Maternal Cardiac Disease Flashcards
2012 Simpson – ACOG Clinical Expert Series. Berghella, Evidence Based MFM
What is NYHA (New York Heart Association) class 1?
No cardiac symptoms
What is NYHA (New York Heart Association) class II?
Cardiac symptoms with greater than normal activity
What is NYHA (New York Heart Association) class III?
Cardiac symptoms with normal activity
What is NYHA (New York Heart Association) class IV?
Cardiac symptoms with bedrest
With which two NYHA classes is pregnancy not advised?
NYHA 3-4
How does cardiac dysfunction present?
Fatigue, limited activity, palpitations, tachycardia, SOB, chest pain, dyspnea on exertion, cyanosis
What 4 cardiac conditions are contraindications to pregnancy?
Pulmonary hypertension
Severe ventricular dysfunction
Aortic root dilation (>4cm)
Severe left-sided obstructive lesions
While cardiac disease complicates 1-4% of pregnancies, it accounts for what % of maternal mortality?
Up to 25%
For women with congenital heart disease, what is the risk of fetal transmission?
5% (from 8/1000 background risk)
What features of pregnancy physiology can exacerbate cardiac disease?
Increased intravascular volume
Hypercoagulability
Decreased SVR
What are the general guidelines for pregnancy management in women with cardiac disease
Relative bedrest Treat other medical conditions Multidisciplinary approach Monitor fetal growth q 4-6w NST >34w
What are the general guidelines for labor management in women with cardiac disease?
Lateral decubitus position Epidural O2 \+/- Endocarditis prophylaxis Avoid hypotension (keep women ?wetter?) C/S for obstetric indications
While most cardiac conditions benefit from relative hypervolemia and relative hypotension intrapartum, what is the exception?
Mitral stenosis
Why is fluid overload (ie post-partum autotransfusion) bad for mitral stenosis?
The associated restricted LV filling can lead to pulmonary edema
What are the indications for c/s with maternal cardiac disease?
Aortic root dilation >4cm
Maternal Coumadin
Recent MI
Severe aortic stenosis
Which cardiac patients may benefit from invasive monitoring in labor?
Women with preload dependent conditions (aortic stenosis, PHTN)
Should women with prospthetic cardiac valves receive endocarditis prophylaxis?
Yes
After what time period after repair of CHD with prosthetic material should women receive endocarditis prophylaxis with delivery?
6 months
Does completely repaired CHD (with repair >6m ago) require endocarditis prophylaxis?
No
Does unrepaired cyanotic CHD require endocarditis prophylaxis?
Yes
If your patient had repair of CHD with prosthetic material remotely but there are residual defects, should they receive endocarditis prophylaxis?
Yes
How do we manage a patient with prior infective endocarditis in labor?
With endocarditis prophylaxis
When endocarditis prophylaxis is indicated, what antibiotic is used?
Ampicillin 2g IV
For PCN allergic women who need endocarditis prophylaxis, what antibiotics can be used?
Clinda, Ancef, cetriaxone
Is there an ACOG resource to guide endocarditis prophylaxis?
Yes - committee opinion 421, Antibiotics prophylaxis for infective endocarditis
What is the workup for palpitations?
Thyroid function
Rule out drugs/caffeine/tobacco
EKG
Echo
Are PACs and PVCs more common in pregnancy and typically benign?
Yes
What is the risk of complication or death in pregnancy with isolated VSD, repaired or unrepaired (high, moderate, or low)?
Low, <1%
When you have a patient with a long-standing large VSD, what should you rule out prior to becoming pregnant?
Pulmonary hypertension
Why is decreased SVR bad with pulmonary HTN caused by a VSD?
If pulmonary pressures exceed systemic pressures, the typical L-> R shunt can reverse, resulting in cyanosis
How should patients with VSD be managed intrapartum?
Avoid fluid overload
How is pulmonary hypertension defined? (What peak pulmonary artery pressures and mean PA pressures?)
Pulmonary artery pressure >30 mmHg, or mean pulmonary artery pressure >25 mmHg
What % of women with PHTN on echo have a normal pulm artery cath? (Ie. What is the false + rate of a TTE?)
30%
What is thought to cause the delayed PP death in pulm HTN?
Loss of pregnancy associated hormones and increased pulm vascular resistance
Why is hypotension dangerous with PHTN?
