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Maternal Congenital Heart Disease in

PregnancyMartha Monson, MDMaternal Fetal Medicine Fellow

April 20, 2018

Project ECHO Pregnancy Care

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OBJECTIVES

• MULTIDISCIPLINARY CARE • Maternal cardiac risk stratification • Fetal risk associated with maternal CHD• Antepartum and delivery management

considerations in the CHD patient• Resources

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ADDITIONAL REFERENCES

https://physicians.utah.edu/echo/pdfs/pregnancy-care-didactics/2017-08-25-Cardiac-Disease-in-Pregnancy.pdf

Please refer to Dr. Sullivan’sProject Echo Pregnancy Care Lecture for more information on:

• Hemodynamic changes in pregnancy

• Pathophysiology of specific cardiac lesions

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MATERNAL CARDIAC RISK PREDICTION

• MULTIDISCIPLINARY APPROACH• Step 1 Cardiology Assessment

– Adult Congenital Heart Disease– Cardiologists with expertise in pregnancy

and maternal congenital heart disease• Step 2 Maternal Fetal Medicine (MFM)

Assessment• Step 3 NICU Consultation (if applicable)• Step 4 Anesthesia Consultation for

complex CHD

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MATERNAL CARDIAC RISK PREDICTION

Cardiology AssessmentAdult Congenital Heart Disease Program

• Ideally BEFORE conception or as early as possible in the antepartum period

• Medical/surgical optimization

• +/- ongoing assessment throughout pregnancy (depends on patient risk)

• Continued care postpartum (Ideally Life-long!)

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ACHD EVALUATIONClinic Visit

• Detailed information on type of cardiac lesion, cardiac history

• Symptoms and physical examWork Up:

• EKG or Ziopatch• Transthoracic Echocardiogram• Exercise stress test• Additional imaging if necessary (e.g. Cardiac MRI)

Recommendations• Medication or Intervention• Referral for Genetic Counseling • Plan for ACHD follow up during and after

pregnancy• Intrapartum and postpartum care• Contraception Counseling

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MATERNAL CARDIAC RISK PREDICTION

• CARPREG• Canadian Multi-Center Prospective Study

Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104: 515-521.

• Zahara• Multi-Center Retrospective Study

(Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31: 2124.)

• WHO Classification • ESC 2011 Guidelines (Consensus – Regitz-Zagrosek, EHJ 2011)

(Eur Heart J. 2011 Dec;32(24):3147-97.)

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MATERNAL CARDIAC RISK PREDICTION

• CARPREG• Canadian Multi-Center Prospective Study (Siu, Circ

2001)

• Zahara• Multi-Center Retrospective Study (Drenthen, Eur

Heart J 2010)

• WHO Classification • ESC 2011 Guidelines (Consensus – Regitz-Zagrosek,

EHJ 2011)

Risk for Maternal Cardiac Event in PregnancyPulmonary Edema

ArrhythmiaStroke Death

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CARPREG

• Prior cardiac event or arrhythmia• NYHA Class 3 or 4 (or cyanosis)• Systemic Ventricular Systolic Dysfunction

(EF <40%)• Left Heart Obstruction

– Aortic Valve Area <1.5cm2

– Peak LVOT gradient >30 mmHg– Mitral Valve Area <2.0cm2

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ZAHARA

• History of arrhythmia• Symptomatic Heart failure before pregnancy

NYHA ≥ 2• Severe left heart obstruction

• Mean pressure gradient >50mmHg or AV area <1cm2

• History of cardiac medication before pregnancy

• Mod to Severe pulmonary or systemic AV valve regurgitation

• Mechanical Heart Valve

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WHO CLASSIFICATION

4 Risk Categories Class I

Cardiology f/u 1-2x in pregnancy

(Eur Heart J. 2011 Dec;32(24):3147-97.)

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WHO CLASSIFICATION

Class II or II-III

Cardiology f/u every trimester

(Eur Heart J. 2011 Dec;32(24):3147-97.)

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WHO CLASSIFICATION

Class III

Cardiology f/u q4-8 weeks

(Eur Heart J. 2011 Dec;32(24):3147-97.)

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WHO CLASSIFICATION

Class IV

(Eur Heart J. 2011 Dec;32(24):3147-97.)

Pregnancy Contraindicated

Termination should be considered

Cardiology follow up q4-8 weeks in continuing pregnancies

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PREDICTING MATERNAL CARDIAC COMPLICATIONSAPPLICATION OF CARPREG SCORING SYSTEM

• NYHA >II• Obstructive Left Heart

• MV <2cm; AV <1.5cm; Peak Gradient >30mmHg

• Prior cardiac event (before pregnancy)• Heart Failure, Arrhythmia, TIA or Stroke

• Ejection Fraction <40%

# of Predictors0 = 5% % Risk of Cardiac Event 1 = 27% During Pregnancy

>1 = 75% (Eur Heart J. 2011 Dec;32(24):3147-97.)

