulous volume homeostasis

• ITU / HDU support

• In-patient observations for 3-5 days.

• Contraception

• Pre-pregnancy counselling and follow-up.

• Don‟t take your eye off the ball……….

Blood volume Stroke volume

LV pressure & work Pressure gradient across AV

Coronary blood flow requirement

Symptoms

Sudden death

Usually congenital, bicuspid valve Usually diagnosed pre pregnancy

Opportunity for pre-pregnancy assessment & counselling

Aortic Stenosis in Pregnancy

Pregnancy ok if asymptomatic AND • Normal ECG: no ST changes • Normal ETT : normal BP response

target HR no ST changes

• Good LV • DPG <80mmHg, mean <50mmHg, valve area >1cm2

Aortic Stenosis : Pre Pregnancy Assessment

Risk of Adverse Event in Pregnancy With Aortic Stenosis

Siversides Am J Cardiol „03

AVA (cm2) Mild 2.0±0.2 Moderate 1.3 ±0.2 Severe 0.8 ±0.2

Aortic Stenosis : ANC – similar to MS • Usually secondary to a congenital bicuspid valve –

therefore pre-pregnancy planning should occur

• If first presentation consider a coarctation

• Mild and moderate disease will probably be well tolerated

• Moderate disease can become symptomatic for the first time during pregnancy

• Discuss termination of pregnancy for Severe disease or deteriorating disease.

• Bed rest; beta blockade; diuretics; oxygen.

• Balloon valvuloplasty ; more risk ; fewer cases

• CP Bypass : Maternal Death 15%; Fetal Death up to 30%

AS : Intrapartum – as for severe MS but even more caution

• Mode of delivery

• Timing of Delivery

• Place of delivery

• Monitoring in Labour

• Meticulous volume control

AS : Postpartum

• Meticulous volume homeostasis

• ITU / HDU support

• In-patient observations for 3-5 days.

• Contraception

• Pre-pregnancy counselling and follow-up.

Coarctation

• Hypertension resistant to medical management.

• Can be difficult in Pregnancy as almost no experience of common interventions.

• If repaired hypertension may still persist (L arm is poor reflection of BP)

• Aneurysms are the worst sequelae

• Fetal risk of coarc‟ is 10%

Cardiac Surgery During Pregnancy

• Risk maternal death 5-13% 2-4 fold ↑cf non pregnant

• Risk fetal death 15-33% ↓risk - normothermic perfusion

- pulsatile flow - pump flow rate >2.5l/min/m2

- perfusion pressure >70mmHg - haematocrit >28% - a-stat pH management

Weiss Am J Obst Gyn ‟98 Chandrasekhar Anesth Analg „09

Whatever next ?

• Community MW booking

• Indian ITU nurse; Mild asthma; 2 Prev CS : Refer Cons clinic.

• 12/40: Nuchal normal : Cons review. No treatment for asthma since last pregnancy. Well. 2 Prev CS book for elective at 39/40 Cons to operate.

• 20/40: Normal anomaly USS

Case : A low risk multip……

Admission.

• 21/40: Acute admission via GP with ↑ SOB over 3/7.

• Obs team: Hx exam. Nothing new. Widespread crackles and wheeze. Sa02 89%. Call Med Reg. Oxygen.

• Med Reg: Hx Exam. Nothing new. Systolic murmer ?flow. Widespread crackles. Continue oxygen. CxR

Admission

• Cardiology team:

• ECG/ECHO.

• Severe mitral stenosis. Valve area 0.8 cm2

• Pulmonary pressure 100 mmHg

• LV, RV, ok.

Management.

• Diuretics : excellent response. (SaO2)

• ECHO repeated: confirmed.

• Beta blocked: no problem.

• Thromboprophylaxis (Tinzaparin)

• Frusemide reduced: Pulm oedema returned.

• Ex tolerance reduced, orthopnoea.

• 23/40 underwent balloon valvuloplasty.

Valvuloplasty

• Success • Multidisciplinary team;

cardiac theatres • Valve area increased

to 1.2 cm2 • Pulm‟ pressures

reduced to 70mmHg post procedure.

