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

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

PREGNANT RHEUMATIC: Pre-natal and Post-natal Care

“The management of cardiac disease during

pregnancy poses a double challenge.....”

(

“...To ensure maternal survival but at the same time promote fetal well-

being and to allow a gestational period

sufficient for adequate fetal maturity.”

(

• Management should be MULTIDISCIPLINARY–OB–Cardiologist–Anesthesiologist

–Accurate diagnosis–Assessment of the severity–Degree of impairment –Evaluation of concomitant therapy

–Optimizing management • Pregnancy • Labor and Delivery

– Preconceptional counseling– 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

• 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 vascularresistance (dyne.cm.sec) 1530+-520 1210 +-266

Pulmonary vascularresistance 119 +- 47 78 +- 22

Colloid oncotic pressure 20.8 +-1.0 18.0 +- 1.5(mmHg)

• HEMODYNAMIC CHANGES IN NORMAL PREGNANCY

Non-pregnant Pregnant

Mean arterial pressure 86.4 +- 7.5 90.3 +-5.8

Pulmonary capillary wedgepressure (mmHg) 6.3 +- 2.1 7.5 +- 1.8

Central venous pressure 3.7 +-2.6 3.6 +-2.5

Left ventricular strokevolume 41 +- 8 48 +- 6

Clark et al, 1989

• 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

• DURING LABORsympathetic 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

• DURING LABORDuring the second stage of labor, maternal pushing

decreases the venous return to the heart

decrease in cardiac output

• AFTER DELIVERY AND PLACENTAL SEPARATIONSudden transfusion of blood from the lower extremities and the

utero-placental vascular tree to the systemic circulation

Large and abrupt increase in blood volume

• 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

“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)

• 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)

– 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

– 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

THE LEVEL OF ANTEPARTUM CARE REQUIRED BY A PREGNANT WOMAN DEPENDS ON THEIR RISK CLASSIFICATION:

GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS

NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION

FUNCTIONAL CLASS

DESCRIPTIONI No limitations of activities

No symptoms from ordinary activity

II Mild limitation of activityComfortable with rest or mild exertion

III Marked limitation of activityComfortable only at rest

IV Should be at complete rest, confined to bed or chairAny physical activity brings discomfortSymptoms occur at rest

“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)

FIVE RISK FACTORS PREDICATIVE OF POORMATERNAL 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)

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)

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 IIwith 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 cyanosisNYHA class III and IV

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.



II. Anesthesiologist- consulted early in pregnancy to

assess anesthetic risk of the patient- discuss pain control during labor and

delivery



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


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.

Bed rest/Activity restriction

Diet Modification – dietary salt restriction (4-6 g daily)

- limitation of fluid intake (1-1.5 l/day)

GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

Prenatal visits – every 2 weeks until 28 weeks then weekly thereafter

Emphasis:1. Pulse rate check2. Presence of

palpitations

Lanoxin 0.25 mg tab ODMetoprolol – may cause fetal

growth restriction


Prenatal visits – 3. Signs of congestion

Furosemide 20 mg tab OD - may cause oligohydramnios


Prenatal visits – Fetal growth monitoring and status of amniotic fluid done with ultrasound

Instruction:Left lateral decubitus position


Antibiotic prophylaxis:

Pen V 250 mg cap BID or Erythromycin 250 mg cap BID


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

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

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 output2. Increase heart rate3. Expansion of blood volume4. Increase demand for oxygen


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


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

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.

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

exertional dyspnea and fatigue-1st symptoms of MS

decreased exercise capacityOrthopneaparoxysmal nocturnal dyspneapulmonary edemaatrial fibrillation, or an embolic eventRarely, patients may present with

hoarseness, hemoptysis or dysphagia

Tocolytic agents that are positively chronotrophic are contraindicated

Magnesium sulfate

PRETERM LABOR:

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

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

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

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

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 activityReduce left atrial pressure

Diuretics- caution must be exercised to avoiud uteroplacental hypoperfusion associared w/ use of diuretics

“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)

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

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.


