Cardiac disease in pregnancy

Pregnancy in Women with Cardiovascular Diseases

Patients with cardiovascular disease represent a significant cohort at risk for complications during pregnancy. The normal physiologic changes of pregnancy could further compromise the hemodynamics of various cardiovascular conditions, resulting in clinical deterioration and even death. The fetus of a gravida with cardiovascular disease also has an increased risk of morbidity, including an increased risk of inherited cardiac genetic disorders, fetal growth restriction, and premature delivery. These complications also increase the risk for antenatal and perinatal mortality. Ideally, the management of a patient with cardiac disease who is considering pregnancy should start with pre-conception counseling that outlines the maternal and fetal complications associated with her particular cardiac disorder. The pregnancy is best managed by a dedicated team of specialists in maternal-fetal medicine, cardiology, cardiovascular surgery, anesthesiology, and neonatology, preferably in a tertiary care center.

Pregnancy in women with thalassemia: challenges and solutions

Advances in treatment of thalassemia have led to the aging of thalassemic patients, and consequently concern about successful reproductive outcome is augmented. Although women with thalassemia intermedia only were considered competent of achieving pregnancy, case series reveal the willingness of both thalassemia major and thalassemia intermedia women to have a family. Pregnancy in general is characterized by dynamic multiple-system changes and increased susceptibility to oxidative stress, while homozygous, transfusion-dependent, β-thalassemia patients manifest cardiac, hepatic, endocrine, and metabolic disorders attributable to chronic anoxia and iron overload and thalassemia intermedia, usually nontransfused, is associated with augmented risk of thromboembolic events. Pregnancy in thalassemia should be considered a high risk for both mother and fetus, and favorable outcomes are the result of continuous preconception, antenatal, and postpartum assessment and management by a team of thalassemia experts.

[Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy]

BACKGROUND

The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality.

OBJECTIVE

To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy.

CASE REPORT

We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus(®) monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs.

CONCLUSION

This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future.

Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy

BACKGROUND

The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality.

OBJECTIVE

To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy.

CASE REPORT

We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus(®) monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs.

CONCLUSION

This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future.

The pregnant patient with congenital heart disease

Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.

Risk factors associated with preterm delivery in women with cardiac disease

BACKGROUND

The purpose of this study was to identify clinical characteristics of preterm delivery at less than 37 weeks of gestation (PD37G) and prenatal events associated with preterm delivery at less than 35 weeks of gestation (PD35G) in women with cardiac disease (WCD).

METHODS

A case-control study was conducted of 599 pregnancies in 479 single pregnant women with congenital or acquired cardiac lesions or cardiac arrhythmias. The relevant variables were compared between women who had PD35G (n=37) and the controls (n=562). Cardiac dysfunction was defined as the appearance of clinical symptoms of heart failure, abnormal electrocardiogram, or cardiac ultrasonography.

RESULTS

PD37G occurred in 77 cases (12.9%). The spontaneous and indicated preterm delivery was 26 (33.8%) and 51 (66.2%) cases, respectively. The presence of cardiac dysfunction [odds ratio (OR) 21.82, 95% confidence interval (CI) 8.3-57.49], New York Heart Association class II (OR 3.96, 95% CI 1.05-14.93), cardiomyopathy (OR 7.74, 95% CI 1.69-35.45) and pregnancy-induced hypertension (PIH) (OR 3.15, 95% CI 1.37-7.24) was significantly associated with an increased risk of PD35G. No maternal death was seen within one year after delivery.

CONCLUSIONS

Although pregnancy and delivery are generally safe in WCD, it is necessary to be aware of the risk factors of cardiac dysfunction, cardiomyopathy, and PIH from the aspect of PD35G.

Maternal valvular heart disease in pregnancy

Valvular heart disease is common in pregnancy. Maternal physiology changes significantly during gestation with substantial increases in cardiac output and blood volume; this can cause unmasking or worsening of cardiac disease. Acquired valvular lesions most frequently arise from rheumatic fever, especially in patients who have emigrated from developing nations. Congenital lesions are also encountered. The most common conditions seen, mitral stenosis and regurgitation and aortic stenosis and regurgitation, each require a specific evaluation and management and are associated with their own set of possible complications. Patients with prosthetic valves require anticoagulation, and maternal and fetal risks and benefits must be carefully weighed. Patients with heart disease should be meticulously managed preconceptionally up to the postpartum period by maternal-fetal medicine specialists, obstetricians, cardiologists, and anesthesiologists using a multi-disciplinary approach to their cardiac conditions.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After the completing the CME activity, physicians should be better able to examine the epidemiology of valvular heart disease in pregnancy, categorize key physiologic parameters that change in the cardiovascular system during pregnancy, classify the pathophysiology of valvular lesions, and evaluate the general principles of maternal and fetal management for cardiac disease.

Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.

Anaesthetic management for caesarean section in a parturient with uncorrected coarctation of the aorta

We present the case of a woman who refused RMI examination to diagnose a coarctation of her aorta before her third pregnancy. At term of 34 weeks of gestation the caesarean delivery was scheduled under spinal-epidural anaesthesia. Despite the use of a titrated regional anaesthesia, an important arterial hypotension occurred, restored with low doses of vasopressive agents.

Anaesthesia for the obstetric patient with (non-obstetric) systemic disease

The number of women with serious (non-obstetric) systemic diseases achieving pregnancy and requiring obstetric anaesthetic management is increasing. The conditions that are most likely to cause maternal morbidity and mortality are cardiac disease, respiratory disease, neuromuscular disease, haematological disease, connective and metabolic diseases and psychiatric conditions including substance abuse. This article discusses the anaesthetic management of the pregnant mother with such serious systemic diseases.

Effect of maternal congenital heart defects on labor and delivery outcome: A population-based study

OBJECTIVE

The primary objective of this study was to characterize the delivery outcome of parturients with congenital heart defects (CHD), from maternal and from neonatal perspectives.

STUDY DESIGN

A retrospective population-based study was conducted, covering a 13-year period (1989-2002) with an aggregate of 151,487 deliveries of all women with and without CHD. Maternal demographics, obstetrical and medical history, delivery outcome, and neonatal outcome were drawn from a computerized perinatal database.

RESULTS

Sixty-seven women with CHD had 156 deliveries. The severity of CHD, based on the New York Heart Association (NYHA) classification, was I or II in 99.1% of the deliveries. CHD patients had significantly higher rates of labor induction and neonatal malformations. Maternal CHD was discovered as an independent risk factor associated with neonatal malformations (OR 2.10, 95% CI 1.18-3.72). No significant differences were noted between women with CHD and the controls regarding maternal morbidities and Apgar scores.

CONCLUSIONS

The labor outcome of CHD patients with NYHA classification I and II resembles that of non-CHD women in a tertiary center setting. Neonates of CHD mothers have higher rates of congenital malformations even among asymptomatic or mildly symptomatic mothers. A careful sonographic follow-up is warranted among all pregnancies of CHD patients.

Asymptomatic hypoxia in a young pregnant lady--unusual presentation of atrial septal defect

Atrial septal defect (ASD) accounts for approximately a third of all congenital heart disease in adults. It is rarely diagnosed and less likely to cause any symptoms during infancy, but approximately more than half become symptomatic around their fifth decade. In clinical setting it commonly presents as exertional dyspnoea, atrial arrhythmias, right heart failure and is rarely related to the thromboembolic complications due to paradoxical embolism. ASD is usually well tolerated in pregnancy with low risk of miscarriages, stillbirth, preterm delivery and perinatal mortality. We report an interesting case of undiagnosed large ostium secundum atrial septal defect in a young pregnant lady presented as 'asymptomatic hypoxia'. All pregnant women with hypoxia either pre or post-partum should be investigated to rule out any undiagnosed intra cardiac shunts to minimise maternal and foetal complications.

Congenital heart disease in pregnancy

INTRODUCTION

Pregnancy, birth, and the puerperium are associated with significant physiological changes and adaptations in the cardiovascular system, which pose a significant risk to pregnant women with congenital heart disease (CHD). Thanks to advances in pediatric cardiac surgery and cardiology the majority of children with CHD survive to adulthood, and an increasing number eventually become pregnant. In fact, cardiac disease - mostly congenital - is now a leading cause of maternal death in western industrialized countries.

METHODS

Selective literature review.

RESULTS AND DISCUSSION

Optimal care of women with CHD before, during, and after pregnancy requires a multidisciplinary team including obstetricians, cardiologists, and anaesthetists. Successful pregnancy at a minimum risk is feasible for most women with CHD when appropriate counseling and optimal care are provided.

Using reflective nursing practice to improve care of women with congenital heart disease considering pregnancy

This article examines the issue of congenital heart disease (CHD) in women, specifically women who are considering pregnancy. Some of the authors' experiences with women with CHD are described, and a reflective approach to clinical practice is used to gain a greater understanding of the women's perspective. Women with CHD need to balance general lifespan developmental tasks with issues specific to their CHD, such as changes in functional abilities or the possibility of a shortened life expectancy. In women with CHD, physiological, psychological, and family issues need to be considered when they are contemplating pregnancy. As women with CHD move through this debate, nurses may play a key role in assisting them in their decision-making process by exploring issues related to pregnancy and CHD. This exercise in reflective nursing practice allowed us to review the literature, gain new knowledge from our patients, use that knowledge to help other patients, and thoughtfully consider what still needs to be discovered in the care of reproductive-aged women with CHD. The subject of pregnancy contemplation in women with CHD in requires systematic research.