Pulmonary perfusion depends on preload
Are patients with PHTN better managed wet or dry?
Wet (to avoid hypotension and decreased preload)
How is inhaled NO helpful in PHTN?
Inhaled NO selectively reduces pulmonary vascular resistance while sparing SVR (maintaining preload)
What are the goals for medical management of pulmonary HTN (think PVR and ventricular function)?
Avoid increasing pulmonary vascular resistance
Maintain RV preload
Maintain RV contractility
What medication is used in the treatment of pulmonary HTN by decreasing pulmonary vascular resistance?
Inhaled NO (which causes selective vasodilation of the pulmonary vascular bed)
What is the maternal mortality associated with pulmonary HTN?
17-28%
What is the ideal mode of delivery for patients with pulmonary HTN?
Vaginal
What are the genetic causes of dilated aortic roots?
Marfans
Ehlers-Danlos
Loeys-Dietz
Turner syndrome
When is aortic root repair recommended (what dilation, and rate of dilation)?
Repair outside of pregnancy is recommended for dilation >5.0cm, or a rapidly dilating dilation (>0.5cm per year)
Does pregnancy accelerate pathologic aortic root dilation?
Yes
What medication is used in pregnancy to reduce strain on the ascending aorta and reduce the rate of aortic dilation, ie in cases of Marfans?
B-blockade
When is vaginal delivery safe for a patient for Marfans
With epidural, aortic root <4cm, and assisted second stage
What is the mortality associated with Marfans if aortic root is <4cm?
<1%
What is the risk of aortic dissection or death associated with Marfans if aortic root is >4cm?
20-50%
How should we evaluate patients with Marfans (or FH of Marfans) on initial presentation (cardiac, ophtho?)?
Echocardiogram
Slit lamp study for ectopia lentis
How should we follow patients with Marfans in pregnancy
Serial evaluation of the aortic root by echo
B-blockade
Avoid HTN
What spinal anomaly is present in 90% of pt with Marfans that may affect epidural placement?
Dural ectasia (widening of the dural sac at the lumbar spine)
Which genetic condition is associated with aortic dissection at diameters smaller than Marfans
Loeys-Dietz
What non-genetic conditions predispose women to aortic dissection?
Bicuspid aortic valve, CHTN, coarctation
What is the pregnancy outcome with corrected asymptomatic aortic coarctation?
Good
When is aortic coarctation associated with increased risk for maternal mortality
With aneurysmal dilation and associated cardiac disease
How should cases of aortic coarctation be managed in labor?
Avoid hypotension and bradycardia
In general, how is cardiomyopathy treated?
Oxygen Diuretics B-blockers (to avoid tachycardia) Vasodilators Inotropes (digoxin) Anticoagulation
What principles should guide intrapartum management of hypertrophic CM?
Avoidance of hypotension, hypovolemia, and tachycardia
How is hypertrophic cardiomyopathy inherited?
AD (with variable penetrance)
What is the classic echo finding in hypertrophic cardiomyopathy?
Asymmetric LV hypertrophy
What physiologic changes in pregnancy result in worsening cardiac function in patients with hypertrophic cardiomyopathy?
Decreased SVR worsens outflow obstruction, and tachycardia decreases diastolic filling time -> decreases cardiac output
Do young asymptomatic women with hypertrophic cardiomyopathy tolerate pregnancy well?
Yes
With hypertrophic CM, at what LV gradient do patients become symptomatic?
30 mmHg
With hypertrophic CM, at what LV gradient are patients at risk for heart failure and sudden death?
100 mmHg
What are the causes of dilated cardiomyopathy?
Myocarditis Ischemia CHTN Alcohol Familial
With dilated CM, what ejection fraction is concerning for adverse outcome?
<40%
Peripartum cardiomyopathy is defined as new onset left ventricular dysfunction (EF <45%) at what time points relative to delivery?
1 mo prior to delivery and 5 mos post-partum
When, relative to delivery, does peripartum CM most commonly occur?
2 months postpartum
What % of peripartum cardiomyopathy cases occur before delivery?
10%
What are the risk factors for peripartum cardiomyopathy?
Age >30 Obesity CHTN Multiparity Multiples Terbutaline Preeclampsia Low socioeconomic status African American race
What is the mortality associated with peripartum CM?
25-50%
What % of patients fully recover from peripartum CM?
