IN THE NAME OF GOD

Pregnancy in women with heart disease fetus point

Dr. M.MoshfeghiOBS&GYN

fellowship of perinatology

Shariati.Hospital ,TUMS

Improved techniques of surgical repair have resulted in

women with congenital heart disease surviving to bear children

■Preconceptional CounselingWomen with severe heart disease will benefit from

counseling before undertaking pregnancy ,

significant worsening of NYHA class in4.4 percent of pregnancies in which

the baseline class wasI or II.

The risk tothe womanshould be spelled out as clearly as possible.

•

A woman may require a prosthetic valve in the future .

should be advised to have her family beforevalve replacement

with its associated anticoagulant risk

One of the most important questions is

whether the mother’s heart

disease is hereditary, ?

Congenital Heart Disease in Offspring

inherited as polygenic

Environmental factors living at higher altitudes (> 3600 meters) and was presumablydue to lower oxygen concentrations

Recurrence in the fetus IS 2.7percent

–with concordance (recurrence of the same parental or sibling defect) in approximately one-third

The risk of recurrence was greater if the mother rather than the father had congenital heart disease

(5.7 versus 2.2 percent)

cardiomyopathies, especially hypertrophicinherited in a mendelian manner.

FAMILIAL dilated cardiomyopathy has also been

described .Approximately

20% of idiopathic cardiomyopathy is inherited .

strong familial tendency in,such as PDA and atrial septal defect (ASD)

the risks

to her fetus of drugs, other therapies, and

diagnostic tests?Echocardiography poses nothreat to the fetus,

but radiation incurred with radionuclideangiography, cardiac catheterization with contrast angiography,

or computed tomography pose a potential hazard to the fetus.

CARDIOVASCULAR DRUGS

Some of the drugs commonly used in the management of cardiovasculardisease have potentially harmful effects on the developingembryo and fetus

Warfarin embryopathy ,consisting of nasal hypoplasia,

optic atrophy, digital abnormalities, and mental impairment,occurs in a minority of cases .

A risk of 4% to 10%.

embryopathy is less likely ifthe warfarin dosage is 5 mg/day or less

β-Adrenergic blocking agents , for hypertension and tachyarrhythmia ,

associated withneonatal respiratory depression, bradycardia, andhypoglycemia when administered late in pregnancy

The thiazideharmful effects on the fetusin the third trimester

impairnormal expansion of plasma volume.

Rarely, severe neonatalelectrolyte imbalance, jaundice, thrombocytopenia, liverdamage, and even death have been reported.

angiotensin-convertingenzyme (ACE) inhibitors

profound and deleterious effect on fetal renalFunctionoligohydramnios,neonatal renal failure .

absolutelycontraindicated during pregnancy

Hydralazine, vasodilator andoral antihypertensive agent, can be substituted for ACE inhibitorsduring pregnancy.

Amlodipine is another alternative to

ACE inhibitors ,and it can be used with hydralazine if needed

Digoxin©

Maternal and fetal arrhythmias,heart failureNo evidence for unfavorable sideeffects on the fetus

PERIPARTUM MANAGEMENT CONSIDERATIONS

In some, pregnancy termination may be advisable

MAJOR MATERNAL&FETAL CARDIAC RISKS  — Pulmonary hypertension (pulmonary vascular disease) Maternal cyanosis Poor maternal functional class History of arrhythmia Maternal anticoagulants

Pulmonary hypertension  Eisenmenger syndrome ,

Preterm delivery and fetal growth retardation at least 50 percent ,

15 to 25 percent of pregnancies progressing to term

Cyanosis —  The arterial oxygen saturation before pregnancy important predictors of poor fetal and maternal outcomes The likelihood of a live birth was much lower in women with a resting arterial oxygen saturation below 85 percent

Oxygen administration  — The value of antepartum oxygen in cyanotic

women is unproven .

There is little convincing evidence that oxygen benefits the mother, and there is no evidence that a favorable effect is exerted on a growth-

retarded fetus ,

Pregnancy is contraindicated in women with

Eisenmenger syndrome because of

high maternal mortality risk ,fetal risks ,

risk of thromboembolism

CARPREG risk indexFour predictors of cardiac events were identified :

(NYHA class III or IV ) or cyanosis

Previous cardiac events (eg, heart failure, transient ischemic attack, stroke) or arrhythmia

Left heart obstruction (mitral valve <2 cm2, aortic valve <1.5 cm2, or peak left ventricular outflow gradient >30 mmHg)

Left ventricular systolic dysfunction (EF<40 %)

CARDIAC SURGERY DURING PREGNANCY   —

perform reparative cardiac surgery before conception.