Case Studies

Ms A was a 28 year old woman in her second pregnancy (she had one previous termination of pregnancy) who booked-in at 19 weeks’ gestation. She was known to have sickle cell disease (specifically sickle cell anaemia [HbSS]), and her last crisis had occurred 3 years before this pregnancy.

Pulmonary arterial hypertension and women

Pulmonary arterial hypertension (PAH) is a progressive disorder with a poor prognosis. It is characterized by sustained elevation of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). It is defined hemodynamically by a mean PAP over 25 mm Hg, a pulmonary arterial wedge pressure of 15 mm Hg or less (which excludes left sided lesions), and a PVR of 3 or more Wood units (240 dyn.sec.cm-5). Patients are limited by exertional dyspnea, pre- or true syncope, chest pain, and edema/ascites when right heart failure supervenes. PAH afflicts predominantly young women and the diagnosis is often delayed. Three processes contribute to progressive arterial narrowing: vasoconstriction, vascular remodeling, and thrombosis in situ. The diagnosis of PAH must be confirmed and its etiology must be identified before appropriate therapy can be instituted. Right heart catheterization is necessary to establish the diagnosis, severity, and prognosis of PAH and to ascertain its etiology and to evaluate vasoreactivity, which guides therapy. Treatment of PAH includes vasodilators, supplemental O2, anticoagulation, diuretics, digoxin, intravenous inotropic therapy for decompensated right ventricular failure, and lung or combined heart-lung transplantation for those patients who continue to deteriorate with a poor quality of life despite pharmacologic therapy. Calcium channel blockers are beneficial in a small minority of patients. Prospective, controlled, randomized trials of approved vasodilator agents have enrolled a large proportion of women (70-85%). Agents such as the endothelin-1 receptor antagonist bosentan, the phosphodiesterase-5 inhibitor sildenafil, and the prostanoids have been shown to improve symptoms, exercise capacity, and, in most instances, delay clinical worsening. The clinical outcomes of patients with PAH have improved with the judicious use of contemporary therapies.

The Team Approach to Pregnancy and Congenital Heart Disease

The successful pediatric management of congenital heart disease has resulted in increasing numbers of these patients in the reproductive age group and increasing clinical challenges for their physicians. These challenges can be met successfully, with improved results for mother and child, through a concerted comprehensive team approach that relies on a thorough understanding of the patient's underlying cardiac pathology and its anticipated interaction with the pregnancy, and ongoing close evaluation and communication with a team of trained and experienced specialist, including (but not limited to) cardiologist, obstetricians, anesthetists, pediatricians, clinical nurse specialists, and clinical geneticists. Such teams are not always available locally and it will be necessary to refer medium- and high-risk patients to a specialized tertiary care center.

Practical management of the parturient with congenital heart disease

Cardiac disease is becoming more common in women presenting for maternity care and is a major cause of maternal mortality in the UK. We present a review of the management of parturients with congenital heart disease, focusing on practical aspects and the problems that may be expected.

Hemodynamic assessment in a pregnant and peripartum patient

PATHOPHYSIOLOGY

Critical care in obstetrics has many similarities in pathophysiology to the care of nonpregnant women. However, changes in the physiology of pregnant woman necessary to maintain homeostasis for both mother and fetus, especially during critical illness, result in complex pathophysiology. Understanding the normal physiologic changes during pregnancy, intrapartum, and postpartum is the key to managing critically ill obstetric patients with underlying medical diseases and pregnancy-related complications.

HEMODYNAMIC MONITORING

When the pathophysiology of critically ill obstetric patients cannot be explained by noninvasive hemodynamic monitoring and the patient fails to respond to conservative medical management, invasive hemodynamic monitoring may be helpful in guiding management. Most important, the proper interpretation of hemodynamic data is predicated on knowledge of normal values during pregnancy and immediately postpartum. Invasive hemodynamic monitoring with pulmonary artery catherization has been used in the obstetric population, particularly in patients with severe preeclampsia associated with pulmonary edema and renal failure.

Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease

In the United Kingdom, cardiac disease is the second most common cause of all maternal deaths. The best anaesthetic technique for caesarean section in these patients has yet to be established. We describe a low-dose combined spinal-epidural technique in four high-risk obstetric patients who presented to this unit. Invasive monitoring was used in each case, and drugs with significant cardiovascular effects were avoided or used with extreme caution. Multidisciplinary team involvement, including serial echocardiography in the antenatal period, is strongly recommended.

