Pregnancy & Cardiovascular
diseases
By
Mohammad H. soliman
(MSc. Cardiology)
Expected cardiovascular changes in pregnancy
Measurement
Normal value
Change in pregnancy (%)
Heart rate
71 + 10 bpm
+ 10%–20%
Stroke volume
73.3 + 9 mL
+ 30%
Cardiac output
4.3 + 0.9 L/min
+ 30%–50%
Blood volume
5L
+ 20%–50%
1,530 + 520 dyne/cm/sec
- 20%
Mean arterial pressure
86.4 + 7.5 mm Hg
Not significant
Oxygen consumption
250 mL/min
+ 20%–30%
Systemic vascular resistance
Source: Clark SL, et al.1 and Elkayam U, Gleicher N. Hemodynamics and cardiac function during normal pregnancy and
the puerperium. In: Elkayam U, Gleicher N, eds. Cardiac Problems in Pregnancy. 3rd ed. New York, NY: Wiley-
Figure 1 Physiological changes in pregnancy.8 Systemic and
pulmonary vascular resistance fall during pregnancy. Blood pressure
may fall in the second trimester, rising slightly in late pregnancy. Note
that cardiac output and stroke volume peak by 16 weeks gestation.
PRE-PREGNANCY COUNSELLING
To estimate maternal mortality as well as
morbidity
Join antenatal care with a high risk pregnancy
obstetric team.
Minimising maternal risk: e,g
if necessary by catheter or surgical intervention
before conception
Estimation and minimising fetal risk e,g
maternal drug treatment may need changing
before conception or once pregnant
Signs and symptoms of normal
pregnancy versus heart failure
A risk index to predict
complications
1. A prior cardiac event (including stroke, transient ischemic attack,
or arrhythmia).
2. Cyanosis or poor functional class.
3. Left heart obstruction.
4. Systemic ventricular dysfunction.
One point was assigned for each risk factor present. No pregnancy
received more than 3 points. Women with 0 points had an estimated
risk of a cardiac event of 5% (low risk), those with 1 point had a risk
of 27% (intermediate risk), and those with more than 1 point had a
75% risk of having a cardiac event (high risk). All three deaths in the
study of 562 women occurred in pregnancies with more than one
point.
Maternal mortality risk
associated with pregnancy
Group I: Minimal risk of complications (mortality <1%)
-Pulmonic/tricuspid disease, ASD ,VSD ,PDA
-Bioprosthetic valve ,mild AR, mild PS
-Mitral stenosis, NYHA Class I or II
Group II: Moderate risk of complications (mortality 5% to 15%)
- Mitral stenosis with AF
-Artificial valve
-Mitral stenosis, NYHA Classes III or IV
-mild to mod AS,sever PS
-Previous myocardial infarction
Group III: Major risk of complications or death (mortality >25%)
-
Sever Pulmonary hypertension
Eisenmenger syndrome
Complex cyanotic heart disease
Sever AS or NYHA class III IV with any valvular disease
I.
Valvular heart disease and
pregnancy
1- mitral stenosis
The most common rheumatic valvular lesion in
pregnancy
When the valve area falls below 1.5 cm2 filling of the left
ventricle during diastole is severely limited, resulting in a
fixed cardiac output
The pressure gradient across narrowed valve may
increase greatly seconadry to increase in HR and blood
volume
Increased left atrial pressure can result in arrhythmia
Decrease serum coloid osmotic pressure and excessive
peripartum fluid administration predispose to pulm
edema
Changes in NYHA class between 1st visit and
follow up during pregnancy
Theraputic approach
Aiming to:
reduce heart rate
Decrease left atrial pressure
1- restriction of physical activity
2- drugs as B blockers and digoxin used to control
HR
3- cautious use of diuretics
Vaginal delivery is permitted in most patients with MS
In symptomatic patients with moderate to sever MS
continuous monitoring and use of IV dugs like diuretics
digoxine BB and nitrates
Mitral valve repair or
replacement
Should be considered only in sever cases of MS
refractory to optimal medical therapy
Or when close follow up during pregnancy and
labour is not possible
Risk of foetal death during surgery is 20- 30%
VS 2-12% in PBMV
Epidural anesthesia is the most apprpriate form
of analgesia for both vaginal and abdominal
delivery
2-Mitral regurgitation
Most common causes is rheumatic and
myxomatous degeneration
MR is well tolerated during pregnancy
New AF or sever hypertension can
precipitate homodynamic deterioration
Women with sever MR are advised to
under go surgical repair before conception
3-Mitral valve prolapse
4-Aortic stenosis
AS is far less frequent than MS and most
cases are congenital
Delivery is safe in patients whose
functional tolerance is good
Valve repair or termination of pregnancy
considered only after Appearance of
symptoms like dyspnea, syncope or pulm.
