Cardiorespiratory Disease in Pregnancy

Question 1

What are the recommendations for management of mechanical heart valve anticoagulation in perinatal care?

Answer 1

Continue warfarin in pre-conception until pregnancy confirmed.

Wafarin < or = 5 mg: Continuation through all trimesters reasonable after full discussion of risks and benefits (IIa) OR LMWH T1, followed by warfarin in T2 & 3 (IIb)

Warfarin > 5 mg: Start weight based LMWH BID targeting an anti-Xa level 0.8-1.2 u/mL 4-6 hours post dose for first trimester, switch back to warfarin in 2nd & 3rd trimester (IIa) OR LMWH all three trimesters (IIb)

Question 2

What is the peripartum management of anticoagulation for mechanical valves?

Answer 2

On VKA - Switch to LMWH or IV UFH at least 1 week before planned delivery. If labor begins or urgent delivery is required in women on VKA, cesarean section should be performed after reversal of anticoagulation.

On LMWH - Must switch to UFH at least 36 hours prior to planned delivery and stop at least 6 hours prior to planned vaginal delivery.

Question 3

What are common physiologic cardiac symptoms in pregnancy?

Answer 3

Dizziness
Palpitations
Dyspnea
Orthopaedic
Peripheral Edema

Question 4

How does cardiac output and plasma volume change during pregnancy?

Answer 4

Cardiac output and plasma volume increases by 50% and peak in T2

Question 5

When does peripartum cardiomyopathy typically occur?

Answer 5

Usually in the last month of pregnancy, up until 5 months postpartum.

Question 6

What is the prognosis of peripartum cardiomyopathy?

Answer 6

1/3 recover spontaneously postpartum

Question 7

What are the implications for future pregnancy in patients who have a history of peripartum cardiomyopathy?

Answer 7

If EF recovers > 40%, then 20% recurrence of peripartum cardiomyopathy.

If EF remains < 40%, then 50% recurrence of peripartum cardiomyopathy and 20% associated mortality.

Question 8

How do you treat peripartum cardiomyopathy?

Answer 8

• Furosemide (caution, avoid excessive volume contraction.
• Beta-blocker (metoprolol preferred if compensated)
• Consider nitrates, hydralazine and digoxin
• Avoid ACEi/ARB & spironolactone

Question 9

What medications are safe in the treatment of SVT during pregnancy?

Answer 9

(1) Adenosine
(2) Beta-Blockers (Exception = Atenolol)
(3) CCB (Verapamil)

Can cardiovert if need be

Question 10

What is the concern with amiodarone in pregnancy?

Answer 10

Fetal Hypothyroidism

Question 11

What is the recommended pre-pregnancy planning for women with valvular heart disease?

Answer 11

Pre-pregnancy evaluation with a TTE and consult with cardiologist who is an expert in management of VHD in pregnancy.