,eliminates the fetal risk

Cardiac surgery during pregnancy

The maternal risks are about the same as those in nonpregnant women

but cardiopulmonary bypass during pregnancy incurs risk for the fetus

Fetal risksnonpulsatile blood flow

reduced uteroplacental flow during cardiopulmonary bypass ,

deep hypothermiapreterm labor and delivery

If cardiopulmonary bypass is needed, high blood flow (2.5 L/min per m2) and mean arterial blood pressure greater than 70

SO If a woman presents early in pregnancy with one of the high risk valve lesions,

we recommend

termination of pregnancy

followed by reparative surgery

before another attempt at pregnancy.

If the mother declines termination, we manage the patient medically

and operate only for refractory NYHA class III or IV symptomsIt is preferable to delay surgery, if possible, until the fetus is viable;

a cesarean delivery can then be performed as part of a combined procedure

During surgery, foam wedges should be placed The fetal heart rate should be monitored

continuously .Fetal bradycardia often responds to an increase in pump flow rate.

In viable fetuses, prolonged bradycardia (less than 80 beats per minute) that is unresponsive to increased pump flow rates is an indication for cesarean delivery if the fetus is at a viable gestational age

Cesarean delivery has been successfully performed while the mother was on cardiopulmonary bypass

the catastrophe of sudden maternal death, immediate postmortem caesarean delivery is an important option.

an infant survival of approximately 15 percent ,cesarean delivery should be performed within four

minutes of maternal cardiac arrest

The resulting decompression of the gravid uterus aids maternal resuscitation

Fetal heart rate monitoring   —FHR should be documented pre- and post-operatively at all gestational ages.

Maternal hemodynamic stability does not guarantee that placental perfusion and fetal

oxygenation are optimal .

Intraoperatively, fetal heart rate monitoring can be a more sensitive assessment of maternal cardiorespiratory status than maternal vital

signs .

We suggest continuously monitoring all viable fetuses (greater than 23 to 24 weeks of gestation) throughout surgery, if technically possible.

.

For abdominal operations, some centers use transvaginal ultrasound to monitor fetal heart

rate.

reduced variability with induction of general anesthesia,

.Baseline FHR may also decrease, but within the normal range .

Vasoactive and chronotropic-modifying agents cross the placenta and can produce changes in the fetal heart rateIf bradycardia, tachycardia, or repetitive decelerations occur, the anesthesiologist should optimize uteroplacental oxygen delivery and blood flow by ensuring there is no aortocaval

compression ;

FETAL RISK  — functional class of the mother ,

maternal cyanosismaternal medications

……………expose the fetus to IUGR.

 Overall fetal outcomes :

miscarriage in 15 percent

Fetal mortality was 1.7 percent

perinatal mortality was 2.3 percent (compared to an expectation of less than 0.5 percent in the general population),

adverse neonatal outcomes in 28 percent of pregnanciespreterm (21 percent),

SGA (8 percent) ,IUFD(3 percent) ,

IVH and neonatal death (1.4 percent each). An adverse neonatal outcome was

independently predicted by a basal left ventricular outflow gradient >30 mmHg

Maternal cyanosis

IUGR37% prematurity

fetal wastagea live birth 43%

The mean birth weight of full term 2575 g compared to a normal term 3500 g .

.We suggest that antepartum fetal monitoring begin

at 28 weeks of gestationultrasound examinations at 28 and 34 weeks of gestation to screen for fetal growth

retardation ,with additional assessment if growth delay is diagnosed

Cyanotic congenital heart disease

A successful pregnancy was unlikely

if hemoglobin ≥ 20 g/dL

(live birth rate of 8 percent )

maternal arterial oxygen saturation was ≤ 85% (live birth rate of 12 percent).

Complete heart blockcongenital or acquired.

The congenital form called the neonatal lupus syndrometrans-placental passage of maternal anti-Ro/SSA and anti-La/SSB antibodies.

Congenital third degree (complete) atrioventricular block

 present with fetal bradycardia between 18 and 28 weeks of gestation

(95 percent )are due to neonatal lupus ,

PREGNANCY — Approximately 50 percent of patients with congenital complete heart block are female

survival into childbearing age is anticipatedmost of these patients will have indications for pacemaker insertion

syncopal episodes occasionally first occur during gestation

and the heart and circulation may not respond adequately to the acute circulatory demands of labor and delivery

Management of congenital CHB in utero and in the perinatal period

steroid therapy if associated with anti-Ro/SSA and anti-La/SSB antibodies,

and isoproterenol and/or pacemaker insertion immediately after birth.

  warfarin potentially teratogenic.

Embryopathy sixth to ninth weeks of

toxicity after this period is still possible

Fetal hemorrhage ,increases the risk of hemorrhagic fetal death

during vaginal delivery.

To minimize this risk, warfarin should be discontinued after 34 to 36 weeks of gestation and/or cesarean delivery should be considered

,infusion of fresh frozen plasma into the mother does not reliably reverse fetal anticoagulation.