Oedema resistant to medical treatment
5-Aortic regurgitation
It may be due to bicuspid aortic valve,
rheumatic,or infective endocardities
It is well tolerated during pregnancy
In symptomatic patients diuretics,digoxine
and hydralazine can be safely used
6-Prothetic valves and pregnant
woman
The risk of PV. related to increase in
heamodynamic burden and increase incidence
of thromboembolism
Selection of type of prosthesis should be
individualized as
The bileaflet mechanical valves more durable,
excellent hemodynamic profile, and relatively
small risk of thromboembolic and bleeding
complications with careful anticoagulation
In women who are not interested in
anticoagulation or for whom close followup is not possible, a tissue valve is
preferred
In the aortic position, homografts,
pericardial valves, and stentless porcine
xenografts have not been extensively used
in pregnancy
The pulmonary autograft (Ross procedure)
is an excellent elternative but associated
more with structural valve deterioration
Outcome of pregnancy in women with mechanical or
biological prostheses
Study
No. of pregnancies Live births
(%)
Thromboembolic
complications
Valve thrombosis
(%)
Emboli
(%)
Mechanical valves
Hanania
95
53
11
9
Sbaroun
i
151
73
9
5
Born
35
63
8
3
Bioprosthetic valves
Hanania
60
80
0
0
Sbaroun
i
63
83
0
0
Born
25
100
0
5
Conditions warranting
anticoagulation during pregnancy
Mechanical prosthetic valve
History of venous thromboembolism
Acute deep venous thrombosis
Antiphospholipid antibody syndrome
Inherited deficiency of naturally occuring
anticoagulant
Chronic AF
Eisenmger’s syndrome
ACC/AHA Recommendation for Anticoagulation During Pregnancy in Patients With
Mechanical Prosthetic Valves
1. The decision whether to use heparin during the first trimester or to continue oral anticoagulation
throughout pregnancy should be made after full discussion with the patient and her partner.
2. High-risk women who choose not to take warfarin during the first trimester should receive
continuous unfractionated heparin intravenously in a dose to prolong the mid-interval (6 h after
dosing) activated PTT time to 2 to 3 × control value. Transition to warfarin can occur thereafter.
3. In patients receiving warfarin, the INR should be maintained between 2.0 and 3.0 with the lowest
possible dose of warfarin, and low-dose aspirin should be added.
4. Women at low risk might be managed with adjusted-dose SC heparin (17,500 to 20,000 U twice
daily to prolong the mid-interval (6 h after dosing) activated PTT time to 2 to 3 × control value.
5. Warfarin should be stopped no later than week 36 and heparin substituted in anticipation of labor.
6. If labor begins during treatment with warfarin, a cesarean section should be performed.
7. In the absence of significant bleeding, heparin can be resumed 4–6 h after delivery, and warfarin
begun orally.
Anticoagulation options during pregnancy
Mode of delivery
Vaginal delivery is safe in most cases with PV using
epidural anesthesia
Invasive heamodynamic monitoring indicated only
in sever valve stenosis or HF
Heparin should be withdrawn 4 hours before CS or
at onset of labor and resumed 6-12 h after
In high risk patient with previous endocarditis or
heart valve prosthesis prophylactic antibiotics
should be given
II.
1-
Congenital heart diseases
high risk patients
• Any patient reaches NYHA III,IV is at high risk
• The situations carries high risk as follow
1- sever pulm. HTN with or without septal defects
(maternal mortality 30-50%)
2-sever left ventricular outflow obstruction
3- cyanotic heart diseases with maternal mortality about
2%and incidence of complications of 30%
Such as infective endocardities , arrhythmias
and CHF
Treatment of high risk patients
Pregnancy is not recommended
If pregnancy occurs termination of pregnancy is advised
Physical activity is restricted and bed rest
The patient should be hospitalized at the end of 2nd
trimester
LMWH is given subcutaneous against thromboembolism
In sever aortic stenosis balloon valvotomy can relief
symptoms it is done in the 2 nd trimester
In sever cyanotic heart disease :oxygen
sturation,,heamatocrite,and HB monitoring is important
2-Low risk patients
Patients with small or moderate shunts
without pulm, HTN
Patients who have had cardiac surgery
early in life without prothesis
Patients with mild , mod valve regurg.
