Pregnancy and Heart Disease

Physiology Blood volume increases (about 50%) Hg concentration falls “physiologic anemia of pregnancy” Cardiac output increases by about 50% Systemic blood pressure falls during the first and second trimester, returning to normal before term

Physical Exam Normal pregnancy is often accompanied by symptoms of: – fatigue –decreased exercise capacity – hyperventilation – dyspnea –palpitations –lightheadness –syncope

Physical Exam LE edema is common RV heave is usually present in the second and third trimesters Pulmonary trunk and pulmonic valve closure are often palpable

Physical Exam The S1 is increased with exaggerated splitting that may mimic S4 Innocent systolic murmurs may be heard as a result of the hyperkinetic circulation of pregnancy –They are midsystolic and soft –Heard best over the pulmonic area and radiate to the suprasternal notch

Physical Exam Continuous murmurs –Venous hum, heard over the right supraclavicular fossa –Mammary souffle heard over the breast late in gestation and decreases when pressure is applied with the stethoscope

Effect of pregnancy on various cardiovascular conditions

Mitral Stenosis The majority of patients with moderate- severe MS worsen during gestation The pressure gradient across the narrow valve increases secondary to the increased heart rate and blood volume Left atrial pressure increases and may lead to atrial arrhythmias

Mitral Stenosis There is marked increase in the following issues regarding the fetus –Rate of prematurity –Fetal growth retardation –Low neonatal birth weight

Mitral Stenosis Therapeutic approach is to reduce the heart rate and decrease left atrial pressure –Restrict physical activity –Restrict salt intake –diuretics –Beta blockers –Digoxin (if patient is in a. fib)

Mitral Stenosis Repair or replacement of the valve may be necessary if medical therapy is ineffective –Balloon valvuloplasty –Surgery (repair/replacement)

Mitral Stenosis Vaginal delivery can be permitted in most patients Hemodynamic monitoring is recommended (Swan) and should be continued several hours following delivery

Aortic Stenosis Mild AS is usually tolerated Moderate to severe AS is likely to be associated with symptomatic deterioration during pregnancy Women with valve area <1.0 should consider valve replacement prior to pregnancy

Aortic Stenosis Symptoms often develop in the 2nd and 3rd trimester –Exertional dyspnea –Chest pain –Syncope

Aortic Stenosis Patients may require balloon valvuloplasty or surgical intervention Fetal effects included –Intrauterine growth retardation –Premature delivery –Reduced birth weight –Increase in cardiac defects

In general regurgitant valvular lesions are well tolerated during pregnancy

Eisenmenger Syndrome High risk of maternal morbidity and mortality Death usually occurs between the first few days and weeks after delivery, but the cause is unclear Patients should be advised against pregnancy

Eisenmenger Syndrome Patients should be monitored closely for any signs of deterioration Early elective hospitalization is recommended Hemodynamic monitoring is required

Marfan’s Syndrome Pregnancy in patients with Marfan’s poses 2 problems –Cardiovascular complications of the mother –Risk of having a child who inherits Marfan’s syndrome

Marfan’s Syndrome Cardiovascular problems –Dilation of the ascending aorta, may lead to development of aortic regurg. and heart failure –Proximal and distal dissections of the aorta with possible involvement of the coronaries or iliacs Patients with only mild dilation (<40mm) of the ascending aorta usually do well

Marfan’s Syndrome Obstetrical complications –Cervical incompetence –Abnormal placental location –Postpartum hemorrhage

Marfan’s Syndrome Patients with more than mild dilation of the aorta, or history of aortic dissection should be advised against pregnancy Progressive dilation of the aorta during gestation may occur even with a normal-sized aorta –Preconception echo evaluation allows for evaluation of the aortic root. Periodic echocardiographic follow-up is recommended

Marfan’s Syndrome Management –Vigorous physical activity should be avoided –Beta blockers (reduces the rate of aortic dilation) –If substantial dilation/dissection should occur, depending on the stage of pregnancy, therapeutic abortion, early delivery or surgical intervention should be considered

Hypertrophic Cardiomyopathy Most cases have favorable outcomes Symptoms may worsen, especially in patients who were already symptomatic –Increased SOB –Fatigue –Chest pain –Syncope The risk of the fetus of inheriting the disease is as high as 50%

Hypertrophic Cardiomyopathy Management –Avoid blood loss and drugs that can lead to vasodilation –Treat any tachyarrhythmias with medication as needed –Patients who meet criteria for placement of ICD, should have it done prior to conception

Primary Pulmonary Hypertension Associated with high maternal mortality estimated to be 30-40% Clinical deterioration can not be predicted on the basis of the patient’s pre-pregnancy status Deterioration usually occurs in the second/third trimester

Primary Pulmonary Hypertension Symptoms may include –Fatigue –Dyspnea –Chest pain –Syncope Death often occurs a few hours to several days post partum usually related to sudden death or progressive RV failure, although the exact cause of death is not clear

Primary Pulmonary Hypertension Fetal effects include –High incidence of prematurity –Fetal growth retardation –Fetal loss Pregnancy should be discouraged in all patients with primary pulmonary HTN

Primary Pulmonary Hypertension For patients who chose to continue pregnancy –Anticoagulation –Continuous hemodynamic monitoring during labor and delivery –Oxygen therapy and possibly inhaled nitric oxide or prostaglandins