A cesarean delivery may prevent hemorrhagic fetal death, and fresh frozen plasma should be administered to the neonate

• For women who are taking long-term vitamin K antagonists and are attempting to become pregnant, the 2012 ACCP Guidelines have made a weak suggestion in favor of performing frequent pregnancy tests and substituting treatment with LMW heparin as soon as pregnancy is achieved, rather than switching to a LMW heparin preparation while attempting pregnancy

We believe that this is a reasonable option for a woman who meets all of the following criteria :She has regular monthly menstrual cycles .

She agrees to have a blood pregnancy test within the first seven days of the missed first day of expected menses .

She can be switched to a LMW heparin preparation promptly if the pregnancy test is positive, and will have a second blood pregnancy test if the first test is negative and menses have not begun within 10 days of the missed first day of expected

menses .She understands the baseline risk of birth defects (3 percent) in the population and the further increased risk and types of embryopathy if she continues to take her long-term vitamin K antagonist during or after the sixth week of pregnancy (ie,

≥14 days after the missed first day of expected menses) .

Antepartum management Serial ultrasound fetal growth ,fetal behavior (FPP) ,amniotic fluid ,

blood flow .The frequency is based upon the severity of

findings and whether the examinations are being done to monitor fetal well-being (one to seven times per week) or fetal growth (every two to four weeks).

Doppler velocimetry of the umbilical artery is recommended

for monitoring pregnancies in which growth restriction is diagnosed

Timing of deliveryRemote from term ,

normal umbilical artery flow by Doppler velocimetry is reassuring We would immediately deliver any pregnancy

≥32 weeks with reversed flow ,

under 34 weeks with absent flow

 Delivery of the late preterm (34 to 36 6/7ths weeks)

or early term (37 0/7ths to 37 6/7ths weeks) IUGR fetus is recommended

if there are additional risk factors for adverse outcome, such as maternal medical/obstetrical disorders, arrest of growth over a three- to four-week interval, and/or absence or reversal of Doppler flow in the umbilical artery

For pregnancies with mild growth restriction at 34 to 37 weeks, normal umbilical artery Doppler flow, and no additional maternal/fetal risk factors,

delivery can be delayed until 38 to 39 6/7ths

weeks, when pulmonary maturity is likely

Delivery at 37 to 38 weeks is reasonable if umbilical artery flow is decreased .

INTRAPARTUM MANAGEMENT — 

perform continuous intrapartum fetal monitoring to detect nonreassuring fetal heart rate patterns

.Umbilical cord blood analysis should be considered as a component of establishing

baseline neonatal status .

INDICATIONS FOR FETAL ECHOCARDIOGRAPHY    

Familial risk factors Maternal risk factors

Fetal risk factors

Familial risk factors First or second degree relatives with congenital heart disease

(eg, the fetus’ siblings, parents, and grandparents )

Syndromes including congenital heart disease (eg, Noonan, tuberous sclerosis, Holt-Oram, velocardiofacial [DiGeorge] syndrome)

Maternal risk factors Maternal congenital heart disease

Cardiac teratogen exposure (eg, lithium , folate antagonists, organic solvents thalidomide , anticonvulsants, isotretinoin , paroxetine , warfarin )

Maternal medical illness (eg, diabetes, phenylketonuria, anti Ro/SSA or anti La/SSB antibodies)

Exposure to prostaglandin synthetase inhibitors (can cause premature closure of the ductus arteriosus in the third trimester) Rubella infection in the first trimester In vitro fertilization

Fetal risk factors Suspected cardiac anomaly during basic sonogram Extracardiac anomaly

AneuploidyNonimmune hydrops Arrhythmia Abnormal fetal situs

Increased nuchal translucency at 11 to 14 weeks of gestationChromosomal abnormality

Monochorionic twins, with or without twin-twin transfusion syndrome

•Fetal karyotype, with screening for deletion in 22q11.2 when conotruncal anomalies are present

Simpson (2012) recommends cesareandelivery for women with the following:

(1 )dilated aortic root >4 cm or aortic aneurysm(2 )acute severe congestive heart failure;

(3 )recent myocardial infarction ;(4 )severe symptomatic

aortic stenosis; (5 )warfarin administration within 2 weeks of

delivery ;( 6 )need for emergency valve replacement immediately

after delivery

•Indications for Fetal EchocardiographyFetalArrhythmiasExtracardiac anomaliesHydropsHydramniosGrowth restrictionChromosomal defectsIncreased nuchal translucency thickness at 11 + 0 - 13 + 6 weeks'

gestationTrucuspid regurgitation at 11 + 0 - 13 + 6 weeks' gestationRetrograde flow in the ductus venosus at 11 + 0 - 13 + 6 weeks'

gestationAbnormal heart at 18-20 weeks routine scan (usually abnormalfour-chamber view)