Ma. Socorro C. Bernardino, M.D. FPOGS

1. PREGNANT RHEUMATIC: Pre-natal and Post-natal Care Ma. Socorro C. Bernardino, M.D. FPOGS

2. “The management of cardiac disease during pregnancy poses a double challenge.....” (

3. “...To ensure maternal survival but at the same time promote fetal well-being and to allow a gestational period sufficient for adequate fetal maturity.” (

4. Management should be MULTIDISCIPLINARY • OB • Cardiologist • Anesthesiologist

5. Accurate diagnosis • Assessment of the severity • Degree of impairment • Evaluation of concomitant therapy • Optimizing management • Pregnancy • Labor and Delivery

6. Preconceptionalcounseling • Hemodynamic changes during pregnancy • Effects of Pregnancy on maternal cardiac disease • Effect of Maternal cardiac disease on pregnancy • General Measures for the care of pregnant patients with heart disease

7. HEMODYNAMIC CHANGES IN NORMAL PREGNANCY Non-pregnant Pregnant Cardiac output (L/min) 4.3+-0.9 6.2 +- 1.0 Heart rate (beats/min) 71 +- 10 83 +- 10 Systemic vascular resistance (dyne.cm.sec) 1530+-520 1210 +-266 Pulmonary vascular resistance 119 +- 47 78 +- 22 Colloid oncotic pressure 20.8 +-1.0 18.0 +- 1.5 (mmHg)

8. HEMODYNAMIC CHANGES IN NORMAL PREGNANCY Non-pregnant Pregnant Mean arterial pressure 86.4 +- 7.5 90.3 +-5.8 Pulmonary capillary wedge pressure (mmHg) 6.3 +- 2.1 7.5 +- 1.8 Central venous pressure 3.7 +-2.6 3.6 +-2.5 Left ventricular stroke volume 41 +- 8 48 +- 6 Clark et al, 1989

9. EFFECT OF PREGNANCY ON MATERNAL CARDIAC DISEASE • Periods during pregnancy when the danger of cardiac decompensation is great: 1. 12 – 16 weeks – start of hemodynamic changes in pregnancy 2. 28 – 32 weeks – hemodynamic changes of pregnancy peak and cardiac demands are at a maximum

10. DURING LABOR sympathetic response to pain + uterine contractions 1. 300-500 ml blood injected into general circulation/contraction 2. Increase in systemic vascular resistance increase stroke volume by 50% Stress in CVS

11. DURING LABOR During the second stage of labor, maternal pushing decreases the venous return to the heart decrease in cardiac output

12. AFTER DELIVERY AND PLACENTAL SEPARATION Sudden transfusion of blood from the lower extremities and the utero-placental vascular tree to the systemic circulation Large and abrupt increase in blood volume

13. EARLY SIGNS OF CARDIAC COMPROMISE • Starts at first trimester • Peak at 20-24 weeks • CO reaches maximum • Beyond 24 weeks • CO maintained at high levels • Post-partum • CO only begins to decline

14. “Intensive monitoring should be continued for at least 72 hours after delivery, preferably in a high care or intensive care environment” (Mulder BJM et al. Valvular heart disease in pregnancy. New England Journal of Medicine 2003)

15. When an underlying valvular disease is present , its not surprising that signs and symptoms of cardiac failure do occur “Following delivery the cardiovascular status of patient will normalize at 6-8 weeks post delivery” (Van Oppen ACA et al. A longitudinal study of the maternal hemodynamics during normal pregnancy. Obstetrics and Gynecology 1996; 88:40-6)

16. EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY • Pregnancy outcome is compromised by the presence of cardiac disease. • Fetal Death – usually secondary to chronic severe or acute maternal deterioration • Fetal morbidity – secondary to preterm delivery and fetal growth restriction > relative inability to maintain an adequate uteroplacental circulation

17. EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY • Fetal morbidity – secondary to preterm delivery and fetal growth restriction • Frequency of effects is related to severity of functional impairment of the heart and severity of chronic tissue hypoxia

18. GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS THE LEVEL OF ANTEPARTUM CARE REQUIRED BY A PREGNANT WOMAN DEPENDS ON THEIR RISK CLASSIFICATION:

19. NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION FUNCTIONAL CLASS DESCRIPTION I No limitations of activities No symptoms from ordinary activity II Mild limitation of activity Comfortable with rest or mild exertion III Marked limitation of activity Comfortable only at rest IV Should be at complete rest, confined to bed or chair Any physical activity brings discomfort Symptoms occur at rest

