Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon...

37
Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend

Transcript of Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon...

Page 1: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Pregnancy & Heart DiseasesDonna Kang, MD

Oregon Heart & Vascular InstitutePeaceHealth Sacred Heart Medical Center at RiverBend

Page 2: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Disclosures

● None

Page 3: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Objectives

● Demonstrate the importance of recognizing cardiovascular diseases (CVD) in

pregnancy.

● Define risk factors for increased CVD in pregnancy.

● Define physiologic cardiovascular changes in pregnancy.

● Identify signs and symptoms of CVD in pregnancy, and when to refer.

● Identify important cardiac tests.

● Evaluate CVD using various risk stratification methods.

● Familiarize in pre-existing high risk and acquired CVD in pregnancy.

● Identify commonly used cardiac medications.

● Demonstrate general principles of antepartum, intrapartum, and postpartum

care.

Page 4: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Background

● CVD affects 1-4% of

almost 4 million

pregnancies in US

● CVD is leading cause of

maternal mortality (26%)

● Diagnosis is challenging!

Page 5: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Risk factors for increased CVD

● Race/ethnicity: non-Hispanic black women*

● Age: >40 years old*

● Obesity: 60% of maternal death*

● Hypertension*

● Diabetes

● Obstructive sleep apnea (moderate or severe)

● History of preterm delivery

● Strong family history of heart disease

● Exposure to cardiotoxic drugs

● Social determinants○ Patient, physician, and health systems

○ Education

Page 6: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

CV physiologic changes in pregnancy

Page 7: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Hematologic, coagulation, and metabolic changes

● Anemia○ HF, MI

● Hypercoagulability

● Catabolic state○ Insulin resistance -> gestational diabetes

○ Increased serum fatty acids -> fatty liver

Page 8: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Signs and symptoms of CVD and when to refer to specialists

Page 9: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Cardiac tests

● Natriuretic peptides (BNP, NT-proBNP)

● Troponins

● D-dimer

● Electrocardiogram

● Chest x-ray

● Echocardiogram

● Exercise stress test

● Computed tomography

● Magnetic resonance imaging

● Holter monitor or prolonged cardiac monitoring device

Page 10: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Preparing women with known heart disease for pregnancy

● Optimization prior to pregnancy

● Cardiology evaluation prior to pregnancy or early as possible during

pregnancy

● Multidisciplinary Pregnancy Heart Team○ OB, MFM, cardiology, anesthesiology

● Pregnancy is not recommended for women in modified WHO pregnancy risk

category IV○ Pregnancy can worsen cardiac status that may not return to baseline after pregnancy

○ Maternal morbidity and mortality

○ Fetal risk of heart disease, fetal growth restriction, preterm birth, fetal demise, high perinatal

mortality

Page 11: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Risk assessment

● All women○ California Improving Health Care Response to Cardiovascular Disease in Pregnancy and

Postpartum toolkit algorithm

Page 12: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 13: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Risk assessment

● Women with known CV disease○ Modified World Health Organization (WHO) classification of maternal CV risk**

○ Canadian Cardiac Disease in Pregnancy risk index (CARPREG II)

○ Zwangerschap bij Aangeboren HARtAfwijkingen (ZARAHA)

Page 14: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Modified WHO Pregnancy risk classification

Page 15: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 16: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 17: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

CARPREG II

Page 18: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Pre-existing

high risk

CVD

Page 19: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Acquired CV diseases in Pregnancy

● Peripartum cardiomyopathy

● Acute coronary syndrome

● Maternal cardiac arrest

Page 20: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Peripartum cardiomyopathy

● 25-100 per 100,000 live births in US

● Non-ischemic cardiomyopathy occurring late in pregnancy or the first few

months of postpartum with LV EF <45%

● Unclear etiology, autoimmune?

● 5-10% death or cardiac transplant rate by 1 year postpartum

● Risk factors: non-Hispanic blacks, increased age, multifetal pregnancies,

gestational hypertension, preeclampsia

● 20% recurrence with subsequent pregnancies

● Heart failure symptoms; echocardiogram

● Cardiology consult, pregnancy heart team, appropriate level of care.