With mild or mod LV out flow tract
obstruction
Follow up done every trimester
Specific conditions
1- pulm stenosis
RVOT obstruction tend to be well tolerated
during pregnancy
No deaths and low maternal complications
15% have been reported
In cases of sever RT ventricular failure
balloon valvotomy is the method of choice
2- Tetralogy of Fallot
Pregnancy in non-operated patient carries a risk
for mother and fetus
The risk is high when O2 stauration below 85%
Close monitoring of BP and gases with
avoidance of any further systemic dilatation
The risk in good repaired patient is very low
All patients with TF should have genetic
counseling before conception
3- Coarctation of aorta
Should be repaired prior to pregnancy
The management of hypertension is difficult in
non-operated patient
Toxemia doesn’t occur but treatment may cause
very low pressure in distal segment
This may result in abortion or foetal death
Rupture of aorta is the commonest cause of
death
BB should be prescribed with avoidance of
volume excess and CO
4-Eisenmenger syndrome
associated with a high risk of maternal
morbidity and mortality
It is also associated with a poor fetal
outcome, with a high incidence of fetal
loss, prematurity, intrauterine growth
retardation, and perinatal death
patients with Eisenmenger syndrome
should be advised against pregnancy and
early abortion should be recommended
Because of increased incidence of peripartum
thromboembolism, anticoagulant therapy seems
indicated in the third trimester of gestation and
for 4 weeks post partum
Spontaneous labor is preferred to induction and
should lower the chance of prematurely or the
need for cesarean section
an attempt should be made to shorten the 2nd
stage of labor by the use of forceps or vacuum
extraction with good oxygenation
ANTIBIOTIC PROPHYLAXIS
for vaginal delivery in all patients with CHD
(except those with an isolated secundum
type of ASD or surgical ligation and
division of PDA) seems reasonable
Cardiovascular disorders
aquired during pregnancy
1- peripartum cardiomyopathy
(modified criteria for diagnosis )
1-Development of cardiac failure during
pregnancy or within 6 months of delivery
2-Absence of a determinable cause for
cardiac failure
3-Demonstrable impairment in left
ventricular systolic function
ETIOLOGY
A distinct etiology of PPCM remains unknown
Nutritional deficiences
Myocarditis
– Infections
– Autoimmune
Idiopathic
The incidence of peripartum cardiomyopathy is
greater in multiparous women and in those with
preeclampsia and twin pregnancies
Echocardiography
TREATMENT
Non-pharmacological
– Salt restriction (4gm/d)
– Water restriction (2 L/D)
Pharmacological
– Pre-load reduction (diuretics, nitrates)
– After-load reduction (hydralazine, nitrates,
amlodipine)
ACE-I contraindicated during pregnancy
– + ionotropes (digoxin, dopamine, dobutamine)
– Beta-blockers
Con.
TREATMENT
Immunosuppressive agents
May be initiated in patients with PPCM and
biopsy-proven myocarditis, but efficacy is
unclear
Empiric immunosuppression, in the absence of
evidence of myocarditis, is not currently
recommended
Figure 3 Cardiac causes of maternal deaths in the UK: confidential
enquiry into maternal deaths 1997–99 (total maternal deaths = 409,
cardiac deaths = 41).
2-Hypertension in Pregnancy
Classification
Chronic hypertension
Preeclampsia-eclampsia
Preeclampsia Superimposed upon chronic
hypertension or Renal Disease
Gestational hypertension (only during pregnancy)
Transient hypertension (only after pregnancy)
A.Chronic Hypertension
Defined as hypertension diagnosed
Before pregnancy
Before the 20th week of gestation
During pregnancy and not resolved
postpartum
B.Gestational Hypertension
Diagnosis of gestational hypertension:
Detected for first time after midpregnancy
Gestational Hypertension:
– Systolic >140
– Diastolic>90
No proteinuria
If preeclampsia does not develop and
BP returns to normal by 12 weeks postpartum, diagnosis is transient
hypertension.
BP remains high postpartum, diagnosis is chronic hypertension.
Proteinurea develops Preeclampsia is diagnosed (25% incidence)
Drug Therapy of Hypertension in Pregnancy
Drug
Example
Comment
α2-adrenergic blockers
Methyldopa
Most commonly used.
Safety well established.
Drug of choice.
Beta-blockers
Atenolol, Metoprolol
Appear safe. Case reports of
fetal bradycardia, growth
retardataion.
α, β blockers
Labetolol
Appears effacious. Very scant
safety data.
Arteriolar vasodilators
Hydralazine
Effacacious and safe during
pregnancy and lactation.
ACE inhibitors
Captopril
Absolutely contraindicated
during pregnancy due to fetal
toxicity.
Calcium channel blockers
Diltiazem
Appear safe, but not as much
data to support their use.
