Cardiac Diseases in Pregnancy - University of Arkansas for 心臟病在妊娠-阿肯色大學

1、Cardiac Diseases in Pregnancy Ibrahim Elias Fahdi, MDUniversity of Arkansas for Medical Sciences& Central Arkansas Veterans Healthcare SystemDivision of Cardiovascular MedicineFebruary 18, 2005ObjectivesNormal Physiology during pregnancyCardiac TestingCommon cardiac problemsCardio-circulatory change

2、s during normal pregnancyparameterChanges at various times (weeks)51220243238HRSBPDBPSVCOSVRLV EF 5%; 6-10%; 11-15%; 16-20%; 21-30%; 30%, 40%.“Our only hope is if we all write a letter to Santa”The Wall Street JournalChanges in plasma volume, erythrocyte volume, and hematocrit during pregnancyPlasma

3、 volume 50% (20-100%).“Physiologic anemia of pregnancy”.Estrogen-mediated stimulation of the RAS.Role of other hormonesdeoxycorticosterone, prostaglandins, estrogen, prolactin, placental lactogen, GH, ACTH, ANPFrom Pitkin RM, Nutritional support in obstetrics and gynecology. Clin Obstet Gynecol 1976

4、;19:489.Percent change in heart rate, stroke volume, and cardiac output measured in the lateral position throughout pregnancy compared with pregnancy valuesModified from Robson SC, Hunter S, Boys RJ, Dunlop W. Serial study of factors influencing changes in cardiac output during human pregnancy. Am J

5、 Physiol 1989;256:H1060-H1065Cardio-circulatory changes during normal pregnancyparameterChanges at various times (weeks)51220243238HRSBPDBPSVCOSVRLV EF 5%; 6-10%; 11-15%; 16-20%; 21-30%; 30%, 40%.Hemodynamic changes during labor and deliveryAnxiety, pain, uterine contraction.Oxygen consumption three

6、fold. CO during labor ( SV and HR). SBP & DBP (especially 2nd stage)Those changes are influenced by the form of anesthesia and analgesia.Hemodynamic changes post partumBlood shifting “auto-transfusion” (from the contracting uterus to the systemic circulation)Increase in effective blood volumeSubstan

7、tial increase in LV filling pressure, SV and COClinical deteriorationBlood loss during delivery- HR and CO return to pre-labor values within 1 hour. MAP and SV within 24 hours. Hemodynamic adaptation persists post partum and return to pre-pregnancy values within 12-24 weeks after delivery.Increase i

8、n venous return(relief of caval compression)HistoryExercise capacityCurrent or past evidence of HFAssociated arrhythmiasPhysical examCardiac HemodynamicsSeverity of heart disease, PA pressuresEcho, MRI.Exercise testingUseful if the history is inadequate to allow assessment of functional capacityDuri

9、ng pregnancyEvaluate once each trimester and whenever there is change in symptoms Multidisciplinary approach, Fetal EchoBefore conceptionReimold, S. C. et al. N Engl J Med 2003;349:52-59During Labor & DeliveryMultidisciplinary approach (Obstetrician, Cardiologist, Anesthesiologist)Tailor management

10、to specific needsHigh-risk pregnancyPulmonary HTN and Eisenmengers syndrome.Symptomatic obstructive cardiac lesions:AS, PS, uncorrected coarctation of the aorta.Marfans Syndrome with dilated aortic root.Systemic ventricular dysfunction (LVEF 40%).Severe cyanotic heart disease.Patients with prostheti

11、c valves.Significant uncorrected CHD. Contraindications to PregnancyLesionMaternal death rate (%) Severe Pulmonary Hypertension50 Severe obstructive lesions: AS,PS, HOCM, Coarctation.17 Systemic Ventricular Dysfunction, NYHA class III or IV7Pregnancy OutcomesThe prevalence of clinically significant

12、maternal heart disease is low ( 2 classes.Need for urgent invasive cardiac procedure (percutaneous cardiac valvuloplasty, permanent pacing).N.B.: There was no association between the type of delivery and peripartum cardiac event rate (3% vs. 4%, P=0.46).Siu SC, Sermer M, Colman JM, et al. Prospectiv

13、e multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-521. Predictors of primary cardiac eventsOdds ratio (95% CI)p1. Prior cardiac event (HF, TIA or stroke) or arrhythmia.6 (3-14) II or cyanosis.6 (2-22)0,0093. Left heart obstruction (MVA 2cm2, AVA 30 mmHg)

