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ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY

ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY. INTRODUCTION. Prevalence of maternal heart disease -< 1%, its presence increases the risk of adverse maternal, fetal, and neonatal outcomes

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ACQUIRED HEART DISEASES IN PREGNANCY ANTICOAGULATION IN PREGNANCY

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  1. ACQUIRED HEART DISEASES IN PREGNANCYANTICOAGULATION IN PREGNANCY

  2. INTRODUCTION • Prevalence of maternal heart disease -< 1%, its presence increases the risk of adverse maternal, fetal, and neonatal outcomes • 0.2–4% of all pregnancies in western industrialized countries. {Am J ObstetGynecol 1998;179:1643–1653.}. In western countries maternal heart disease is now the major cause of maternal death during pregnancy

  3. RHD dominates in non-western countries [56–89% ] Congenital heart disease [just 9–19%]. Eur J Heart Fail 2008;10:855-860, Circulation 2001;104:515-521.

  4. STUDY • A Canadian study analyzed the outcomes of pregnancy in a group of women with congenital or acquired heart disease (562 women and 599 pregnancies) CARPREG study (Circulation.2001;104:515-21.)

  5. Maternal outcomes • Incidence of adverse maternal cardiac events • 13% of completed pregnancies • More likely if: • EF below 40% • Left heart obstruction (AS with a valve area of less than 1.5 cm2 or MS with a valve area of less than 2.0 cm2) • Previous cardiovascular events or arrhythmia • NYHA class > II or cyanosis. • These events occurred in: • 4% of the women with none of these risk factors • 27 % of those with one risk factor • 62 % of those with two or more risk factors • The 3 women that died had two or more risk factors Sui et al

  6. Fetal outcomes • NYHA class III or IV and left heart obstruction were predictors of fetal outcomes also. • Other predictors of adverse fetal outcomes include: • The use of anticoagulant drugs • Smoking during pregnancy. • Multiple gestation. • Mother’s age (> 35 yrs or < 20 yrs). ZAHARA study • Fetal mortality : • 4 % among pregnancies in women with one or more of these risk factors. • 2% among those with none of these risk factors.

  7. WHO CLASS IIMost arrythmiasWHO CLASS II/IIIMild LV impairment VHD not included in class IVWHO CLASS IIIMechanical valve

  8. CLASS IV Pulmonary hypertension of any causePrevious PCM with LV impairmentSevere MS and severe symptomatic ASSevere LV dysfunction

  9. Evaluation • The evaluation- Pre conceptional and entail a full cardiac assessment. H/o exercise capacity, current or past evidence of heart failure and associated arrhythmias. • Cardiac hemodynamics -PAP and the severity of valve dysfunction - assessed by echo. • Exercise testing - Assessment of functional capacity. • During pregnancy evaluation of each trimester - Assess any deterioration in maternal cardiac status.

  10. INVESTIGATIONS -ECHO • Gradients in RVOT and LVOT increase • Increased stroke volume cause increase in severity of regurgitation. • LVEDD increased • TEE can be performed safely • Fetal echo best in 20 weeks gestation.

  11. TMT • 80% of predicted heart rate • No evidence of spontaneous abortion • Dobutamine stress should be avoided • Assessment of myocardial reserve pre pregnancy in PPCM & VHD • Nuclear stress tests are avoided.

  12. Fluoroscopy risks Majority of procedures are < 1mGy to fetus RCR -2009 guidelines During the first 14 days of fertilization -no risk After 14 days major risk occurs if doses > 100mGy Doses <50 mGy –no risk 50-100 mGy –risk not clear

  13. Estimated radiation exposure

  14. Valvular Heart Disease Severity • Risk Stenotic lesions > Regurgitant lesion • Left sided diseases> Right sided disease

  15. MS • Poorly tolerated [ moderate & severe MS]- Tachycardia, increased plasma volume • PHT, Trans valvular gradients, PAP measurements are less reliable marker of severity • Maternal Risks- HF symptoms, Pulmonary edema in II & III trimester. AF [increases risk of T.Emb, pulmonary edema] ( El Kayametal, 2005 JACC) • Moderate & severe MS counseled against pregnancy without prior intervention • Fetal risks- prematurity 20-30%; IUGR 5-20% ( El Kayam & Hameed 2001) & Silversides JACC 2001: 37:893-899

  16. MS INTERVENTIONS • NYHA III or IV patients or valve area less than 1 cm2 , BMV or MVR before pregnancy. • BMV - second trimester in NYHA III/ IV or with PAP above 50 mm Hg despite optimal medical therapy. • MVR during pregnancy- high fetal loss (30%) hence reserved till all measures fail and mother`s life is in danger. • Anticoagulation in AF OR in bed rest.