Diuretics
Furosemide
Appears safe, but limited
efficacy.
Sodium nitroprusside
Avoid in pregnancy due to
potential for fetal thiocyanate
toxicity
Magnesium sulfate
Treatment of choice for
prevention of ecclamptic
seizures.
Adapted from reference 7.
Treatment of Acute Severe
Hypertension in Pregnancy
SBP > 160 mm Hg and/or DBP > 105 mm Hg
Parenteral hydralazine is most commonly
used.
Parenteral labetalol is second-line drug
(avoid in women with asthma and CHF.)
Oral nifedipine used with caution. (Shortacting nifedipine is not approved by FDA for
managing hypertension.)
Sodium nitroprusside may be used in rare
cases.
C.Preeclampsia-Eclampsia
Diagnosis
Gestational Hypertension:
– Systolic >140
– Diastolic>90
Proteinuria is defined as urinary excretion
– 0.3 g protein or greater in a 24-hour
– +2 or greater on urine dip specimen
Criteria for Severe Preeclampsia
(one or more)
–
–
–
–
Blood Pressure: >160 systolic, >110 diastolic
Proteinurea: >5gm in 24 hours, over 3+ urine dip
Oligurea: less than 400ml in 24 hours
CNS: Visual changes, headache, scotomata,
mental status change
– Pulmonary Edema
– Epigastric or RUQ Pain: Usually indicates liver
involvement
Indications for Delivery in
Preeclampsia
Gestational age 38 weeks
Platelet count < 100,000 cells/mm3
Progressive deterioration in liver and
renal function
Suspected abruptio placentae
Persistent severe headaches, visual
changes, nausea, epigastric pain, or
vomiting
Preeclampsia
III. ARRHYTHMIAS
Serious cardiac arrhythmias are uncommon in
pregnancy due to the low prevalence of heart
disease in women in the reproductive age group
Pre-existing arrhythmias may be aggravated and
new arrhythmias appear for the first time in
pregnancy
Arrhythmias occurring in structurally normal
hearts are uncommon and usually benign.
Tachyarrhythmias such as AF, VT and
VF tend to be associated with SHD
 DC cardioversion can be safely performed
and should not be withheld if the
arrhythmia is associated with
haemodynamic instability
 Although no drug is completely safe,
digoxin, quinidine, procainamide and
adenosine are well tolerated
 BB are useful agents but use of atenolol,
specifically during the first trimester may
be associated with intrauterine growth
retardation
COMPLETE HEART BLOCK
 it is usually congenital
 Patients with CHB may remain asymptomatic
during pregnancy and have an uncomplicated
labor and delivery without treatment
 Symptomatic patients with conduction
abnormalities treated during pregnancy with
either temporary or permanent pacemakers
 It has been done with electrocardiographic and
echocardiographic guidance in some cases to
avoid ionizing radiation
IV.
Coronary artery disease and
pregnancy
Familial hyper chlesterolimia, obesity smoking
and diabetes is the main factors
Acute myocardial infarction during pregnancy is
rare, occurring in 0.01 percent of pregnancies
Most myocardial infarctions occur during the
third trimester in women over age 33
in situ coronary thrombosis, and coronary
dissection occur more frequently than classic
obstructive atherosclerosis
Medical therapy for acute myocardial
infarction must be modified in the pregnant
patient
Thrombolytic agents increase the risk of
maternal hemorrhage substantially to 8%
Low dose aspirin and nitrates..BB Short-term
heparin generally are safe.
(ACE) inhibitors and statins are
contraindicated
Hydralazine and nitrates may be used as
substitutes for ACE inhibitors.
