Transcript Risk Assesment of Cadiac disease in pregnancy

PREDICTORS OF CARDIAC
DISEASE IN PREGNANCY
Golnaz Houshmand.MD
Cardiologist
Why we concern !
 Approximately 2% of pregnancies involve
maternal cardiovascular disease, associated with
increased risk to both mother and fetus.
 Heart disease is the third most common cause of
maternal death and the leading non-obstetric
cause.
 In 2011, guidelines on the prevention of
cardiovascular disease in women identified
pregnancy complications as risk factors for
cardiovascular disease.
 Pulmonary embolism, arrhythmias, preeclampsia and peripartum cardiomyopathy,
develop as a complication of pregnancy in
previously healthy women.
 women with pre-existing heart disease may be
predisposed to some of these complications and
less able to cope with them
 Advances in the practice of cardiology , The
increasing success of neonatal surgery allows
more infants with complex anomalies to
reach adulthood, wanting normal lives with
jobs and families.
 Career women postponing pregnancy
account for larger numbers of older patients
with hypertension and coronary disease
hemodynamic
 during the first trimester steep increase in
plasma volume, which causes dilution and
anemia.
 The stroke volume and, to a lesser extent, the
heart rate increase and the cardiac output
increases progressively.
(around 40–50% above the pre-pregnancy.)
 Accompanying decrease in vascular
resistance, and diastolic and mean blood
pressure.
 In cyanotic or potentially cyanotic congenital
heart disease,
 The drop in peripheral vascular resistance
encourages right-to-left shunting, leading to
increasing cyanosis
 Rise in hematocrit with increased risk of
thrombosis and paradoxical embolism.
 When trouble occurs it usually begins early,
often by the end of the first trimester.
 These considerations are of pivotal importance
if the physician is to advise the woman correctly
and not simply retreat with the easy option of
advising against pregnancy or encouraging early
termination
Significant heart conditions are usually known
about before pregnancy but important
exceptions are:
 Pulmonary hypertension,
 Mitral stenosis,
 Cardiomyopathies
 Fragile Aorta
 ASD
 Coronary Artery Disease
PMH &
Examination
 Many disorders are apparent from the personal and
family history, particularly cardiomyopathies,
Marfan syndrome and congenital heart disease.
 Ask specifically for possible sudden deaths in the
family
 There may be previous knowledge of a cardiac
murmur, which may or may not be linked to a
specific valve disease.
 The outcome of any previous pregnancies
(hypertension, pre-eclampsia, pulmonary emboli or
peripartum cardiomyopathy)
 An understanding of the normal findings on
cardiac examination in a pregnant patient is
important
Normal clinical findings that can
mimic heart disease in pregnancy
 Raised jugular venous pressure (prominent ‘a’ and ‘v’ waves, brisk ‘x’
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and ‘y’ descents)
Volume-loaded left ventricle; full, sharp and collapsing pulse
Warm extremities
Peripheral edema
Palpitations
Tachycardia
Premature atrial/ventricular beats
Increased intensity of mitral closure sound
Third heart sound (rapid ventricular filling and is found in up to 90%)
Systolic murmur (90%)
Continuous murmur from venous hum, mammary soufflé
 A cervical venous hum, best heard over the
supraclavicular fossa, is common in children,
and is also found in pregnancy.
 The mammary murmur, either systolic or
continuous, is heard maximally at the second
left or right intercostal space during late
pregnancy in some women.
 differentiated from a persistent arterial duct
by applying gentle pressure, makes the
mammary murmur disappear.
 An ejection systolic murmur never more than
grade 3/6 in intensity
 There should be no diastolic murmur.
Electrocardiography
 The heart rate may be increased by 10–15%.
 Re-entrant supraventricular tachycardia is a
relatively common benign arrhythmia.
 persistent sinus tachycardia, atrial flutter,
atrial fibrillation or ventricular tachycardia
suggests underlying heart disease and should
prompt further investigation.
 The appearance of ventricular tachycardia in late
pregnancy or in the puerperium should arouse
suspicion of peripartum cardiomyopathy.
ECHOCARDIOGRAPHY
 Referral is often triggered by the detection of
a systolic murmur by the obstetrician
 Occasionally, the distinction between
normality and abnormality may be subtle and
an expert interpretation should be sought
before the final report.
 In most pregnancies echocardiography will
reassure the mother-to-be who can then
continue to enjoy her pregnancy.
A progressively increasing awareness in pregnant
women during the third trimester is the presence of
breathlessness.
 A common symptom during pregnancy, this may be
difficult to distinguish from breathlessness related to
the onset of peripartum cardiomyopathy.
 New onset of intraventricular conduction delay or left
bundle-branch block on the ECG, together
 with an ‘unusual’ breathlessness, should constitute an
absolute indication for an early echocardiographic
examination to assess left ventricular function.
RISK ASSESSMENT
 Worrisome predictors of maternal cardiac events
include(from the CARPREG study)
 (1) prior cardiac event (e.g., heart failure, transient
ischemic attack, or stroke before pregnancy) or
arrhythmia;
 (2) baseline New York Heart Association (NYHA) class
higher than class II or cyanosis;
 (3) left-sided heart obstruction (mitral valve area smaller
than 2 cm2, aortic valve area less than 1.5 cm2, or peak left
ventricular outflow tract gradient greater than 30 mm Hg
as assessed by echocardiography);
 (4)ejection fraction less than 40%
 When none of the risk factors was present, the
risk of a cardiovascular complication during
pregnancy was less than 5%
 The presence of one of the above risk factor, a risk
of a cardiovascular complication during
pregnancy of over 20%
 more than one risk factor, the risk of a
cardiovascular comaplication during pregnancy
was over 70%.
