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Maternal Risk

Stratification

Population of Europe of
Childbearing Age

EU population 2008 499 million total *


105 million of women in childbearing age (15-45
years)
5 million live births
1% of pregnancies are complicated by heart
disease **

Heart disease during


pregnancy
Congenital heart disease

Most frequent cause of cardiac complication in


industrialised countries (70-80%), rare in developing
countries (10-20%)

Valvular disease
Most frequent cause of cardiac complications in
developing countries (50-90%), 15% in industrialised
countries

Cardiomyopaties
Rare but severe

Coronary heart disease


Rare but increasing frequency

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

blood volume 50%


cardiac output 30-50%
maximum between, 5th
8th months
systolid and dyastolic
blood pressure
systemic arterial
resistance (hormones,
placenta)

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

Other Changes During


Pregnancy
Haemostasis

Increased platelet adhesiveness


Increased consentration of coagulation factors,
fibrinogen
Impaired fibrynolisis

Maternal glucose metabolism


Drug metabolism:
Absorbtion, excretion, and bioavailability

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

Disease spesific analyses


Small series with statistical analyses

Risk Stratification CARPREG

Predictors of maternal cardiovascular events and


risk scores from The CARPREG Study

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.

For a woman with a low-risk condition, care


can be provided by her local obstetrician,
cardiologist, and community midwife, in her
local hospital.
Women with high-risk cardiac conditions will
require care from a specialised obstetric
cardiac team in a tertiary referral hospital,
with obstetric, cardiology, cardiac surgery,
specialised anaesthetic, intensive care, fetal
medicine, and neonatal facilities all co-located.
Other disciplines may also need to provide
input, such as haematology, perfusionists,
genetics, dentistry, reproductive and sexual
health (abortion services and contraception).

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.

Post partum care


Women who are stratified as high risk
antenatally are still likely to be at high risk in
the postpartum period.
Cardiac output is at its highest immediately
after delivery, and many complications such
as heart failure and dissection occur at this
time.
Plans for management of the woman in the
immediate postpartum period should be
made antenatally by the multidisciplinary
team, and included within the care plan.

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

Risk for fetus depend s on the maternal heart


disease as well as maternal ventricular and
valvular functions, functional class, cyanosis, use
of anticoagulants
Overall fetal mortality 4%

Congenital Heart
Disease
Left to right shunts

Low to moderate risk

Right to left shunts (cyanotic heart disease)


Moderate risk if previously repaired
High fetal risk if not repaird and O2 saturation <
85%
Major maternal risk (30-50%) if Eisenmenger
syndrome contraindication for pregnancy or early
termination

Obstructions without shunts:


High risk if severe left ventricular outflow track
obstruction

Low Risk Patients


Patients who have undergone previous successful
surgical repair for congenital heart disease
tolerate pregnancy often well if:
No mechanical valve is implanted
The exercise tolerance is good
The ventricular function is normal

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

Congenital Heart Diseases


(CHD)
Essential
Women Messages
with CHD may tolerate pregnancy well
The risk depends on the underlying spesific
contellation
All patients with CHD should be seen by the end
of the first trimester and an individualised follow
up plan should be established
Vaginal delivery can be planned in most patients
Discuss high-risk conditons, contraindications and
indications for caesarean delivery on an individual
basis

Diseases of Aorta
Increased risk of dissection during pregnancy
May lead to consider prophylactic surgery

Aortic Diseases - Delivery

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)

Stenotic valve disease


High risk of haemodynamic decompebsation if:
Moderate and severe mitral stenosis consider
percutaneus intervention during pregnancy if
symptomps persist (IIaC)
Symptomatic aortic stenosis
Intervention is indicated before pregnancy (IC)
Regurgitant valve disease
Good prognosus if preserved left ventricular
function
Medical therapy is recommended (IC)
Avoid surgery during pregnancy

VALVULAR HEART
DISEASE (II)

Oral anticoagulation (OAC) with vitamin K


antagonists are the safest therapy to prevent
valve thrombosis and are therapy of choice during
the secondand third trimester (IC)
During the first semester continuation ofOAC
should be considered when warfarin daily dose is
<5 mg (IIaC)
With higher dose requirements, unfractionatedor
low-moleculer weight heparin should be
considered with strict dose adjustment according
tp APTT or anti-Xa levels (weekly control) (IIaC)
At the 36th week, OAC should be discontinued and
replaced by dose-adjusted heparin (IIaC)

Recommendations for the


Management of Valvular Heart
Disease

CORONARY ARTERY
DISEASES

Acute Coronary Syndromes:


Complicate 3-6/100.000 pregnancies
May be due to atherosclerosis but also thrombosis
on normal arteries or coronary dissection
Should be managed invasively with angiography
and percutaneus coronary intervention if
indicated, except if non-ST elevationECG and no
risk factors
Stable Coronary Arteri Diseases
Pregnancy may be considered in women with
known CAD, if there is no residual ischaemia and
EF>40%

Coronary Artery Dieases


ACS in pregnancy is rare, complicatea 3-6of
100.000 deliveries
ECG and Troponin T levels should be obtained in
all women and with chest pal(I)
Spontaneus dissection of coronary arteries is
more frequent in pregnant than in non pregnan
woman.
Coronary angioplasty is the prefered reperfusin
strategy for STEMI (I)
Pregnancy maybe consideredin woman with
known, CAD, if there is no residual and EF>40%

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

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