Advanced Medicine, Manchester June 2016

Cardiac Problems in Pregnancy Sara Thorne

Global Maternal Mortality

UK 9 per 100 000 maternities

Maternal Mortality By Cause UK 2011-2013

Cause of death Number (early n =53) Ischaemic heart disease 11 Cardiomyopathy 4 (+1 late death) Peripartum CM 9 (+ 6 late deaths) Aortic dissection 7 Sudden death 10 Congenital heart disease 1 Endocarditis 2 Pulmonary hypertension 2 Thrombosed mechanical valve 2

Major Causes Of Maternal Death From Cardiac Disease UK 2006-2008.

2009-2014

~20%

~20%

~20%

~20%

20% others

0

10

20

30

40

50

60

Continuing Rise in Cardiac Maternal Deaths N

um

ber

of

dea

ths

Malhotra 2006

Did We Know About Their Heart Disease Before Pregnancy?

Known heart disease

risk factors

de novo

80% of cardiac maternal deaths occur in women not previously known to have heart disease

Mortality

Successes

Near misses

Morbidity

Pregnancy Outcome in Women With Heart Disease

Hb

Karamermer et al ‘07

Cardiovascular Changes In Pregnancy

Who is most at risk? • Unable to increase cardiac output Impaired systolic ventricular function Severe mitral stenosis Severe aortic stenosis Coronary artery disease Pulmonary arterial hypertension • Mechanical valves • Aortopathy

Case History

21 year old ♀ 28/40 weeks pregnant, twins. Admitted to local hospital with 3 days SOB & orthopnoea PMH

Polycystic kidney disease Hypertension – nifedipine Asthma Eczema- oral prednisolone 10mg O/E Breathless, sitting up P123 SR BP 138/80 HS normal Chest wheezy, quiet bases

Case History

What happened next… DD PE or chest infection Rx Enoxaparin 1.5mg/kg Oxygen Steroids for fetal lung maturation (betamethasone) CT scan attempted, but unable to lie flat scout film = congestion Cardiology opinion…. echo- impaired LV & MR no Rx or Mx plan suggested

Case History

Who does the obstetrician need to talk to? Consultant cardiologist with expertise in pregnancy Consultant obstetrician & neonatologist – 2 neonatal cots Cardiac HDU and ITU bed What should they do before transfer?

CXR Furosemide U&E ‘normal’ Cr 48, K 4.3 ABG on 5L O2: pH 7.43 pCO2 4.2 pO2 9.8 HCO3 21.9 Lact 1.76 BE -3.6

Creatinine in pregnancy (mmol/L) Non pregnant female 1st T 2nd T 3rd T 44-80 35-62 35-71 35-80

Case History

Arrives with CPAP, 20mg furosemide given pre transfer Sitting upright, unable to speak in sentences P130 SR BP 150/85 Gallop rhythm Chest – widespread crackles and wheeze

Furosemide 40mg IV GTN infusion CXR: Echo: Dilated LV, severe systolic dysfunction, EF 20% Torrential MR

Case History

Diagnosis: Dilated cardiomyopathy or Peripartum cardiomyopathy

Case History

Good diuresis Feels much better, can speak in sentences and lie down P120, BP148/85 Now what?

Joint obstetric & cardiology review Fetal heart beats present Delivery pack and 2 resuscitaires on CCU Looks better, but still tachycardiac 120 Needs delivery? tonight? tomorrow morning? in next 2 weeks?

Case History

What is her metabolic state? Is she perfusing her kidneys?

BAD, getting worse NO

48

-3.6

Case History

Needs delivery… tonight? tomorrow morning? in next 2 weeks?

How will she be delivered? Where will she be delivered? Where will she go post delivery? Will delivery make her decompensate – can you support her?

Intra-aortic balloon pump placed en route to cardiac theatres

Case History

Who needs to be in theatre? Consultant obstetrician & senior colleague Obstetric scrub team Obstetric & cardiac anaesthetist Midwife 2 neonatal resuscitation teams Perfusionist Cardiac surgeon Cardiologist

Case History

Uneventful CS under GA Twins in good condition, electively intubated TOE on table post delivery: MR now mild, LV unchanged

Extubated quickly Remained tachycardic Acidosis resolved over 24 hours Renal function recovered over 4 days

Case History

Babies extubated and transferred to local NNU at 1 week Mother discharged home same day Cardiology follow up – no improvement in LV at 2 weeks, mod MR

Chest pain… …. is it a pulmonary embolus an acute coronary syndrome,

aortic dissection, or just reflux?

Mortality From Ischaemic Heart Disease UK CEMACE 06-08

11 deaths -6 acute coronary syndrome Atheroma except: 1 Kawasaki, 1 LAD dissection 9 deaths post natal None known to have cardiac disease, BUT… All had risk factors

35 years old Obese Smoker Hypertensive FH +ve Type 2 diabetes Asian Poor attenders for ANC Parous

2016 Significant proportion = sudden death D at PM

How do I Manage a Pregnant or Post Partum Woman with Chest Pain?

Take a good history • ECG – interpret as for a non pregnant patient ECG in pregnancy – leftwards axis, T inversion in III, V1, V2, small inferior Q

• Troponin – not affected by pregnancy

• D dimers – usually raised in pregnancy (so only negative result useful)

• CXR fetal radiation dose = day trip to Cornwall for B’ham woman CT or V/Q fetal radiation dose = month’s holiday in Cornwall…. maternal breast tissue – breast cancer risk

Do not withhold potentially life saving Ix or Rx because of pregnancy

Management of ACS in Pregnancy

• Involve high risk obstetric team • Drugs Aspirin safe in pregnancy Clopidogrel ok - short case reports and series BUT DAPT = high risk haemorrhage at delivery Heparin safe, does not cross placenta B blockers safe (fetal growth monitoring) Statins embryopathy ACEI/AIIRB renal dysgenesis, cardiac malformations • STEMI – immediate PCI, as for non pregnant pelvic wedge reduce frame rate (consider BMS to allow clopidogrel to be stopped for delivery) • Non STEMI – early PCI haemodynamic stress of continuing pregnancy and delivery = major abdominal surgery

How to Manage a Pregnant Woman with non ACS Chest Pain

• If PE suspected, start LMWH whilst confirming diagnosis Perfusion scan or CT • If dissection suspected Urgent CT (or MRI) (TOE stressful and risk of aspiration in pregnancy) IV labetalol, opiate analgesia Urgent consultant involvement: cardiologist, aortic surgeon, obstetrician, anaesthetist Deliver 1st? Repair dissection 1st? Often occurs post partum

Who is at Risk of Aortic Dissection in Pregnancy?

• Marfan syndrome (FBN-1) ….. up to 10% risk

• Loeys Dietz syndrome (TGFBR) …. worse than Marfan, often post natal

• Bicuspid aortopathy • Vascular type Ehlers Danlos syndrome • Turner syndrome

• Coarctation • Normal…

50% of aortic dissections in women <40y are pregnancy related

• Get help – senior, from someone who knows what they’re doing

• Think – what would I do if she wasn’t pregnant? – then, usually, do it

• Don’t be fooled - Young patients compensate Worry if:

Persistent tachycardia Acidosis ‘Normal’ but deteriorating biochemistry

Key Messages 1

• Many women who die are never seen by a cardiologist - education in A&E, acute medicine needed • Need good communication between medical and obstetric teams - consultant to consultant - write in handheld pregnancy notes • Tired and emotional patients can still have pathology Post natal women don’t come to A&E with trivia • Chest pain requiring opiates needs a positive diagnosis -don’t just exclude a PE

Key Messages 2