• Discharged. • Serial ECHO with

regional MDT.

MRI and Placental implantation

32/40

• Repeat USS : Major placenta Praevia Accreta.

• Plans for delivery : n=40

– Obs anaes‟ (team)

– Cardiac anaes‟ (team)

– Cardiac team/theatre/surgeon.

– Gynaecologist.

– Interventional radiology (team).

– Midwifery team with satellite neonatal cover

– Oh …and an obstetrician.

Delivery……the best laid plans!!!!! • 37/40 stable and well. Valve area 1.2 pulm‟ pressures

>50 mmHg. LV func ok. Major placenta praevia. • IIA catheters placed 10.30 am • Inv monitoring: CVP,Art line, LITCO CO. • Epidural (sequential) ……..x2. • Surgery: 15.30 • 15.40 Confirmed placenta accreta • Baby delivered, proceed to Hysterectomy. • 15.50 Despite IIA catheters blood loss 1500 mls. • 1 hr 45 min to complete operation. • Total blood loss 3500 mls. (6 units transfused) • LITCO very stable. CO at rest 5-5.5 L/Min and increased

to 6.5-7 with a tachycardia. • Transferred to Cardiac ITU PN. Transferred to Obs unit

36 hours. Home day 5 • Alive and well.

AccretaCS.wmv

AccretaCS.wmv

Case 2 : First visit • DS ; referred from the communty October

2010 ; unplanned pregnancy ; 16 years old.

• Age 10 months – viral myocarditis - Heart transplant

Age 13 Renal failure secondary to

immunosuppression and post streptococcal glomerulonephritis - Renal transplant

– Live related (mother) – Post transtplant ureteric stenosis and subsequent

reconstruction – 3 episodes of proven rejection – Baseline creatinine 110

PMH (continued)

• Age 14 : Post transplant Lymphoproliferative disorder – Radio and chemotherapy

• Needle phobia – Midazolam for bloods – Counselling – Psychology

• Chronic neck pain – Extensively investigated, no cause found

Meds

• Tacrolimus 4mg OD

• Prednisolone 7.5mg alt days

• Codeine phosphate 60mg QDS

• Morphine (Oral) 10-20mg evening

• Amytripyline 25mg evening

• Cephalexin 250mg nocte

• Good LV/RV function on ECHO

• BP 126/90 mmHg

• Proteinuria – 3+ proteinuria

• pcr 317 mg/mmol

• Creatinine 119

First trimester

Discussion

• Effect on transplants inc. rejection, infection • Pharmacology • Preeclampsia • Thromboprophylaxis • Phlebotomy frequency • Prematurity, growth restriction • Long term parenting • Surgical risks • Option for termination • Opportunity to transfer to adult services

By 20/40 gestation

• 12/40;16/40;19/40 • Normal fetal anatomy • PCR 435 • Tinzaparin declined because of needles • TEDS declined because of fashion concerns • Stopped codeine and morphine

(unsupervised) • Continues to have midazolam for bloods with

paed team

• 20/40 : – Day Unit admission. – Febrile, tachypnoeic, cough……. – Diagnosis : H1N1 – Self discharged : no anti-virals – (MRSA+ve) – Recovered.

• 26/40 • Increasing PCR – up to 1000 with a stable creatinine • Normal growth and blood pressure

• 29/40 • Slightly increased BP – commenced nifedipine following

cardiac discussions. • ?rejection ?preeclampsia • Steroids for fetal lung maturity

The week of delivery

• 29+6 • Increasing proteinuria and worsening

hypertension. – Delivery by GA LSCS (maternal request) – Difficult anaesthetic post op pain control – Declined implanon

• Female infant • 1400g • Uncomplicated neonatal course

Postnatal

• Continued hypertension and proteinuria

• ?Rejection component

• Renal biopsy 1 month postnatal (+implanon)

– Features typical of preeclampsia

– Rejection could not be excluded

• Continued relentless deterioration

– Now on dialysis !!!!

Thanks for listening…

On behalf of the NUTH GUCH pregnancy service. (Crossland, O‟Sullivan, Choudhary, Griffiths, Murphy, Wight and Waugh)