Congenital heart disease in a population of dizygotic twins: an echocardiographic study

BACKGROUND

Congenital heart disease (CHD) is the most common malformation in the fetal and neonatal period but little is known about its cause. The distribution analysis of CHD in dizygotic twins could provide a useful tool to evaluate the role of genetic and environmental factors in the development of CHD. Dizygotic twins are siblings with different genes, growing together in the same womb.

AIM OF STUDY

To investigate the occurrence of CHD in a large sample of dizygotic twins of nonconsanguineous healthy parents, comparing the data from non-twin patients.

METHODS

From January 1999 to December 2002, we enrolled 1743 CHD patients with, at least 1 sibling, and 66 pairs of dizygotic twins, referred to our tertiary center. The diagnosis of CHD was based on clinical and echocardiographic evaluation.

RESULTS

Considering only the sibling nearest in age for each non-twin patient the recurrence was 67/1743 (3.8%). Among these 67 patients, 35 (52.2%) had a sibling with the same or similar CHD. Conversely, considering all 1886 siblings, recurrence of CHD in the non-twin group was 70/1743 (4%). Of the 70 patients, 36 (36/70, 51.4%) had a sibling with the same suspected pathogenic mechanism of CHD. In 9/66 pairs of twins (13.6%), both siblings had a CHD. In the nine pairs of twins in whom both siblings had a CHD, the percentage of concordance (based on the suspected pathogenic mechanism) for CHD was 100% (p<0.05).

CONCLUSIONS

Our findings suggest that the higher recurrence and concordance of CHD found in dizygotic twins could depend on some poorly identified environmental risk during the pregnancy.

Cardiac arrest during pregnancy

This case involves cardiac arrest of a 29-week old pregnant African American woman, occurring 2 days after surgical correction of an incarcerated ventral hernia with small bowel obstruction. The patient could not be resuscitated from this arrest. Details of the case are presented, and diagnostic and unique management considerations for this uncommon occurrence are set forth.

Maternal collapse

PURPOSE OF REVIEW

This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working.

RECENT FINDINGS

Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year.

SUMMARY

Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

Pregnancy outcome in women with heart disease undergoing induction of labour

OBJECTIVE

To examine the safety and outcome of induction of labour in women with heart disease.

DESIGN

Prospective single-centre comparative study.

SETTING

Major university-based medical centre.

POPULATION/SAMPLE

One hundred and twenty-one pregnant women with heart disease.

METHODS

The sample included all women with acquired or congenital heart disease who attended our High-Risk Pregnancy Outpatient Clinic from 1995 to 2001. The files were reviewed for baseline data, cardiac and obstetric history, course of pregnancy and induction of labour and outcome of pregnancy. Findings were compared between women who underwent induction of labour and those who did not. Forty-seven healthy women in whom labour was induced for obstetric reasons served as controls.

MAIN OUTCOME MEASURES

Pregnancy outcome.

RESULTS

Of the 121 women with heart disease, 47 (39%) underwent induction of labour. There was no difference in the caesarean delivery rate after induction of labour between the women with heart disease (21%) and the healthy controls (19%). Although the women with heart disease had a higher rate of maternal and neonatal complications than controls (17%vs 2%, P= 0.015), within the study group, there was no difference in complication rate between the patients who did and did not undergo induction of labour.

CONCLUSION

Induction of labour is a relatively safe procedure in women with cardiac disease. It is not associated with a higher rate of caesarean delivery than in healthy women undergoing induction of labour for obstetric indications, or with more maternal and neonatal complications than in women with a milder form of cardiac disease and spontaneous labour.

Recognition and management of maternal cardiac disease in pregnancy

Heart disease is a leading cause of maternal death. The aim of this study is to review the most common causes of cardiac disease, highlight factors that should be recognized by the clinician, and address recent advances in the anaesthetic management of these patients. Incipient cardiac disease, including peripartum cardiomyopathy, myocardial infarction and aortic dissection, accounts for approximately one in six maternal deaths. The keys to successful diagnosis and management of incipient disease are: a high index of suspicion, particularly in women with known risk factors for cardiovascular disease; a low threshold for radiological investigations; early cardiology input; and invasive monitoring during labour and delivery. Echocardiography is a safe, non-invasive test, under-used in pregnancy. Management of pregnant women with pre-existing cardiac problems should be undertaken by multidisciplinary teams in tertiary centres. In women with pre-existing cardiac disease wishing to proceed to term, cardiac status must be optimized preoperatively and planned elective delivery is preferable. Vaginal delivery is preferable, and with careful incremental regional anaesthesia is safe in most women with cardiac disease. The presence of adequate systems for early detection, appropriate referral to specialist centres, and timely delivery with multidisciplinary support can minimize the serious consequences of poorly controlled heart disease in pregnancy.