35-50%
What are poor prognostic factors for peripartum cardiomyopathy (LV size, EF, and status at 6 months)?
Large LV EDV and EF <30% at initial diagnosis, and failure of LV function to normalize by 6 months
What % of women with peripartum CM and EF <25% will require a transplant?
57%
What is the recurrence risk of peripartum CM?
35%
What is the medical management of peripartum CM?
Inotropic therapy (digoxin) Afterload reduction (hydralazine +/- B-blockade) ACE inhibitors (postpartum) Anticoagulation (for EF <35%), Bromocriptine
When in pregnancy is the risk of MI the greatest?
In the first days post-partum (6x increase)
Does pregnancy increase the risk of MI?
Yes (by 2-4x)
Which study identifies ischemia and ventricular dysfunction in patients at risk for MI?
Stress echo
Which cardiac enzymes should not be ordered in the peripartum state to assess for cardiac ischemia?
CK (as CK is increased 2x in labor)?only TROPONINs are helpful
How can we treat stable angina in pregnancy?
Nitrates
Ca channel blockers
B-blockers
What is “stable” angina?
Chest pain with exertion that resolves with rest and nitrates
How do we treat ischemic heart disease (MI)?medications and other therapy?
Morphine Nitrates B-blockers Ca channel blockers Heparin Low dose Aspirin Coronary angioplasty
If cardiac catheterization is indicated for MI, what should you tell your IR colleagues is the max dose of radiation considered safe in pregnancy?
1 Rad
Is thrombolysis considered a safe management option for MI in pregnancy?
No ? use only if no other options
How should women with history of MI be counseled on future pregnancy?
Best not to become pregnant! (but may be considered if EF and coronaries are normal one year s/p MI)
What are the main causes of aortic stenosis in developed countries?
Bicuspid aortic valve
What are the main causes of aortic stenosis in developing countries?
Rheumatic heart disease
Women with aortic stenosis can expect good pregnancy outcomes if which criteria are met (what symptoms, what testing, what drop in aortic valve peak pressure)?
Asymptomatic
Normal EKG/stress test
Good EF
Aortic valve peak pressure drop <80 mmHg
When should pt with aortic stenosis undergo repair prior to childbearing (what aortic valve peak gradient, and what EF)?
Peak gradient >50 mmHg (possibly >30 mmHg), or EF <30%
If aortic valve replacement is required during pregnancy, what is the risk for fetal death with ECMO
20%
What intervention may be used to temporize patients with severe aortic stenosis during pregnancy in anticipation of valve replacement?
Balloon valvuloplasty
At what aortic diameter do people become symptomatic from aortic stenosis?
<1cm
What are the potential bad outcomes associated with aortic stenosis
Angina, MI, syncope, sudden death
Why is it important to avoid hypovolemia with aortic stenosis
In aortic stenosis, cardiac output is preload dependent. Hypovolemia causes decreases CO, and inadequate coronary/cerebral perfusion
Why is cardiac output fixed in aortic stenosis
Outflow obstruction leads to LV hypertrophy and subsequent poor filling (diastolic dysfunction)
Why is the fixed cardiac ouput of aortic stenosis dangerous in pregnant states of increased preload and HR?
Without the ability to increase output, coronary and carotid perfusion decreases
Is it better to keep pt with aortic stenosis wet or dry?
Wet (as preload dependent)
What effect does the fixed cardiac output of aortic stenosis have on fetal growth?
10%
How is aortic stenosis managed in pregnancy
Bedrest and B-clockers (to decrease HR and increase LV ejection time to maximize coronary filling)
What is the main cause of mitral stenosis?
Rheumatic heart disease
How does mitral stenosis present?
Pulmonary edema and a-fib
How is mitral stenosis treated in pregnancy?
Restricted activity
Diuretics
B-blockers (rate control)
Women with mitral stenosis but valve area greater than what value have a good outcome?
> 1.5 cm2
How does mitral stenosis lead to a fixed cardiac output?
Prevention of LV filling
Why should patients with mitral stenosis be managed on the ?dry side
With fluid overload, CO cannot increase, and pulmonary edema can result
When in pregnancy is mitral stenosis likely to decompensate, due to the peak maternal blood volume levels?
30-32w
Why should tachycardia be avoided in patients with mitral stenosis?
Poor LV filling may result -> hypotension
When should B-blockers be given to pt with mitral stenosis to prevent tachycardia-associated poor CO?