Pulmonary edema, arrhythmia, stroke, TIA

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PREDICTING MATERNAL CARDIAC COMPLICATIONS

Complicated process!Takes into account:

– Maternal cardiac lesion (risk index score)– Prior obstetric and medical history– Multidisciplinary approach with Adult

Congenital Heart Disease, Anesthesia and Maternal Fetal Medicine Consultation in pregnancy

• Low Cardiac Risk ≠ No Cardiac Risk

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FETAL RISK

Increased risk of:• Spontaneous abortion• Intrauterine growth restriction• Stillbirth• Fetal heart disease (5-10%)

– Advocate for formal fetal echocardiography at 22-24 weeks’ gestation

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FETAL RISK

MFM Recommendations• OB Ultrasound• Antenatal testing• Referral for fetal echocardiogram• Referral for genetic counseling• Referral for NICU consultation• Pregnancy specific medications • Delivery timing, mode & location (in

conjunction with ACHD, Anesthesia)

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INTRAPARTUM & POSTPARTUM MANAGEMENT

All complex CHD patients should have a delivery plan detailing intrapartum and postpartum care plans in the medical chart prior to delivery.

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INTRAPARTUM DELIVERY MANAGEMENT

• Delivery Location• Appropriate Level of Maternal Care

– Critical Care Services, blood bank, telemetry capabilities, in house 24 hour OB, anesthesia, ECMO, catheterization lab, NICU, CT surgery, etc.

• Delivery Mode– Cesarean vs. Assisted 2nd Stage vs.

Spontaneous Vaginal Delivery• Most patients can undergo vaginal delivery with

adequate pain control and cesarean delivery for obstetrical indications

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INTRAPARTUM DELIVERY MANAGEMENT

Delivery ModeCesarean vs. Assisted 2nd Stage vs. Spontaneous Vaginal Delivery

• Critical maternal illness• Aortic dilation/aneurysm >45mm• Critical/symptomatic AS• Current maternal warfarin use

• Aortic dilation 40-45mm or any aortopathy

• Maternal critical illness• Eisenmenger physiology,

pulmonary hypertension, mitral stenosis if no significant HF

Consideration of assisted 2nd stageContraindications to Vaginal Delivery

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INTRAPARTUM DELIVERY MANAGEMENT

Anesthesia ConsultationPre-delivery multidisciplinary planning is key!

• Anticoagulation plan• Monitoring

• Telemetry, A-Line• Labor Analgesia

• Early epidural • combined, low dose, spinal-epidural

• Surgical Anesthesia• Emergency cesarean delivery

• Hemorrhage

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OTHER DELIVERY CONSIDERATIONS

Lesion dependent considerations• Fluid Balance• BP parameters• HR Parameters• Air filters on IV lines (prevent paradoxical embolism)

Medication considerations (lesion specific)• E.g. avoid pitocin in PAH (↑ PVR, ↓ 𝑆𝑆𝑆𝑆𝑆𝑆), avoid

methergine in aortopathy, PGEs may ↓ 𝑆𝑆𝑆𝑆𝑆𝑆.

Endocarditis Prophylaxis• Prosthetic Valves• Cyanotic Heart Disease

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POSTPARTUM CARE

All ACHD patients should be flagged as high risk – for many CHD patients, the postpartum period is THE MOST dangerous time.

Postpartum Care Plan• ICU vs. routine postpartum floor• Telemetry• Strict I/Os• BP and HR parameters• Medication management• CONTRACEPTION COUNSELING

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POSTPARTUM CARE

CONTRACEPTION COUNSELING• Risk of thrombosis • Risk of procedure• Method efficacy in context of maternal

cardiac risk in pregnancy and fetal risk in future pregnancy

• Bleeding profile• Consider your cyanotic patient (avoid anemia!)• Consider your chronically anticoagulated patient

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UNIVERSITY MATERNAL ACHD CARE RESOURCE LISTHEART DISEASE & PREGNANCY

Women with heart disease during pregnancy need additional medical care and oversight to stay healthy. Our adult congenital heart disease providers

work closely with doctors in maternal fetal medicine and anesthesia to improve communication, identify problems early, and

help women prepare for labor and delivery.

Maternal Fetal Medicinehttps://healthcare.utah.edu/womenshealth/pregnancy-birth/high-risk-pregnancy.php

Adult Congenital Heart Diseasehttps://healthcare.utah.edu/cardiovascular/conditions/adult-congenital-heart-disease.php

Anesthesia Preoperative ClinicUniversity of Utah Health Care Anesthesia Preoperative Clinic Scheduling Line 801-585-1449

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QUESTIONS