  17. BMV OUTCOMES • BMV in pregnancy KEM study (Gupta et al) –successful outcomes of 40 pregnancies. • Ribeiro et al (1992)study on maternal outcomes in 78 patients-8 patients developed mod MR, No evidence of PE • De Souza et al(2001) compared the outcomes of PBMV v/s OMC in 21 pts with severe MS -38% fetal death in OMC • Current consensus –PBMV to symptomatic patients with severe MS with OMT/ MVA 0.75-1.2cm2 • Complications- CT , AF ,MR ,emboli, uterine contractions & labor

  18. PERIPARTUM MANAGEMENT • Vaginal delivery is the usual approach. • Avoidance of volume overload and tachycardia is the main hemodynamic goal. • In unstable patients, monitoring with arterial line and PCWP aids in optimum hemodynamic management.

  19. PERIPARTUM MANAGEMENT • Epidural analgesia. • Assisted-delivery devices during the second stage of delivery eliminate hemodynamic effects of valsalva maneuver during “pushing”. • Caesarean section for obstetrical indications.

  20. Pharmacological management of symptoms MS with symptoms or PAH, restricted activities and β1-selective blockers are recommended. Diuretics are recommended when congestive symptoms persist despite β-blockers. BMV NYHA class III/IV or sys PAP > 50mm Hg, preferably after 20 weeks POG. [CI in asymptomatic women] • Anticoagulation • Paroxysmal or Permanent AF, LA thrombus, prior embolism • Considered in mod/sev MS with spontaneous echo contrast, LA > 40ml/m2, low CO, CCF

  21. MITRAL REGURGITATION • Well tolerated due to reduction in SVR. • Women with symptomatic MR may benefit from mitral-valve surgery (preferably repair))before becoming pregnant. • Diuretics may be indicated. • Outcome data that would help to guide clinical decision making in this area are lacking.

  22. AORTIC STENOSIS • Congenital valvular abnormalities are usually the cause of AS in young women in the US. • Severe AS is poorly tolerated during pregnancy. • Maternal and perinatal mortality of 17% and 32% respectively have been reported. (Pieper et al 2008)

  23. AORTIC STENOSIS • Symptomatic patients - peak outflow gradient > 50 mm Hg are advised to delay conception until after surgical correction. • Termination of pregnancy- if patient is symptomatic before the end of the 1st trimester. • Even severe AS may be asymptomatic • Aortic-valve replacement and palliative aortic balloon valvuloplasty have been performed during pregnancy with associated maternal and fetal risk.

  24. CONTD….. • Maternal risk HF 10%, Arrhythmias 3-25%(Pieper et al 2008) • Fetal risk- Preterm Labour, IUGR, LBW

  25. PERIPARTUM MANAGEMENT • Vaginal delivery is the usual approach. Oxytocin may decrease the SVR and increase PAP. Epidural analgesia may be given. Avoid sudden decrease in SVR. • Cesarean section GA has traditionally being advocated to avoid sudden decreases of SVR. Case reports of regional anesthesia with positive outcomes.

  26. Pharmacological management of symptoms HF- treat with diuretics AF- b-blockers, CCB to control HR, Digoxin also may be used • Pre- pregnancy intervention • Symptomatic severe AS • LVEF<50%, severe LVH (PW> 15mm) • TMT- symptoms or falling BP • Recent progression of AS • Asc. Aorta> 50 MM (27.5mm/m2) • During Pregnancy • Severe symptomatic AS + refractory to medical therapy/ life threatening symptomsNon calcified valve may be subjected to BAV/ emergency AVR • Delivery • Vaginal delivery + regional anesthesia in non-sev AS • LSCS in Sev AS

  27. Aortic Regurgitation • Root dilatation (Marfan syndrome ),Bicuspid Aortic valve, and RHD are the commonest causes. • The reduced SVR of pregnancy reduces the volume of regurgitated blood • Women with an abnormal functional capacity or left ventricular dysfunction are predicted to have a high risk of abnormal maternal outcomes, but few data concerning this population are available

  28. Tricuspid valve lesions • Better tolerated • Maternal risk- HF, Arrhytmias, Progressive worsening of regurgitations • Moderate to severe Regurgitant lesions may undergo exercise testing to decide pre pregnancy intervention • Severe lesions + symptoms/ impaired LV function/ Ventricular dilatation  treated surgically, if possible repair • TV repair if moderate Secondary TR with annular dilatation >40mm, usually during left sided valve surgeries

  29. PS & PR PS is generally well tolerated • Complications of sev PS- RV failure & Arrhythmias • Pre pregnancy balloon valvuloplasty in severe stenosis (peak Doppler gradient > 64 mmHg) • LSCS is considered in patients with severe PS and in NYHA class III/IV despite medical therapy and bed rest, in whom percutaneous pulmonary valvotomy cannot be performed or has failed. Hameed et al ( JACC 2003 )