Peripartum Cardiomyopathy A form of dilated CMP with LV systolic dysfunction that results in the signs and symptoms of heart failure Criteria –Development in last month of pregnancy or the first 5 months after delivery –Absence of heart disease prior to last month of pregnancy –Absence of identifiable cause of heart failure –LV systolic dysfunction

Peripartum Cardiomyopathy Can occur at any age, more common in women over 30 Strong relationship between the development of peripartum CMP and gestational hypertension, twin pregnancy and use of tocolytic therapy

Peripartum Cardiomyopathy Clinical exam –Enlarged heart –S3, murmurs of MR and TR –Tachycardia –ST-T wave abnormalities –arrhythmias

Peripartum Cardiomyopathy clinical course varies –50-60% of patients demonstrate complete recovery within the first 6 months –The rest of the patients demonstrate either further clinical deterioration, leading to cardiac transplant or premature death, or persistent LV dysfunction and chronic heart failure

Peripartum Cardiomyopathy Management –Acute heart failure treatment with O2, diuretics, digoxin and vasodilators (hydralazine is safe) –Because of the increased incidence of thromboembolic events, anticoagulation therapy is recommended

Peripartum Cardiomyopathy Subsequent pregnancies are often associated with relapse The likelihood of relapse is greater in patients with persistently abnormal cardiac function, but may be seen in patients who demonstrate full recovery Pregnancy should be discouraged in patients with persistent LV dysfunction

Hypertension Defined in pregnancy as >140/90 Complicates 8-10% of pregnancies May effect maternal morbidity/mortality: – abruptio placenta – pulmonary edema – respiratory failure – DIC –Cerebral hemorrhage –Hepatic failure –Acute renal failure

Hypertension Chronic HTN –HTN that preceded pregnancy or is detected prior to the 20th week –Occurs 1 in 5 pregnancies –Drug therapy is recommended for high risk characteristics of preeclampsia (poor obstetric history, renal insufficiency, diabetes, severe HTN with evidence of end-organ involvement) –Low risk patients (SBP ) and normal exam, normal ekg and echo, antihypertensive therapy has not been shown to prevent the development of preeclampsia or affect fetal outcome

Hypertension Gestational HTN –Begins after 20 weeks and resolves by the 6 postpartum week Transient (without proteinuria) Preeclampsia (proteinuria) –Preeclampsia should be considered and seizure prophylaxis should be instituted empirically in patients with BP >160/110

Hypertension Preeclampsia-Eclampsia –Usually occurs after 20 weeks –SBP>140/ DBP>90 and proteinuria –The disease is highly suspect even in the absence of proteinuria if symptoms of headache, blurred vision, pulmonary edema, elevated LFT, low platelets –Usually reversible within hours after delivery

Hypertension The majority of patients with SBP> and DBP <110 are at low risk of cardiovascular complications and are candidates for nondrug therapy Indications for drug therapy include –SBP>160, DBP>110 –End-organ damage (LVH, renal insufficiency)

Hypertension Management –Methlydopa is the preferred therapy but may also use labetalol and nefedipine. –An effective prepregnancy regimen can often be continued with the exception of ACE inhibitors or ARBs –ACEI/ARB may cause significant fetal risks including damage to the cardiovascular, renal and central nervous systems –Delivery is the only definitive treatment of preeclampsia

Prosthetic Heart Valves Increased thromboembolic events have been reported during pregnancy in women with prosthetic valves, incidence as high as 10-15% 2/3rds of these patients presented with valve thrombosis which led to death in 40%

Prosthetic Heart Valves Oral anticoagulants can cross the placenta and be harmful to the fetus Exposure during the first 8-12 weeks can be associated with a teratogenic effect leading to warfarin embryopathy (nasal deformity) as well as other complications –intracranial bleeding –Congenital anomalies –Fetal wastage –Spontaneous abortion/fetal loss

Prosthetic Heart Valves ACCP recommendations for anticoagulation in pregnant patients with porsthetic heart valves –Unfractionated heparin(UFH) SQ q12 hours throughout pregnancy following PTT levels –LMWH (Lovenox) throughout pregnancy following anti-Xa levels –LMWH or UFH until week 13, then coumadin until middle of third trimester, then restart UFH/LMWH until delivery

Imaging CXR - radiation exposure is minimal Echo - safe Stress testing - use low level exercise protocol to obtain 70% maximal heart rate, use with fetal monitor CT scan - radiation may vary MRI- no known risk to the fetus Cardiac cath - relatively high doses of radiation, obtain access via the brachial artery rather than femoral to limit fetal radiation

Imaging Radiation exposure –5 rads - low risk –5-10 rads - provide counseling regarding the low risk of problems –10-15 rads - during the first 6 weeks, individual consideration for termination –>15 rads - termination recommended

Case 34 year old female presents to the emergency room 2 weeks after giving birth to twins. Her pregnancy and delivery were uneventful. She now is feeling short of breath. She notes that she can not sleep flat at night anymore.

On physical exam she has bibasilar rales and is tachycardic with an S3 present. –What disease state do you suspect? –What testing would you like to order?

EKG: ST with non-specific ST-T wave abnormalities CXR: pulmonary edema with cardiomegaly Echo: dilated LV with depressed ejection fraction at 30%

How would you treat this patient? What does the diagnosis of peripartum cardiomyopathy mean for her long term prognosis?

Treatment is similar to other forms of heart failure –Diuretics –Vasodilators –Digoxin 50-60% of patients make a full recovery within 6 months.