20. “A New York Heart Association functional class III or IV has been estimated to carry a > 7% risk of mortality and a 30% risk of morbidity” “ Although women in these functional classes should be counselled against childbearing, it is not infrequent that they are encountered in the prenatal clinic (or even in labor ward, or at the theater door!” (Joubert IA and Dyer RA. Anaesthesia for the pregnant patient with acquired valvular heart disease.Update in Anesthesia. Issue 19 2005 Article 9)

21. FIVE RISK FACTORS PREDICATIVE OF POOR MATERNAL AND OR NEONATAL OUTCOME • 1. Prior cardiac event • heart failure, transient ischemic attack or stroke • 2. Prior arrythmia • symptomatic brady or tachy arrhytmia requiring therapy • 3. New York functional > class II or the prescence of cyanosis • 4. Valvular or outflow tract obstruction • Aortic valve area < 1.5 cm2 or mitral valve area < 2 cm2 • Left ventricular outflow tract pressure gradient > 30 mmHg • 5. Myocardial dysfunction • Left ventricular EF < 40% • Restrictive or hypertrophic cardiomyopathy (Siu SC et al. Rik and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96: 2789-94)

22. COMPLICATIONS ASCRIBED TO VALVULAR HEART DISEASE • 1. Increased incidence of maternal cardiac failure and mortality • 2. Increased risk of premature delivery • 3. Lower APGAR scores and low birth weight • 4. Higher incidence of interventional and assisted deliveries (Malhotra M et al. Maternal and fetal outcome in valvular heart disease. International Journal of Gynecology and Obstetrics 2004;84:11-6)

23. LOW Maternal and Fetal Risk HIGH Maternal and Fetal Risk HIGH Maternal Risk HIGH Neonatal Risk Asymptomatic aortic stenosis low mean outflow gradient (<50mmHg) with normal left ventricular function Severe aortic stenosis with or without symptoms Reduced left ventricular systolic function (LVEF <40%) Maternal age <20 yr or >35 yr Aortic regurgitation of NYHA class I or II with normal left ventricular syustolic function Aortic regurgitation with NYHA class III or IV symptoms Previous heart failure Use of anticoagulant therapy throught pregnancy Mitral regurgitation of NYHA class I or II with normal left vertricular systolic function Mitral regurgitation with NYHA class III or IV symptoms Previous stroke or transient ischemic attack Smoking during pregnancy Mild to moderate mitral stenosis (valve area >1.5cm2, gradient <5mmHg) without severe pulmonary hypertesion Mitral stenosis with NYHA class II, III or IV symptoms Multiple gestations Mitral valve prolapse with no mitral regurgitation or with mild to moderate mitral regurgitation and with normal left ventricular systolic function Aortic valve disease, mitral valve disease, or both, resulting in severe pulmonary hypertension (pulmonary pressure > 75% of systemic pressures) Mild to moderate pulmonary valve stenosis Aortic valve disease, mitral valve disease, or both, with left ventricular systolic dysunction (EF <40%) Maternal cyanosis NYHA class III and IV

24. GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS MULTIDISCIPLINARY TEAM APPROACH: I. Primary care physician/high-risk pregnancy specialist - monitor fetal condition and maternal cardiac function at frequent intervals in order to determine if the physiological changes elicited by pregnancy are exceeding the functional capacity of the heart - use medications to limit the extent of changes and improve outcome.

25. GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS MULTIDISCIPLINARY TEAM APPROACH: II. Anesthesiologist - consulted early in pregnancy to assess anesthetic risk of the patient - discuss pain control during labor and delivery

26. GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS MULTIDISCIPLINARY TEAM APPROACH: III. Cardiologist - consult on a regular basis and be available if primary care physicians sees signs of compromise IV. Neonatologist - if fetus is affected by a congenital heart disease

28. Patients who are otherwise healthy • require little or no specific treatment • usual obstetric recommendations and monitoring. • NYHA Class I or II • may need to limit strenuous exercise • adequate rest, supplementation of iron and vitamins • low-salt diet • regular cardiac and obstetric evaluations • NYHA Class III or IV • may need hospital admission for bed rest and close monitoring • may require early delivery if there is maternal hemodynamic compromise.

29. GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Bed rest/Activity restriction Diet Modification – dietary salt restriction (4-6 g daily) - limitation of fluid intake (1-1.5 l/day)

30. GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – every 2 weeks until 28 weeks then weekly thereafter Emphasis: 1. Pulse rate check 2. Presence of palpitations Lanoxin 0.25 mg tab OD Metoprolol – may cause fetal growth restriction

31. GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – 3. Signs of congestion Furosemide 20 mg tab OD - may cause oligohydramnios

32. GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Prenatal visits – Fetal growth monitoring and status of amniotic fluid done with ultrasound Instruction: Left lateral decubitus position

33. GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM: Antibiotic prophylaxis: Pen V 250 mg cap BID or Erythromycin 250 mg cap BID

34. RHEUMATIC HEART DISEASE: RHEUMATIC FEVER Rheumatic fever seldom occurs for the first time young adults and usually preceeded by an episode during childhood (mean age 13) Uncommon in western countries but still prevalent in developing countries Women with a history of rheumatic fever should take daily penicillin before and throughout pregnancy

35. RHEUMATIC HEART DISEASE: RHEUMATIC FEVER Acute rheumatic fever is managed similarly in pregnant and non-pregnant patients Acute streptococcal infection mandates a full bactericidal dose for 10 days Manifestations of pericarditis, symptoms of heart failure, cardiac murmurs and heart enlargement necessitates prompt suppression with prednisone and bed rest

36. RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - the most common rheumatic heart lesion - one of the most dangerous in pregnant women Pregnancy hemodynamic burdens: 1. Increase cardiac output 2. Increase heart rate 3. Expansion of blood volume 4. Increase demand for oxygen

37. RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 1. Latepregnancy - Increased blood volume, CO and HR near term 2. During labor - further 10-15% increase in CO augmented during uterine contractions resulting in autotransfusion of 300 to 500 ml of blood

38. RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 3. Immediately after delivery - Increase in preload and blood volume from the contracted uterus and release of aortocaval compression - Elevated CO persists several days postpartum and gradually declines over a 2 week period

39. mitral stenosis • increase in cardiac output with the increase in heart rate shortens the diastolic filling time and exaggerates the mitral valve gradient Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

40. added volume load may result in symptoms of dyspnea and heart failure in women with impaired LV function and those with limited cardiac reserve • Stenotic valvular lesions are less well tolerated than regurgitant ones • increased heart rate associated with pregnancy reduces the time for diastolic filling, which can be extremely troublesome for many patients, especially those with MS

41. exertional dyspnea and fatigue-1st symptoms of MS • decreased exercise capacity • Orthopnea • paroxysmal nocturnal dyspnea • pulmonary edema • atrial fibrillation, or an embolic event • Rarely, patients may present with hoarseness, hemoptysis or dysphagia

42. PRETERM LABOR: • Tocolytic agents that are positively chronotrophic are contraindicated • Magnesium sulfate

43. Both maternal and fetal outcomes are directly related to the severity of MS and the pre-pregnancy NYHA functional class

44. intrauterine growth retardation • low birth weight, prematurity • fetal/neonatal death • has been estimated at approximately • 33% in severe MS • 28 % in moderate MS • 14% in Mild MS

45. Associated with 10% maternal mortality • Mortality rises to >50% in NYHA class III and IV • Mortality rises between 5-10% if with concomitant atrial fibrillation

46. Many px w/ moderate to severe MS can be managed successfully with medical therapy w/c includes strict control of heart rate ,volume status and frequent monitoring

47. Reduce Heart rate • Beta Blockers or calcium Channel Blockers • Metoprolol( beta blocker)-preferred beta blocker • Atenolol-can cause IUGR,bradycardia and Death • Digoxin-used in px w/AF for control of ventricular rate and is generally safe, well tolerated and has fewer side effects • Restriction of physical activity • Reduce left atrial pressure • Diuretics- caution must be exercised to avoiud uteroplacental hypoperfusion associared w/ use of diuretics

48. “Severe symptomatic disease, threatening maternal or fetal well-being is an accepted indication for either balloon vulvoplasty or valve replacement” “ Valve replacement is usually undertaken during 2nd trimester. Cardiopulmonary bypass and hypothermia carry substantial risk for the fetus. Fetal bradycardia and death are not uncommon” (Unger F et al . Standards and concepts in valve surgery. Report of the task force: European Heart Institute (EHI) of the European Academy of Sciences and Arts and the International Society of Cardiothoracic Surgeons (ISCTS). Indian Heart Journal 2000;52:237-44)

49. Patients with severe mitral stenosis who develop decompensation during pregnancy should undergo percutaneous trans-mitral commissurotomy • Percutaneous mitral valvuloplasty can be performed with few or no complications to the mother or the fetus and excellent clinical and hemodynamic results

50. The “optimal time” appears to be between 20 and 28 weeks of gestation • Obstetric monitoring of the fetus during the procedure • Maternal functional class is an important predictive factor for maternal death. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.