Akram Sardari.MD Fellowship Of Echocardiography Imam Khomeini Hospital VALVULAR DISEASE IN PREGNANCY

-Cardiovascular disease in 1% - 4% of pregnancies. -With increased numbers of pregnancies heart disease as the leading cause of nonobstetric maternal mortality.

 Plasma volume increase from 6 th week & reaches a maximum of 40% above baseline at 24 weeks gestation.(lesser rise of RBC mass)  A 30–50% increase in CO occurs at the end of the second trimester of normal  A 30–50% increase in CO occurs at the end of the second trimester of normal pregnancy. at 20 weeks and increases until 32 weeks(20%).  HR starts to rise at 20 weeks and increases until 32 weeks(20%). It remains high 2–5 days after delivery. HAEMODYNAMIC ALTERATIONS DURING PREGNANCY

SBP typically falls early in gestation and DBP is usually 10 mmHg below  SBP typically falls early in gestation and DBP is usually 10 mmHg below baseline in the second trimester.  In the third trimester, the DBP gradually increases.  It caused by active vasodilatation, the action of local mediators such as prostacyclin and NO.

 An increase in concentration of : -Coagulation factors -Fibrinogen -Platelet adhesiveness  Diminished fibrinolysis Haemostatic alterations during pregnancy

 Complications are related to: -Severity of MS -Baseline NYHA FC -The rate of premature delivery is 14% in patients with mild MS -up to 33% in patients with severe MS -If severe symptoms develop, there is a 30% risk of fetal mortality MITRAL STENOSIS

- Atrial arrhythmias and HF often occur in the third trimester. -Complications also occur at the time of labor and delivery or within the first week postpartum.

 PMBV is preferably performed after 20 weeks gestation.

with a 30% to 40% fetal mortality rate and up to 9% maternal mortality.  Valve operation during pregnancy is high risk for both the mother and the fetus, with a 30% to 40% fetal mortality rate and up to 9% maternal mortality.

-The patient to be monitiored in a tertiary care center with a didicated Heart Valve Team of Cardiologists,surgeons,anesthesiologists,and obstetericians who have experts in managing high– risk cardiac patients.

 Vaginal delivery should be considered in patients with: - Mild MS -Patients with moderate or severe MS in NYHA class I/II without PHTN.(Decreased second phase time) DELIVERY

 A planned induction is usually advised in women with severe stenotic lesions: -Telemetry monitoring for arrhythmias - Arterial line insertion for accurate measurement of BP  Hemodynamic monitoring during labor and delivery, and for 12 to 24 h post-partum.

 Caesarean section is considered in patients with : -Moderate or severe MS who are in NYHA class III/IV or -Pulmonary hypertension despite medical therapy

 Tocolytic agents with beta-mimetic effects should not be used in women with MS so as to prevent tachycardia-mediated increase in left atrial pressure.

 With asymptomatic mild or moderate AS, pregnancy is well tolerated  With asymptomatic mild or moderate AS, pregnancy is well tolerated. VALVULAR AORTIC STENOSIS -Maternal mortality is rare (<1%) in contemporary pregnancy series.

 Obstetric complications may be increased in patients with severe AS (hypertension-related disorders in 13%).  Pre-term birth, IUGR,LBW occur in up to 25% of the offspring of mothers with moderate and severe AS.

 Women who develop symptoms during pregnancy should be admitted for medical treatment.  There is no effective medical therapy for AS.

 Percutaneous valvuloplasty or valve replacement can be undertaken after early delivery by caesarean section if this is an option.

 The best period for surgery is between the 13th and 28th week.

caesarean delivery should be preferred with endotracheal intubation and general anaesthesia.  In severe AS, particularly with symptoms during the second half of the pregnancy, caesarean delivery should be preferred with endotracheal intubation and general anaesthesia.  In non-severe AS, vaginal delivery is favoured. DELIVERY

 First 72 h postpartum appears to be the time  First 72 h postpartum appears to be the time of greatest risk, with most maternal deaths occurring early after delivery.  The hemodynamic changes reverse most prominently within the first 2 weeks postpartum, but will continue for 6 months.

 There is an increased risk of valve thrombosis in patients with a mechanical prosthesis due to the hypercoagulable state of pregnancy. MECHANICAL VALVES IN PREGNANCY

 All anticoagulant regimens : -Increased risk to the fetus with fetal abnormalities -Increased risk of miscarriage -Hemorrhagic complications(retroplacental bleeding, leading to premature birth and fetal death).

 There is no ideal anticoagulant regimen for pregnant women with mechanical valves.

 Warfarin is the most effective anticoagulant for preventing maternal thromboembolic events during pregnancy(<4%)  Warfarin is the most effective anticoagulant for preventing maternal thromboembolic events during pregnancy(<4%).

 Warfarin crosses the placental barrier and results in anticoagulation of the fetus as well as the mother.

 In patients whose dosage of warfarin is >5 mg per day, the risk of embryopathy is >8% compared with <3% with a warfarin dosage of <5 mg per day.

 Use of UFH throughout pregnancy has the highest risk of thromboembolic events and maternal death in patients with a mechanical prosthesis(33%).

 LMWH given at a fixed dose has resulted in fatal valve thrombosis. When monitored with anti-Xa levels, LMWH has a lower rate of valve thrombosis compared with UFH.

 LMWH may be a better alternative than UFH with potential advantages  LMWH may be a better alternative than UFH with potential advantages : -Better subcutaneous absorption -Better bioavailability -Longer half life - More predictable anticoagulation response

 The optimal anticoagulant used during the first trimester in pregnant patients with mechanical prosthetic valves remains controversial.

 The risk of abortion and fetal loss are increased with any anticoagulant regimen but may be similar in women exposed to oral anticoagulants versus heparin in the first trimester, especially at low doses of warfarin.

 Vaginal delivery in contraindicated in patients on OACs  Vaginal delivery in contraindicated in patients on OACs.

 A planned caesarean section may be considered as an alternative, especially in patients with a high risk of valve thrombosis, in order to keep the time without OACs as short as possible.

 Patients with valve regurgitation tolerate pregnancy better. NATIVE VALVE REGURGITATION

 Patients with severe regurgitation who are already symptom limited or have a reduced LVEF or PHTN may develop HF symptoms because of the volume load of pregnancy.

 Patients with severe regurgitation may be at high risk during pregnancy.  The presence of severe valve regurgitation is also associated with an increased risk to the fetus.

 Valve operation for pregnant patients with severe valve regurgitation is reasonable only if there are refractory NYHA class IV HF symptoms(IIa).

 Valve repair is preferred for the treatment of valve regurgitation in women of childbearing age.

 Vaginal delivery is preferable; in symptomatic patients epidural anaesthesia and shortened second stage is advisable. DELIVERY

 Dilatation and evacuation is the safest procedure in both the first and second trimesters.  If surgical evacuation is not feasible in the second trimester, prostaglandins E1 or E2, or misoprostol, can be administered to evacuate the uterus. METHODS OF TERMINATION OF PREGNANCY

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 One of the major advantages of epidural analgesia is that: -Can be administered in incremental doses -Total dose could be titrated to the desired sensory level -The slower onset of anaesthesia, allows the maternal cardiovascular system to compensate for the occurrence of sympathetic blockade

 General anaesthesia has the disadvantage of: -Increased PAP -Tachycardia during laryngoscopy and tracheal intubation -Adverse effects of positive-pressure ventilation on the venous return may ultimately lead to cardiac failure