14、.6 (3-14)0.0014. Reduced systemic ventricular systolic function (EF 40%)11 (4-34)0.0014%27%62%Adverse neonatal eventsNeonatal events:Premature birthSmall-for-gestational-age birth weight.Respiratory distress.Inter-ventricular hemorrhage.And death.N.B.:in the 6 pregnancies in which the mother receive

15、d warfarin during all (n=2) or part of pregnancy (n=4), embryopathy was not observed in this small series.Predictors of primary cardiac eventsOdds ratio (95% CI)P1. Abnormal functional capacity (NYHA class II or cyanosis)3 (1.1-6.1)0.0352. Use of anticoagulant drugs throughout pregnancy.3 (1.4-8.2)0

16、,00933. Smoking during pregnancy.2 (1.3-13.90.00454. Multiple gestation.22 (6-85) 35 years old or 5 rads: very low risk5-10 rads: counseling for low risk10-15 rads during 1st 6 weeks: individual15 rads: termination pf pregnancyCardiac Tests Performed 2Collettird ed. New York, Wiley Liss, 1998, pp 33

17、-36Magnetic Resonance ImagingPulmonary Artery Catheterization: Great help in managing high risk patient during pregnancy, labor and deliveryCardiac CatheterizationCan be doneCardiac Tests Performed 3Pulmonary hypertension as a risk of adverse outcomePulmonary hypertension(Eisenmenger Syndrome)Increa

18、sed rate of adverse maternal eventsUp to 30-40% ( PVR)When systolic PAP 75% systemic pressure intravascular volume HF (CO limited by Pulmonary vascular disease and Ventricular dysfunction) SVR (after 1st trimester)R-L Shunt CyanosisExacerbated during labor and deliveryBed rest (2nd trimester), O2 (i

19、f helpful), ? Anticoagulation, Cesarian section, invasive monitoring, early ambulation Aortic stenosisSevere AS is poorly tolerated.AVA 50 mmHg.Mortality up to 17%.Symptomatic patients or Mean gradient 50 mmHg Delay conception until after surgical or interventional correction.Consider balloon valvul

20、oplasty, Ross procedure, tissue valve (no need for anticoagulation).Symptomatic patients before end of 1st trimester Terminate pregnancy.-Blockade, Bed rest.Palliative aortic balloon valvuloplasty or AVR.Early Delivery.Reimold, S. C. et al. N Engl J Med 2003;349:52-59Hameed A, et al. The effects of

21、valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol 2001;37:893-9.Prosthetic valves and pregnancyAnticoagulationWarfarin vs. HeparinWarfarinCrosses the placenta.early abortion, prematurity, and embryopathy when used in 1st trimester (6th12th weeks).CNS & Eye abnormal

22、ities (2nd & 3rd trimester).Bleeding in the fetus (especially at delivery)Should be stopped before delivery.HeparinDoes not cross the placentaNo teratogenicityNo fetal bleedingTwice daily SC injectionRisk of osteoporosis 5 3 FT22/25 (88%) 2 WE (9%) 18 SA 1 SB 1 VSD25Total 312758FT = full term, GR =

23、growth retardation; PR = preterm; SA = spontaneous abortion; SB = still birth; WE = warfarin embryopathyVitale N, et al. J Am Coll Cardiol 1999;33:1637-41.Unfractionated Heparin4X higher incidence of Thrombo-embolism during pregnancy than oral anticoagulants1.Hanania G, et al. pregnancy in patients

24、with valvular prosthesis-retrospective cooperative study in France (155 Cases). J Arch Mal Coeur Vaiss 1994;87:429-437.Failure of adjusted dose SC heparin to prevent thrombo-embolic phenomena in pregnant women (n= 40) with mechanical valve prosthesis.Adjusted doses of SC heparin does not improve fet

25、al outcome and increases maternal mortality2.Salazare E, et al. Filure of adjusted dose heparin to prevent thromboembolisc phenomena in pregnant patients with mechanical cardiac valve prosthesis. J Am Coll Cardiol 1996;1698-1703.Frequency of fetal and maternal complications according to the anticoag

26、ulation regimen used during pregnancy in women with mechanical heart valve prosthesis. Adapted from Chen et al. (976 women, 1234 pregnancies) Anticoagulation regimenEmbryopathy (%)Spontaneous abortion (%)Thrombo-embolic complications (%)Maternal death (%)Vitamin K antagonist throughout pregnancy6.42