Drug therapy in pregnancy
Balancing act
maternal
treatment
fetal
effects
Little scientific evidence
Maternal fetal transfer
Placental transfer
Drugs & metabolites in fetus
Fetal GI absorption
Transfer via breastmilk
Cardiovascular Drugs In Pregnancy
Drug
Use
Potential
Side Effects
Safe
Use During
Breastfeeding
Adenosine
Arrhythmia
None reported
Yes
No data
Amiodarone
Arrhythmia
IUGR, prematurity,
hypothyroidism
No
No data
ACE inhibitors
Hypertension
Oligohydramnios, IUGR, PDA,
prematurity, neonatal
hypotension, renal failure,
anemia, death,
musculoskeletal abnormalities
No
Ok
Beta-blockers
Hypertension,
arrhythmias, MI, ischemia,
HCM, hyperthyroidism,
mitral stenosis, Marfan
syndrome,
cardiomyopathy
Fetal bradycardia, low birth
weight, hypoglycemia,
respiratory depression;
prolonged labor
Yes
Ok
Digoxin
Arrhythmia, CHF
Low birth weight, Prematurity
Yes
Ok
Diuretics
Hypertension, CHF
Reduced utero- placental
perfusion
Unclear
Ok
Flecainide
Arrhythmia
? fetal death; limited data
Limited data
Limited data
Lidocaine
Arrhythmia, anesthesia
Neonatal CNS depression
Yes
Ok
Low Molecular Weight
Heparin
Mechanical valve,
hypercoaguable state,
DVT, AF, Eisenmenger
syndrome
Hemorrhage, unclear effects
on maternal bone mineral
density
Limited data
Limited data
Nitrates
Hypertension
Fetal distress with maternal
hypotension
Yes
No data
Procainamide
Arrhythmia
None reported
Yes
Ok
Sodium
nitroprusside
Hypertension,
aortic dissection
Fetal thiocyanate
toxicity
Potentially
unsafe
No data
Sotalol
Arrhythmia
Fetal bradycardia,
IUGR
Limited data
Ok
Unfractionated
Heparin
Mechanical valve,
hypercoagulable
state, DVT, AF,
Eisenmenger
syndrome
Maternal
osteoporosis,
hemorrhage,
thrombocytopenia,
thrombosis
Yes
Ok
Warfarin
Mechanical valve,
hypercoagulable
state, DVT, AF,
Eisenmenger
syndrome
Warfarin
embryopathy, fetal
CNS abnormalities,
hemorrhage
Yes—after the
12th week of
gestation
Ok
IUGR = intrauterine growth retardation, ACE = angiotensin converting enzyme, PDA = patent ductus arteriosus, MI = myocardial infarction, HCM =
hypertrophic cardiomyopathy, CHF = congestive heart failure, CNS = central nervous system, DVT = deep venous thrombosis, AF = atrial fibrillation
V.
Infective endocarditis
although it is rare complication in pregnancy,
causes mortality in 10–30% of those affected
The development of a new cardiac murmur is
common in pregnancy and can make the
diagnosis of endocarditis difficult
predisposing factors in young women include
MVP, CHD and intravenous drug abuse
The use of antibiotic prophylaxis during
uncomplicated deliveries remains controversial
prophylaxis only for women who are at high risk
is recommended
Antibiotic prophylaxis is
recommended for the following:
High-risk category
– Prosthetic cardiac valves, including
bioprosthetic and homograft valves
– Previous bacterial endocarditis
– Complex cyanotic congenital heart disease
(e.g., single ventricle states, transposition of
the great arteries, tetralogy of Fallot)
– Surgically constructed systemic pulmonary
shunts or conduits
Moderate-risk category
– Most other congenital cardiac malformations (other
than above and below)
– Acquired valvular dysfunction (eg, rheumatic heart
disease)
– Hypertrophic cardiomyopathy
– Mitral valve prolapse with valvular regurgitation and/or
thickened leaflets
Endocarditis prophylaxis is not recommended
for the following: (no greater risk than the
general population)
– Isolated secundum atrial septal defect
– Surgical repair of ASD, VSD, or PDA
– Previous coronary artery bypass graft surgery
– MVP without valvular regurgitation
– Physiologic, functional, or innocent heart
murmurs
– Previous Kawasaki disease without valvar
dysfunction
– Previous rheumatic fever without valvar
dysfunction
– Cardiac pacemakers (intravascular and
epicardial) and implanted defibrillators
Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal
procedures
Category
Drug and dosage
High-risk patient
Ampicillin, 2 g IM or IV,
plus
gentamicin sulfate (Garamycin), 1.5 mg/kg IV 30 min before
procedure; ampicillin, 1 g IV, or amoxicillin (Amoxil, Trimox,
Wymox), 1 g 6 hr after procedure
High-risk patient
who has
penicillin
allergy
Vancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr,
plus
gentamicin sulfate, 1.5 mg/kg IV 30 min before procedure
Anaesthesia during pregnancy
The choice of anesthesia depends on circumstances of
the delivery and maternal cardiac status
Epidural anesthesia is well tolerated and provides effective
analgesia.
-It minimize HR and BP changes associated with
inadequate pain relief. With cautious fluid preloading,
gradual increments in drug dosages and positioning in the
lateral position,
-It should still be used with extreme caution in those with
restricted cardiac output or right-to-left shunts.
summary
Women at low risk are those who have
few or no symptoms and good LV function
Those of high risk need to be managed
within or from a cardiac center
The mode and time of delivery should be
discussed and vaginal delivery usually
advised
Antibiotic prophylaxis is not advised for a
normal delivery
Thank you