● Vaginal delivery is preferred

Page 21: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Acute coronary syndrome

● 8 of 100,000 hospitalizations for pregnancy and postpartum care

● 5-11% maternal death, 3-4x higher rate than non-pregnant age-matched

women

● Etiologies: dissection*, atherosclerosis, embolism, spasm, arteritis, coronary

artery occlusion from aortic dissection

● Risk factors: non-Hispanic black, increased age, obesity, DM, tobacco use,

gestational hypertension, h/o coronary artery dissection, blood transfusion,

peripartum infection

● Typical and atypical symptoms

● Hemodynamic compromise, arrhythmia, cardiogenic shock

● EKG, troponins, echocardiogram, +/- cardiac catheterization

● Pregnancy heart team

Page 22: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Maternal cardiac arrest

● Hemorrhagic (38%), amniotic fluid

embolism (13%), ACS (10%),

venous thromboembolism (5%)

● Oxygenation, decrease aortocaval

compression, CPR, defibrillation,

fetal delivery

Page 23: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 24: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 25: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 26: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 27: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 28: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Antepartum management principles

● Comprehensive plan for pregnancy, delivery, and postpartum

● Women with pre-existing high risk cardiovascular disease should be

evaluated and managed by Pregnancy Heart Team

● Control HTN in women with CVD prior to pregnancy

● Regular exercise before and during pregnancy if possible

● Screening fetal echo for congenital heart disease at 18-22 weeks of gestation

● Close monitoring of fetal growth

● Prophylactic aspirin 81 mg daily to be started at 12 weeks (before 20 weeks)

in women with high risk for preeclampsia

● Close monitoring of blood pressure and treatment appropriately

● Delivery in a hospital with appropriate maternal level of care

Page 29: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Intrapartum management principles

● Pre-planned with Pregnancy Heart Team in high risk CVD

● Vaginal delivery delivery at term if possible

● Regional anesthesia

● Anticoagulation

● Pulmonary edema, arrhythmias

● Prophylactic antibiotics for infective endocarditis

Page 30: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Immediate postpartum management principles

● Time of heightened risk of CVD related maternal morbidity and mortality

● High risk for peripartum cardiomyopathy, aortic dissection, and ACS

● Pulmonary edema, arrhythmias

● Prolonged monitoring

● High risk for thromboembolism

Page 31: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Postpartum considerations after hospital discharge

● Follow up with primary care or cardiology within 7-10 days of delivery for

women with hypertensive disorders

● Follow up with cardiology within 7-14 days of delivery for women with CVD

● Breastfeeding is encouraged ○ 10% less likely to develop CVD in the future

● Address contraception

● Regular follow up in cardiology at 3 months, 6 months, and a year after

delivery for high risk CVD

Page 32: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Conclusion

● Education and prevention

● Early recognition and referrals

● Transfer of care to higher level of care facilities for pregnancy heart team

approach

● Continuity of maternal care after delivery

Page 33: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

References

● Ashrafi, R., Curtis, S. Heart Disease and Pregnancy. Cardiology and Therapy.

2017. 6 (2) 157-173.

● Elkayem, U. High-risk cardiac disease in Pregnancy, part I. Journal of

American College of Cardiology. 2016. 68 (4) 386-410.

● Hollier et al. Pregnancy and heart disease. ACOG Practice Bulletin. 2019.

133 (5) 320-356.

● Martin, N., Montagne, R. US has the worst maternal death in developed

world. National Public Radio. 2017.

● Silversides, C. et al. Pregnancy outcomes in women with heart disease, the

CARPREG II study. Journal of American College of Cardiology. 2018. 71 (21)

2419-2430.

Page 34: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Thank you!

Page 35: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.
Page 36: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Gestational hypertension (gHTN)

● New onset hypertension (SBP ≥140 and/or DBP ≥90) at ≥20 weeks of

gestation in the absence of proteinuria or new signs of end organ dysfunction

● Severe gHTN SBP ≥160 and/or DBP ≥110

● Chronic HTN: persistently elevated BP ≥12 weeks postpartum

● Antihypertensives for severe gHTN and/or end organ dysfunction○ Goal SBP 130-150, DBP 80-100

○ Methyldopa, labetalol, metoprolol, propranolol, nifedipine, verapamil, hydralazine,

● Delivery at 37 weeks if severe gHTN

Page 37: Pregnancy & Heart Diseases - PeaceHealth€¦ · Pregnancy & Heart Diseases Donna Kang, MD Oregon Heart & Vascular Institute PeaceHealth Sacred Heart Medical Center at RiverBend.

Arrhythmia

● Atrial arrhythmias○ Very common

○ Premature atrial beats

○ Paroxysmal supraventricular tachycardia: AVNRT

○ Atrial fibrillation and flutter: structural heart disease

○ Beta-blockers, calcium channel blockers, digoxin, adenosine, cardioversion

● Ventricular arrhythmias○ Rare

○ Structural heart disease

○ Right ventricular outflow tract VT: catecholamine

○ Long QT syndrome, risk of VT especially in postpartum

○ Beta-blockers (sotalol), verapamil, magnesium, procainamide, cardioversion/defibrillation

○ Pregnancy heart team: antiarrhythmics,