27、531/788 (3.9%)10/561 (1.8%)Heparin throughout pregnancy0247/21 (33%)3/20 (15%) Low dose0206040 Adjusted dose025256.7Heparin during first trimester, then vitamin K antagonists (with or without heparin before delivery)3.42521/229 (9.2%)7/167 (4.2%)Chan WS. What is the optimal management of pregnant wo

28、men with valvular heart disease in pregnancy? Haemostasis 1999,29 suppl S1:105-6Low-dose ASAThe additional use of low-dose aspirin should be considered, particularly inWomen with high-risk valves.Patients with cyanosis.Patients with intra-cardiac shunts.Women with previous TIAs and/or strokes. And w

29、omen with atrial fibrillation. Chan WS. What is the optimal management of pregnant women with valvular heart disease in pregnancy? Haemostasis 1999,29 suppl S1:105-6 LMWHDo not cross the placenta. Do not require frequent PTT monitoringand have a longer half-life than UFH. The data to support the use

30、 of LMWH, however, is not yet available. A successful use of LMWH was reported in small number of patients and more information is required before LMWH can be recommended for anticoagulation in a patient with a prosthetic valve during pregnancy1.Recently, two cases of LMWH treatment failure resultin

31、g in thrombosed prosthetic heart valves were reported in 20002.LMWH should not be recommended at the present time in patients with heart valve prostheses during pregnancy. Elkayam U. Pregnancy through a prosthetic heart valve. J Am Coll Cardiol 1999;33:1642-5. Lev Rano, Kamer A, Gurevitch J, Shapira

32、, Mohr R. Low-molecular weight heparin for prosthetic heart valves: treatment failure. Ann Thoracic Surg 2000; 69: 264-5. Mechanical Valves and Anticoagulation during PregnancyHeparin may not prevent valve thrombosis: ?how much ?route.Adequate anticoagulation difficult.Heparin can produce osteoporos

33、is.Little data regarding LMWH.Warfarin can cause embryopathy.Baby ASA safe + probably beneficial.1-4% mortality in pregnant women with mechanical valve prosthesis, Whatever the anticoagulation regimen. No Ideal SolutionSuggested algorithm for the management of anticoagulation in patients with mechan

34、ical prosthetic heart valves during pregnancyPregnancy in patients with prosthetic heart valvesHigher riskFirst-generation prosthesis( Starr-Edwards, Bjork- Shiley)In the mitral positionLower riskSecond-generation prosthesis(e.g., St Jude Medical, Medtronic Hall)And any mechanical prosthesis in the

35、aortic positionCoumadin to INR 3.0-4.5 for 36 weeks followed by IV heparin to aPTT of 2.5-3.5 SC or IV (better) heparin-(aPTT 2.5-3.5) for 12 weeksCoumadin (INR 3.0-4.5) to 36th week IV heparin(aPTT 2.5)SC Heparin(aPTT 2.0-3.0) for 12 weeksCoumadin (INR 2.5-3.0) to 36th week SC Heparin(aPTT 2.0-3.0)

36、SC heparin(aPTT 2.0-3.0)Throughout pregnancyBraunwald textbook of cardiovascular medicine, 6th edition1-4% mortality in pregnant women with mechanical valve prosthesis, Whatever the anticoagulation regimen.Mode of deliveryVaginal delivery With facilitated second stage is preferred & safe Invasive he

37、modynamic monitoring only in:Severe valve stenosis Recent heart failure. Severe cyanotic heart diseasePulmonary HTN.Cesarean sectionAvoids physical stress of laborbut not free from hemodynamic consequences.Indications in CHD only for:Obstetric reasons.Therapeutic anticoagulation with coumadin at ons

38、et pf labor.Pulmonary hypertension.Unstable aortic lesion with risk of dissection.Severe obstructive lesionsBreast-feeding Can be encouraged in women taking anticoagulants. Heparin is not secreted in breast milk and the amount of warfarin is low.Hameed A et al. J Am Coll Cardiol 2001;37:8939.Elkayam U, et al. New Engl J Med 2001;344:156771.Bozkurt B, et al. J Am Coll Cardiol 1999;34:17780.Endocarditis prophylaxisAntibiotic prophylaxis at the time of delivery is not recommended for patients expected to have uncomplicated vaginal delivery