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Tags: Obstetrics
Cardiac disease in pregnancy
There are currently multiple risk stratification tools for cardiac disease in pregnancy including the modified World Health Organization (mWHO) Classification of CVD in Pregnancy, Cardiac Disease in Pregnancy Study (CARPREG II), and Zwangerschap bij Aangeboren HARtAfwijkingen (ZAHARA) tools
The mWHO classification is a validated, lesion-specific risk stratification tool that divides different cardiac lesions into five groups based on risk of cardiac events. The mWHO classification facilitates planning with its framework which can be used to determine resources required by subgroup
The CARPREG II score incorporates features such as coronary artery disease which are not included in the mWHO classification in its risk stratification
mWHO classification
| mWHO I | mWHO II | mWHO II-III | mWHO III | mWHO IV | |
|---|---|---|---|---|---|
| Diagnosis∗ | Small or mild -pulmonary stenosis - patent ductus arteriosus - mitral valve prolapse |
Unoperated atrial or ventricular septal defect | Mild left ventricular impairment (EF >45%) | Moderate left ventricular impairment (EF 30–45%) | Pulmonary arterial hypertension |
| Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage) | Repaired Tetralogy of Fallot | Hypertrophic cardiomyopathy | Previous PPCM without any residual left ventricular impairment | Severe systemic ventricular dysfunction (ejection fraction <30%) | |
| Atrial or ventricular ectopic beats, isolated | Most arrhythmias (supraventricular arrhythmias) | Native or tissue valve disease not considered WHO I or IV (mild mitral stenosis, moderate aortic stenosis) | Mechanical valve | Aortic dilation >45 mm in Marfan syndrome or other HTAD, >50 mm in bicuspid aortic valve, Turner syndrome ASI >25 mm/m2, tetralogy of Fallot >50 mm | |
| Turner syndrome without aortic dilatation | Marfan syndrome or other HTAD without aortic dilatation | Systemic right ventricle with good or mildly decreased ventricular function | Vascular Ehlers–Danlos | ||
| Fontan circulation. If otherwise the patient is well and the cardiac condition uncomplicated | Severe re-coarctation of aorta | ||||
| Unrepaired cyanotic heart disease | Fontan with any complication | ||||
| Other complex heart disease | |||||
| Moderate mitral stenosis | |||||
| Severe asymptomatic aortic stenosis | |||||
| Moderate aortic dilatation (40–45 mm in Marfan syndrome or other HTAD; 45–50 mm in bicuspid aortic valve, Turner syndrome ASI 20–25 mm/m2, tetralogy of Fallot <50 mm) | |||||
| Ventricular tachycardia | |||||
| Risk | No increased risk of maternal mortality and no/mild increased risk in morbidity | Small increased risk of maternal mortality or moderate increase in morbidity | Intermediate increased risk of maternal mortality or moderate to severe increase in morbidity | Significantly increased risk of maternal mortality or severe morbidity | Extremely high risk of maternal mortality or severe morbidity |
| Maternal Cardiac Event Rate | 2.5–5% | 5.7–10.5% | 10–19% | 19–27% | 40–100% |
| Pregnancy Heart Team Involvement | Referral to PHT as needed | Core PHT readily available | Core PHT physically present at all times. Additional members readily available at all times | Core PHT physically present and additional members readily available at all times | Core PHT physically present and additional members immediately or readily available as needed |
10 Questions
| Question | Reason |
|---|---|
| 1. What is the cardiovascular problem and its underlying cause? | - The cardiovascular anatomy involved needs to be fully understood by the pregnancy heart team (PHT). |
| 2. How severe is the cardiovascular problem | - The severity and nature of the cardiovascular problem dictates how often the management plan needs to be reviewed by the PHT and the frequency with which diagnostic tests such as echocardiograms are needed. |
| - Termination of pregnancy should be discussed for severe cardiac disease. | |
| 3. What are the likely complications of the cardiovascular problem and what are the contingency plans if these occur? | - It is essential that the PHT has emergency management plans in place for complications |
| - Patients should be educated on signs and symptoms that should prompt evaluation such as dyspnea at rest, orthopnea, agitation, change in or new onset palpitations, syncope, worsening peripheral edema, or chest, back, interscapular and/or epigastric pain. | |
