Valvular Heart Diseases in Pregnancy Faisal Alatawi ,M.D Consultant Cardiologist Assisstant professor Tiabah university
Introduction To be able to take care of pregnant lady with valvular heart disease you need: Knowledge: – Pregnancy – Risk assessment related to VHD
Communication – The patient & her family – Obstetrician – Anesthesiologist – CVS department colleagues – pediatrician
Introduction 1-4% of pregnancies involve maternal CV diseases CV disease does not preclude pregnancy but poses increased risk to mother and fetus
7th report of the Confidential Enquiries into Maternal Deaths in the UK. London: Royal College of Obstetrics and Gynaecology, 2007.
Physiology of pregnancy and labor
COP 50% B. volume SV
30%
HR
10%
10%
30%
50%
5w
20 w
BP=SVR×COP
38 w
SVR
HR
Blood volume
SV
COP
SVR
BP
02 consumption Ă— 3
BP
SVR
50% COP
SV
Blood volume 300-500 cc
HR
Changes during labor
O2 consumption
The hemodynamic changes during the post-partum state
Relief of vena caval compression after delivery& mobilization of fluid Increase in venous return augments cardiac output and causes a brisk diuresis. First 72 hours are critical in significant lesions Return to the pre-pregnant baseline within 3 to 4 weeks following delivery
May be normal in normal pregnancy
Fatigue Exertional dyspnea Palpitation Lower limb swelling Full volume pulse Elevated JVP Lower limb oedema Third heart sound Systolic flow murmur
Not normal in pregnancy Suggest cardiac pathology
Chest pain Severe SOB PND AF,AFF High BP 4th HS Dias.murmur Pulmonary oedema Pleural effusion
Normal exam can mimic heart disease
Supine hypotensive (uterocaval) syndrome 11 % Decrease HR&BP due to compresion on IVC Weakness ,nausea and dizziness even syncope
Cardiac assessment
599 pregnancies ( 1994-1999 , 13 centers in Canada)
22% AHD
74% CHD
4% arrhythmia
102 pregnancies with VHD
MS=48 MVA 1.3±0.3
MS& AS =4
AS=58 MVA 0.9 ± 0.2
RISK ASSESSMENT 4 predictors for primary cardiac events : ( pulm.oedema, sustained arrhy,CVA,Cardiac arrest ,cardiac death ) 1. Prior CHF, TIA, stroke ,or arrhythmia 2. Baseline NYHA class >II or cyanosis 3. Left heart obstruction • •
MVA <2 cm2, AVA <1.5cm LVOT gradient >30 mm Hg by echo
1. systemic vent dysfunction (EF <40%) Primary Cardiac event 13 %, death 1%
CARPREG risk score
75%
si r det a m it s E
27%
No of predictors
5%
0
1
>1
Recommends that maternal risk assessment is carried out according to the modified World Health Organization(WHO) risk classification
Counseling Extreme Risk ,no pregnancy ,termination
Significant mortality severe morbidity
Small mortality Moderate morbidity
Low risk, can conceive no especial precaution
Risk
WHO IV Severe MS Severe symptomatic AS LV EF < 30%, III-IV class PHTN any cause WHO III Mechanical valves Severe asym. AS Severe regurgitation with mild LV dysf. WHO II Moderate stenosis Severe regurgitation with normal LV Mild LV dysfunction Most arrhythmia WHO I Mild PS MVP with mild MR
Care Multidisciplinary approach ,frequent visits
Multidisciplinary approach ,frequent visits
FU every trimester
One cardiac visit
Case Histories
Case I 26 year GA 28 Ws G3P2 ( youngest 3 yr) Class IV SOB IN CHF,Sinus tachy
Case I Severe MS MVG =27/35
PAP> 110
PAP????
Severe MS :On Ry MVG= 18/13
PASP 55 mmHg
Rheumatic heart disease in pregnancy Stenotic lesions: get worse â&#x20AC;&#x201C; Because of increase flow
Regurgitant Lesions : well tolerated â&#x20AC;&#x201C; Because of decrease vascular resistant
Rheumatic Mitral stenosis In severe cases unresponsive to medical therapy Balloon valvoplastey or surgery is recommended Maternal Risk of MV repair or replacement is comparable to non pregnant women. Foetal daeth during open heart surgery (20-30%)
Cardiac Drugs In Pregnancy Most CV drugs cross placenta and secreted in breast milk Weigh risk/benefit ratio - avoid when possible Use drugs with long safety record Prescribe lowest dose for shortest duration No drug is completely safe
Preterm Survival Rate After 32 weeks Survival :95% Brain damage is low lung maturation,betamethasone (less than 34 weeks) Before 28 weeks Survival :<75% Brain damage :10-14% Postpone delivery as long as possible Between 28 and 32:Decisions must be individualized.
Mode of Delivery Spontaneous vaginal delivery is the preferable way of delivery for valvular heart disease in pregnancy
Preconception
counseling
Case II 37 year old in 1999 had 2 bioprosthetics – mitral valve , 29mm – aortic valve, 21 mm – She is G6P4+1
Case II Presented: Nov 2005 23 weeks pregnant Was it planned ? Class II SOB AS and MS murmer
AVR &MVR &pregnancy Peak AV G=122
MVG 32/14
23 weeks pregnant Wt:122 kg Ht:170 BMI:2.3
Case III
Case III: Mech. valve 34 years old September 2003 :CM 25 ,mitral 14 April 2004 prsented with CHF fast AF Pregnant 17 weeks On 17 March 2004 :INR=1,PTT=35!!!!!!!!!!!! SC suboptimal dose UFH
TEE
Case V :OUTCOME LA thrombus extracted MV mechanical valve cleaned AV replaced with 21 CM Baby aborted within 24 hours of CPBP Patient subsequently did very well
1234 pregnancies in 976 women with mechanical heart valve prostheses,twothirds of which were in the mitral position Anteco.regimen Vita K all through pregnancy Heparin all through pregnancy LOW dose Adjusted dose Heparin 12 weeks , then warfarin
Sponat. Trombo abortion % Embolic n%
Maternal death %
6.4
25
3.9
1.8
0
24
33
15
0
20
60
40
0
25
25
6.7
3.4
25
9.2
4.2
Embryopathy %
Hanania G. Management of anticoagulants during pregnancy. Heart 2001;86:125-6.
Antecoagulation 6W
12W UFH Monitored a PTT> 2 control LMWH Monitored anti Xa Warfarin < 5 mg
36W
Warfarin
UFH Monitored a PTT> 2 control LMWH Monitored anti Xa
36 h
Registry of Pregnancy and Cardiac disease (ROPAC)
43 countries and 110 centers are participating in the registry, and more to join.
Conclusion We need to know more education of health providers registries clinical trials
We need to communicate better Form team work in large hospitals Improve patient counseling
We need to give a good standard care
Thank you