Anticoagulation with Warfarin or Heparin can be considered for px with severe left atrial dilatation and Severe MS despite the presence of sinus rhythm, because of the hypercoagulable state of pregnancy

PREGNANT RHEUMATIC: Labor and Delivery

Labor and delivery in lateral decubitus position

Continuous monitoring with pulse oximetry

Control of rate of IV fluid administration to 75 cc/hr

Adequate pain relief (epidural narcotics)

GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:

Antibiotic prophylaxis Short Vaginal delivery with excellent

anesthesiaCesarean section per obstetric

indications Invasive monitoring if neededMedical therapy optimization of

loading conditionsPrevention and treatment of

pulmonary edema

GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:

Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures

Category Drug and dosage

High-risk patient Ampicillin, 2 g IM or IV, plus gentamicin sulfate (Garamycin), 1.5 mg/kg IV 30 min before procedure; ampicillin, 1 g IV, or amoxicillin (Amoxil, Trimox, Wymox), 1 g PO 6 hr after procedure

High-risk patient who has penicillin allergy Vancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr, plusgentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

• EPIDURAL ANESTHESIA– Desirable for vaginal delivery– Performed using small increments of

local anesthetic to achieve T8-T10 level

• GENERAL ANESTHESIA – Best option for NYHA class III and IV– Avoid atropine, pancuronium,

meperidine, ketamine

Shortening of the second stage of labor and assisted vaginal delivery is strongly recommended

Cesarean section are performed for Obstetrics indications

CARDIOVASCULAR DRUGS IN PREGNANCY:

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

contraindicated in pregnancy▪ abnormal renal development in the fetus ▪ oligohydramnios and intrauterine growth

retardation


BETA-ADRENERGIC RECEPTOR BLOCKERS

▪ been used extensively during pregnancy for treatment of arrhythmias, hypertrophic cardiomyopathy, and hypertension

▪ cross the placenta but are not teratogenic

▪ demonstrated to cause fetal growth retardation

▪ be associated with neonatal bradycardia and hypoglycemia


CALCIUM CHANNEL BLOCKERS▪used to treat both arrhythmias and hypertension

▪ limited data regarding use▪Most experience probably exists with verapamil, and no major adverse fetal effects have been recorded

▪Diltiazem and nifedipine have also been used, but studies are limited.


DIGOXIN ▪used during pregnancy for many decades

▪cross the placenta▪no adverse effects with its use have been reported


DIURETICS▪ most commonly furosemide▪ treat congestive heart failure during pregnancy and treatment of hypertension.

▪ may cause reduction in placental blood flow and have a detrimental effect on fetal growth.


WARFARIN▪ contraindicated in the first trimester of pregnancy

▪ crosses the placenta and may cause fetal embryopathy

▪ third trimester (about labor and delivery)▪ immature fetal liver does not metabolize warfarin as rapidly as the mother's liver

▪ reversal of anticoagulation in the fetus may take up to 1 week because of the immature fetal liver


POST NATAL CARE:

Counseling on contraception Permanent sterilization after delivery

discussed during prenatal visits Surgical management prior to the next

pregnancy


Postnatal Care:

failure rate of approximately 15 pregnancies/100 woman-years of use

use of a barrier method depends on how critical it is for the woman to avoid pregnancy, compliance and the ability to use a condom correctly.


Combination estrogen-progesterone oral preparations

▪ increased risk of venous thromboembolism, atherosclerosis, hyperlipidemia, hypertension, and ischemic heart disease

▪ congenital heart disease who have cyanosis, atrial fibrillation or flutter, mechanical prosthetic heart valves, or a Fontan circulation should avoid estrogen-containing preparations

▪ impaired ventricular function from any cause or with a history of any prior thromboembolic


Progesterone-only contraceptives

There is a paucity of data about adverse effects of progesterone agents on the cardiovascular system, but probably these are safe for most women with heart disease


fluid retention and irregular menstruation

cardiovascular contraindications are the same as those for progesterone


performed laparoscopically or via a laparotomy

tenuous cardiac hemodynamics▪ risk of cardiac instability = cardiac anesthesia may be preferable

tubal sterilization has been accomplished with the use of an intrafallopian plug inserted endoscopically


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

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