| 4. What are the treatment options for this problem? | - Usually management plans begin with medical management and then progress to surgical management if unsuccessful. |
| - Defining what is required for the specific pathology is important. | |
| 5. Does the cardiovascular problem affect the mode of birth? | - Greater gestational age and previous successful vaginal birth may predict a successful vaginal birth, but consideration needs to be given to the possibility of patient presenting in labor after hours and whether their cardiac problem can be managed safely with the team in this situation. |
| - Even if vaginal birth is planned, obstetric, cardiac, or fetal decompensation during labor may necessitate cesarean delivery, and consequently a plan for cesarean delivery is always needed. | |
| 6. What is the effect of analgesia and anesthesia on this cardiovascular problem? | - Understanding the physiologic effects of analgesia and anesthesia, specifically the interactions with cardiovascular pathology will dictate the level of monitoring, treatment, and location of care. |
| 7. How will the third stage of labor and postpartum hemorrhage be managed? | - There is often a risk-benefit analysis that needs to be undertaken due to side effects and contraindications associated with certain uterotonics. |
| - Nonpharmacologic methods of hemorrhage management such as fundal rubbing, compressive sutures, uterine artery ablation, and hysterectomy should be considered when use of uterotonics is limited. | |
| 8. Is endocarditis prophylaxis required | - Local and national guidelines should be consulted for the best advice focusing on antibiotic stewardship. |
| 9. What postpartum/postoperative management is required? | - Location of postpartum care, and the need for neonatal cardiac assessment should be determined prior to delivery. |
| - Medication use and breastfeeding should be assessed. | |
| 10. What is the plan for future pregnancies? | - Contraception should be discussed with the patient prior to hospital discharge. |
| - If deferred during pregnancy, plans for treatment and correction of underlying cardiac pathology, such as surgical correction of valvular conditions, may occur in the time between pregnancies. | |
| Referral for consultation with the obstetric anesthesiology team in the second trimester is ideal; the anesthesia team can evaluate maternal tolerance of pregnancy physiology to date and anticipate anesthetic requirements for labor and delivery |
MOD
In general, vaginal delivery is preferred due to less blood loss, inflammatory response, hemodynamic instability, chance of air or thrombotic embolism, and lower risk of infection than cesarean delivery (CD) which is a major abdominal surgical procedure
When people have cardiac lesions that preclude the Valsalva maneuver such as severe aortic stenosis, mitral stenosis, or aortopathy, instrumental vaginal delivery may help avoid CD; however, the associated risks of PPH and severe perineal lacerations must be anticipated
Cardiac indications for CD include cardiopulmonary instability without time or ability for optimization with medical management, and high risk aortopathy
MOA
Epidural and combined spinal epidural (CSE) analgesics and anesthetics are favorable for patients with CVD because they can be slowly titrated to provide adequate analgesia and/or anesthesia while maintaining hemodynamic stability
Early epidural placement during labor facilitates hemodynamic stability by attenuating the catecholamine response to labor and provides the preferred method of anesthesia – conversion of labor epidural to anesthetic - if intrapartum CD is needed
Monitoring
Invasive arterial blood pressure monitoring may be warranted for patients with mWHO Class III-IV or equivalent lesions and can be used for mWHO Class I-II lesions if there is decompensation or other significant obstetric or general comorbidities
Haemorrhage Mx
Oxytocin, commonly administered after delivery for active management of the third stage of labor, has cardiovascular effects including:
- ↓ SVR,
- ↓ inotropy,
- ↓ chronotropy
To mitigate these effects in patients with or without CVD, oxytocin is usually administered as a slow bolus and/or infusion
Carboprost is a prostaglandin that is used as a second line uterotonic for hemorrhage and is contraindicated in patients with pulmonary disease because of the risk of bronchospasm
Methylergonovine is an ergot alkaloid that is another second line uterotonic agent, and its use is contraindicated in patients with hypertension