Professional Documents
Culture Documents
Stratification
Population of Europe of
Childbearing Age
Valvular disease
Most frequent cause of cardiac complications in
developing countries (50-90%), 15% in industrialised
countries
Cardiomyopaties
Rare but severe
Hypertension
Frequent but severe complications are rare
Arrythmias
Frequently combined with structural heart disease
Venous tromboembolism
Deep vein thrombosis
Pulmonary embolism
Haemodinamic changes
during pregnancy
Labour
O2 consumption
baseline cardiac output
cardiac output and blood
pressure during uterine
contractions, depending on
modalities of delivering
(epidural anesthesia,
sectio caesarean)
Post partum
blood shift from placenta
preload and cardiac
output
Risk Stratification
WHO classifications
Overall assessment on 4 classess
CARPREG
Score for congenital and valvular heart disease
Validated in differential populations
ZAHARA, Khairy :
Congenital heart disease
Stratification
High risk states contraindications for pregnancy
Hierarchy of antenatal
care
The aim of an obstetric cardiac service
is
to provide women with appropriate coordinated multidisciplinary care,
by clinicians with the appropriate level
of expertise,
in a setting where the appropriate
facilities are co-located to support the
woman and her baby around the time of
delivery.
Delivery planning
One of the main reasons for antenatal risk stratification of women
with heart disease is to ensure that delivery occurs in a planned
way, with the most appropriate personnel and facilities available.
For low-risk women, this may be in their local hospital, for women
with more complex heart disease, it will be in a specialist centre.
Obstetric, cardiac, anaesthetic, and fetal considerations will all
inform decisions about the mode, timing, and place of delivery.
These decisions will be made antenatally, and should involve the
woman, her family, and all members of the multidisciplinary
team.
The plan should include personnel who need to be notified on
admission, planned mode of delivery, management of the second
and third stages, place of delivery, and plans for the postnatal
care.
Mode of Delivery
Where possible, vaginal delivery should be the
aim, as it is associated with less blood loss and
infection risk compared with caesarean delivery.
Caesarean section also increases the risk of
venous thrombosis and thromboembolism.
Caesarean section reserved for those women who
are unable to safely increase cardiac output during
labour, or where there are obstetric indications for
cesarean section, for example placenta previa.
Women who may need delivery by caesarean
section are those with cyanosis, reduced ejection
fraction, dilated aortic root, severe mitral or aortic
stenosis, pulmonary hypertension, or ischaemia.
Conclusions
Cardiovascular diseases are the most frequent
causes maternal death in industrialised countries
The heterogenity of heart disease and inherent
risks underline the need for an individual risk
assessment and managements.
Conselling should start before pregnancy and
may lead to prphylactic interventions
Interdisciplinary care should involve a team of
gynecologists, cardiologists and others at each
stage of pregnancy
High risk women should be reffered to specialised
centres
SPECIFIC
Congenital Heart
Disease
Congenital Heart
Disease
Left to right shunts
Pregnancy
contraindication in
Women with pulmonary embolism
congenital
heart
Women with saturation
oxygen atdisease
rest < 85 %
Patients with TGA and systematic right ventricle
with > impairement of RV function and / or severe
TR
Fontan patients with depressed ventricular
function and / or moderate to severe
atrioventricular valvular regurgitation or with
cyanosis or with protein losing enteropaty
Congenital Heart
Disease
Spesific maternal high risk conditions
WHO (III)-IV
Congenital Heart
Disease
Special Defects
Congenital HD-examples
Diseases of Aorta
Increased risk of dissection during pregnancy
May lead to consider prophylactic surgery
Aortic Diseases
Full assesement and counselling should be performed
before pregnancy in all patients with kown aortic disease.
Patients with (or history of) type B dissection should be
advised against pregnancy
In pregnant women with known aortic dilatation, (hystory
of) type B dissection or genetic predisposition for
dissection strict blood pressure control is recommended
Prophylactic surgery should be considered during
pregnancy if the aortic diameter > 50 mm and increasing
rapidly. When the fet us is viable, caesarean delivery
followed directly by aortic surgery is recommended.