HR of 90-100
At what mitral valve should pt be offered pre-pregnancy intervention?
<1.2cm (or if pt is symptomatic)
Can balloon mitral valvuloplasty be performed in pregnancy for failed medical management?
Yes
What is the maternal mortality associated with mitral stenosis?
5%
What types of mechanical heart valves are the highest risk
Ist generation: Starr-Edwards and Bjork-Shiley in Mitral position
Do women with mechanical heart valves need prophylactic or therapeutic anticoagulation during pregnancy?
Therapeutic (with weekly blood levels)
Which types of heart valves require anticoagulation in pregnancy ? bioprosthetic or mechanical?
Mechanical
Why do mechanical heart valves require anticoagulation?
Due to the shearing effects of the valve on circulating blood (which can result in platelet activation and thrombus formation)
When using heparin for anticoagulation, when can an epidural be placed after the last dose?
4-6h (good to check a PTT first)
Aside from mechanical heart valves, which cardiac conditions may require anticoagulation?
Afib and PHTN
What is the therapeutic range for heparin?
Heparin: PTT 60-80 sec.
What is the therapeutic range for Coumadin, and Lovenox?
Coumadin: INR 2-3.
What is the therapeutic ranges for Lovenox (peak and trough)?
Peak (4h after 4th dose) anti-Xa 0.8-1.2. Trough 0.6-0.7
What is the risk of warfarin teratogenicity (%) with first trimester exposure?
10-15%
How does warfarin teratogenicity present after first trimester exposure?
Nasal hypoplasia
Optic atrophy
Digital anomalies
Mental impairment
Is Coumadin or heparin a better at preventing thromboembolism in women with a mechanical valve?
Coumadin
To minimize both teratogenicity and risk for VTE with mechanical heart valves, how should women be anticoagulated during pregnancy?
Heparin in first trimester and >36w, and Coumadin from 12-36w
What is the risk of complication or death in pregnancy with L->R shunt with pulm HTN (high, moderate, or low)?
High >25%
What is the risk of complication or death in pregnancy with Eisenmenger?s (high, moderate, or low)?
High >25%
What is the risk of complication or death in pregnancy with Uncorrected aortic coarctation with proximal aortic dilation (high, moderate, or low)?
High >25%
What is the risk of complication or death in pregnancy with left heart obstructive lesions like severe aortic stenosis and hypertrophic CM (high, moderate, or low)?
High >25%
What is the risk of complication or death in pregnancy with mild-mod aortic stenosis (high, moderate, or low)?
Moderate (5-15%)
What is the risk of complication or death in pregnancy with a systemic right ventricle (high, moderate, or low)?
Moderate (5-15%)
What is the risk of complication or death in pregnancy with well functioning Fontan palliation for hypoplastic ventricles (high, moderate
Moderate (5-15%)
What is the risk of complication or death in pregnancy with an isolated ASD or VSD, repaired or unrepaired (high, moderate, or low)?
Low (<1%)
What is the risk of complication or death in pregnancy with pulmonic or tricuspid valve disease (high, moderate, or low)?
Low (<1%)
What test can be recommended before conception to predict clinical outcome in pregnancy in moms with congenital heart disease?
Exercise stress test and echo
What is the indication for a FONTAN procedure
Any anatomic abnormality in which a two-ventricle repair is unfeasible (tricuspid or pulm atresia, hypoplastic heart)
What is the Fontan procedure (ie what vascular structures does it connect, and divert)?
From the RA (systemic venous return) to the pulmonary arteries, bypassing the RV
What is the risk of maternal death in asymptomatic women s/p Fontan with good vent function and no pulm HTN?
2%
What are the 4 features of TOF?
VSD
Overriding aorta
RVH
Pulmonary stenosis
What is the risk of complication or death in pregnancy with uncorrected cyanotic defects like TOF (high, moderate, or low)?
Moderate (5-15%) (high with severe pulm regurg or RV dysfunction)
What is the risk of complication or death in pregnancy with repaired TOF with normal RV function and competent pulmonic valve (high, moderate, or low)?
Low (<1%)
What is the risk of complication or death in pregnancy with palliated TOF with pulm regurg and RV dysfunction (high, moderate, or low)?
Moderate (5-15%)
What complications are seen with repaired TOF in pregnancy?
SVT, right heart failure