WHO CLASSIFICATION
WHO I
• Uncomplicated, small or mild
- PS
- PDA
- MVP
• Successfully repaired simple lesions (ASD or
VSD, PDA, PAPVC).
• Atrial or ventricular ectopic beats, isolated
WHO II or III
WHO II (if otherwise well and uncomplicated)
• Unoperated ASD ,VSD
• Repaired tetralogy of Fallot
• Most arrhythmias
WHO II–III (depending on individual)
• Mild left ventricular impairment
• HCM
• Native or tissue valvular heart disease not considered WHO I or
IV
• Marfan syndrome without aortic dilatation
• Aorta <45 mm in aortic disease associated with bicuspid aortic
valve
• Repaired coarctation
WHO III
• Mechanical valve
• Systemic right ventricle
• Fontan circulation
• Cyanotic heart disease (unrepaired)
• Other complex congenital heart disease
• Aortic dilatation 40–45 mm in Marfan
syndrome
• Aortic dilatation 45–50 mm in aortic disease
associated with bicuspid aortic valve
WHO IV(pregnancy contraindicated)
• Severe PAH of any cause
• Severe systemic ventricular dysfunction (LVEF <30%,
NYHA III–IV)
• Previous peripartum cardiomyopathy with any
residual impairment of left ventricular function
• Severe MS, severe AS
• Marfan syndrome with aorta dilated >45 mm
• Aortic dilatation >50 mm in aortic disease associated
with bicuspid aortic valve
• Native severe coarctation
 The highest maternal mortality from heart
disease is in patients with pulmonary
hypertension, whether idiopathic, or
associated with other disease or with
reversed central shunt in Eisenmenger
syndrome. The maternal mortality rate may
be as high as 50%
 Most women with heart disease who are in New
York Heart Association class I or II before
pregnancy accomplish pregnancy safely.
 Valve regurgitation is generally well tolerated
during pregnancy, primarily because of the
afterload reduction and increased heart rate.
 Patients with simple congenital cardiac defects
do well
 Most patients with heart disease do well.
Congenital Heart Disease
 The category of patients with congenital
heart disease who have had previous surgery.
 If the operation were ‘corrective’, pregnancy
would usually proceed normally but would
sometimes be complicated by arrhythmia, (usually
benign), and endocarditis.
 Patients who have undergone palliative surgery
may be at risk of heart failure or thromboembolism
as well as infection and arrhythmia.
 Echocardiography and transesophageal
imaging helps both in initial assessment of
risk and in serial documentation of progress.
 Cardiac magnetic resonance imaging (MRI)
may be complementary
 A comprehensive pre-pregnancy assessment is
recommended for all patients with a history of
operated or unoperated congenital heart disease
 Optimal management of the pregnant patient
with congenital heart disease includes accurate
diagnosis, and the correct prediction of the
hemodynamic consequences of both the
pregnancy on the cardiac disorder and the
cardiac disorder on the baby’s development.
FETAL ECHO
 the woman with congenital heart disease, a
fetal cardiac echocardiogram can start at
week 14 and is offered at approximately 18
to 22 weeks of pregnancy to determine
whether a congenital cardiac anomaly is
present.
Cardiomyopathies
HCM
 Parents should be informed about the autosomal
dominant inheritance pattern, which has variable
penetrance. genetic counseling and family
screening are appropriate before pregnancy
 The left ventricle seems to fill better during
pregnancy and without undue rise in filling
pressure in most cases.
 Pressure gradients may be high but usually do
not affect outcome
 Generally, hypertrophic cardiomyopathy is well
tolerated during pregnancy.
 Patients with significant symptoms before
pregnancy may not do well and become
hemodynamically unstable.
 Common symptoms include palpitation,
angina, and breathlessness. In a study of 127
women with 271 pregnancies, 36 women
(28.3%) reported cardiac symptoms but 90%
were symptomatic before pregnancy
DCM
 When discovered late in pregnancy, dilated
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cardiomyopathy may be regarded as peripartum because
of its temporal relationship with pregnancy
when detected earlier in pregnancy the condition is likely
to have been pre-existing.
Echocardiography shows a hypokinetic left ventricle that
may or may not be dilated.
Patients with idiopathic dilated cardiomyopathy usually are
counseled not to have a pregnancy if the ejection fraction is
lower than 40%.
Exercise testing also may be helpful, because women with
ejection fractions of 40% to 50% may not tolerate
pregnancy well if they have a poor functional aerobic
capacity
PPCM
 Occurring during the last months of pregnancy or
within 5 months of delivery in previously healthy
women.
 Cardiac imaging (usually with echocardiography) is
essential to establish the diagnosis.
 The higher incidence in some countries suggests
the influence of environmental risk factors or a
common genetic mutation.
 Known risk factors include multiparity, black race,
older maternal age, and particularly preeclampsia
 Normalization of ventricular function occurs in
approximately 23% to 54% of patients with
PPCM
 more likely if the ejection fraction is greater than 30%
at the time of diagnosis.
 Most physicians counsel against a second
pregnancy, even if the ventricular function does
return to normal, PPCM will recur in
approximately 30% of cases.
 recurrence may result in significant clinical
deterioration and even death.
Fragile Aorta
 Women with Marfan syndrome are always a worry in
pregnancy.
 The family history is important and serial
measurement of aortic root diameter are important.
( family history of aortic rupture or evidence of aortic
root widening)
 Dissection occurs most often in the last trimester of
pregnancy (50%) or the early postpartum period
(33%).
 The diagnosis of aortic dissection should be
considered in all patients with chest pain during
pregnancy.
THANKS FOR YOUR ATTENTION