AORTIC DISEASES
Full assesement and counselling shouldbe
performed before pregnancy in all patients with
known aortic diseases.
Patients with (or history of) type B dissection should
be advised against pregnancy
In pregnant women with known aortic dilatation
(history of ) type B dissection or genetic
predisposision for dissection strict blood pressure
control is recommended
Prophylactic surgery should be considered during
pregnancy if tha aortic diameter is >50 mm and
increasing rapidly. When the fetus is viable,
caesarean delivery followed directly by aortic
surgery isrecommended
VALVULAR HEART
DISEASE (I)
VALVULAR HEART
DISEASE (II)
CORONARY ARTERY
DISEASES
Cadiomyopathies
Peripartum Cardiomyopathy
New onset left ventriculer dysfunction without
other cause, occuring at the end of pregnancy or
following delivery
Non-spesific presentation and medical therapy
(excluding ACE-inhibitors) (IB)
Spontaneuous recovery in half of cases
Risk of recurrence during subsequent
pregnancies, even after recovery of left
ventricular function
Perpartum Cardiomyopathy
(PPCM)
HF can develop rapidly, use guidelines for acute
and chonic HF, consider contraindications for
some drugs (I)
Spontaneous recovery can occur (up to 50%)
Avoid ACEI, ARB and renin inhibitor, if possible.
Prefer hydralazine and nitrates, dopamin,
levosimenden, digitalis; 1 selective blocker use
diuretics with caution
Use anticoagulation with LMWH or OAC according
to pregnancy state in pts with intracardiac
thrombi, embolisms, atrial fibrilation (I)
Deterioration in LV funtion occurs in up to 50%
and carries a prognosis
Other cardiomyopathy
Dilated cardiomyopathy:
Left ventricular dysfuntion pre-exist or is revealed
at the begining or pregnancy
High risk if left ventricular ejection fraction <40%
Treatment as in PPCM
Women with DCM should be informed about the
risk of deterioration during gestation and
perpartum
LVEF <40% is predictor of high risk. If LVEF is
<20% maternal mortality is very high and
termination of the pregnancy should be condiderd
Other cardiomyopathies
Hypertrophic Cardiomyopathy:
Low risk if previously well tolerated
Severity of LVOTO determines risk during
pregnancy and delivery
Beta blockers indicated according to hypertrophy
and gradient (IIaC)
Treat AF, use LMWH or OAC if AF occurs
ARYTHMIA
Arythmias requiring treatment develop in up to
15%of the patients wiyh structural and congenital
heart disease
In haemodynamically unstable patients with
tachycardias direct cardioversion should be
considered
Atrial Flutter and atrial fibrilation are rare, prefer
cardioversion after anticoagulan
Life threatening ventricular arythmias during
pregnancy are rare
HYPERTENSION
Heterogeneous entity : pre-existing hypertension,
gestational hypertension and pre-eclampsia
No benefit of treating mild-to-moderate
hypertension (<170/110 mmHg)
Severe hypertension (170/110 mmHg) is an
emergency and hospitalisation is recommended (IC)
Alpha-methyl-dopa is the drug of choice, followed
by labetalol.
Calcium channel blocker are drugs of second choice
ACE inhibitors, angiotensin II antagonist and direct
renin inhibitors are strictly contraindicated in
pregnancy.
VENOUS
THROMBOEMBOLISM
Assesement of risk factors for venous
thromboembolism is recommended in all pregnant
women (IC)
Antenatal dan postpartum (6 weeks) prophylaxis
with LMWH
is recommended in high-risk patients
Should be considerd in intermediate risk patients
(IIC)
D-dimer measurement and compression
ultrasonography is recommended in patients with
suspected venous thromboembolism (IC)
CT Pulmonary angiography is favoured for the
diagnosis of pulmonary embolism