  30. Severe PR with impaired RV function • Pre-pregnancy pulmonary valve replacement (preferably bioprosthesis) should be considered

  31. Prosthetic valves Mechanical valves • Excellent H.D. Performances • Long term durability • Thrombogenic Bioprosthetic valves • Good H.D Performances • Much less thrombogenic • High risk of valve degeneration [~50% women <30yrs at 10 yr post implant] • M> A,T position • Reoperation mortality risk addl 5%

  32. Management of valve thrombosis in pregnancy • Presents as embolism or dyspnoea • TTE and then TEE is required. If still not confirmed a fluoroscopy is done • Fibrinolysis is recommended • ESC 2010 guidelines - anticoagulation optimisation for small clots • Thrombolysis has shown little negative effects on fetus • Streptokinase bolus of 250000 IU followed by 100000 iu/hr for 72hrs

  33. General Management • Percutaneous intervention- • After 4th month in the second trimester [ organogenesis complete, fetal thyroid still inactive, volume of uterus small] • ACT b/w 200-300s • CPBypass- • 13th & 28th week [Fetal malformation - I trim & maternal complication - III trim] • 3-6% late neurological impairment in children, high fetal mortality hence Sx only when refractory to medical therapy, interventional procedures fail, mother’s life threatened

  34. Peripartumcardiomyopathy Eur J Heart Fail 2010;12:767–778.

  35. Etiology Fas/Apo-1, C-reactiveprotein, IFN-g and IL-6 Cathepsin D in response to oxidative stress cleaves Prolactin into angiostatic & proapoptotic fragment 16 kDaProlactin Viruses Autoimmune

  36. Differential diagnosis Eur J Heart Fail 2010;12:767–778.

  37. Natural history . Am J ObstetGynecol 2008;199:415.e1-415.e5.

  38. PRESENTATION • First 4 months after delivery- most of them(78%) • Last month of pregnancy- 9% • > than 4months after delivery or before 1month of pregnancy 13% CLINICAL FEATURES • Features of right heart or left heart failure or both • Can present as ventricular arrythmia • 92% heard a third heart sound (2005 South African study) • LV thrombosis is seen

  39. INVESTIGATIONS • Diagnosis of exclusion • ECG – 66% LVH, 96% ST-T changes • Elevated BNP and NT pro BNP • Echo – Not all have LV dilatation and LVEDD>60 predicts poor recovery • MRI is a better predictor of LV functions and assesses the chamber volumes better.( Late gadolinium enhancement)

  40. FOLLOW UP • Repeat echo after 6weeks, 6months and then annually • MRI at 6months and annually for accurate assessment of LV volumes and function

  41. MANAGEMENT • Similar to HF management • O2 administration to reach saturation of>95% • NIV and PEEP 5-7.5 cm H2O • Loop diuretics and NTG • Inotropics when required • Pts after OMT and IABP ,the pt may require assist device or cardiac transplantation LVAD used as bridge to transplantation or destination therapy

  42. Management of stable heart failure • ACEI and ARB avoided • Hydralazine and nitrates combination used safely • Beta 1 selective agents are preferred • LMWH and UFH used in pregnancy • Role of CRT AND ICD- pt with LV dysfunction for 6 months post presentation • Bromocriptine- used in acute stage- 2.5mg bd (Denise etal 2007)

  43. Delivery need not be done in asymptomatics • Encouraged in deteriorating patients • Vaginal delivery encouraged but LSCS in critically ill patients • Left lateral position encouraged

  44. Prognosis • No European studies • Vary geographically

  45. SA- 6m & 2yr mortality rates 10% & 28%. Brazil & Haiti 6m rate 14– 16% Turkey- 4yr rate 30% LV func. returns to normal in 23–41% Eur J Heart Fail 2010;12:767–778.

  46. Counselling • LVEF <25% subsequent pregnancies discouraged • High risk of relapse in subsequent pregnancies Elkayam et al and Habli et al ( 2 studies)

  47. Hypertensive disorders • Accounts for 15% of all pregnancies • BP recordings in lateral recumbent posture • Ambulatory BP monitoring is superior • Investigations – LFT, RFT, urine r/e, Uric acid , Hct • Proteinuria >2g/d –close monitoring >3g/d – delivery VMA and plasma metanephrine analysis along with USG abdomen Doppler USG for uteroplacental perfusion.

  48. Classification • Pre existing hypertension • Gestational hypertension • Pre existing hypertension with superimposed gestational hypertension with proteinuria • Antenatally unclassifiable hypertension • Hypertension defined as SBP> or = 140 & DBP > or = 90 • Mild- 140-159/90-109 , Severe ->or = 160/110mmHg

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