Women’s Health: Cardiovascular Issues in PregnancyS O N I A T O L A N I , M D

C O L U M B I A U N I V E R S I T Y I R V I N G M E D I C A L C E N T E R

D I V I S I O N O F C A R D I O L O G Y

C 0 - D I R E C T O R O F T H E W O M E N ’ S H E A R T C E N T E R

Objectives1. Understand the cardiovascular physiology of

pregnancy

2. Learn management of common aortopathy & valvular disease

3. Learn management of common arrhythmia

4. Review of peripartum cardiomyopathy

5. Learn how to manage hypertensive disorders of pregnancy

6. Know when to refer pregnant patients to high risk center

Pregnancy CVD Physiology

Increased cardiac output• Sharpest rise in 1st trimester

• Up to 45% increase higher with multiples

• Early increase due to increase SV

• Late increase due to increase HR by 10-20 bpm (20-25% increase)

• Increased blood volume• Activation of Renin-Angiotensin-Aldosterone

• Maintains BP and helps retain salt and water

Monika Sanghavi. Circulation. Cardiovascular Physiology of Pregnancy, Volume: 130, Issue: 12, Pages: 1003-

1008, DOI: (10.1161/CIRCULATIONAHA.114.009029)

Reduced SVR & BP• 35-40% decrease in SVR

• BP lowest in 2nd trimester by up to 5-10 mmHg

• BP increased back to normal postpartum

• Hormonal changes: • Increased estrogen and progesterone

• Relaxin→released after conception works on small arteries

• Increased nitric oxide

Mahendru et al. J Hypertens. 2014

Normal Changes in CV Functionduring Pregnancy

Pre-

pregnancy

1st

Trimester

2nd

Trimester

3rd

Trimester

~16 weeks

Postpartum

SBP (mmHg) 108 ± 9 104 ± 7 103 ± 7 105 ± 8 104 ± 8

DBP (mmHg) 71 ± 7 65 ± 6 63 ± 5 68 ± 6 69 ± 6

HR (bpm) 68 ± 10 71 ± 10 76 ± 5 80 ± 10 68 ± 8

CO (L/min) 5.6 ± 1.0 5.8 ± 1.2 6.2 ± 1.0 6.1 ± 1.0 5.6 ± 1.0

Valve Disease

Preconception Assessment•Preconception counseling by a cardiologist who has expertise in pregnancy and valve disease

• Echocardiogram

• 12-lead ECG

• Detailed history with review of high risk medications: ACEI, blood thinners

• Exercise testing: Stress or cardiopulmonary ET

•Preconception counseling by a maternal fetal medicine (MFM) OB

•Team based approach to assess overall risk and develop appropriate plan for management though pregnancy & delivery

Risk Stratify

CARPREG Score (1 point each)

1. Left heart obstruction (mitral stenosis, aortic stenosis, LVOT obstruction)

2. History of prior CVD event (CHF, TIA/CVA, arrhythmia)

3. NYHA Class 3 or 4 or cyanosis

4. Ejection fraction <40 %

Prospective Multicenter Study of Pregnancy Outcomes in Women with Heart Disease. Circulation Jul 31, 2001. CARPREG investigators.

Risk Stratification

Prognosis (total 599)

1. Score 0= 5% events

2. Score=1 27% events

3. Score >1= 62% events

Prospective Multicenter Study of Pregnancy Outcomes in Women with Heart Disease. Circulation Jul 31, 2001. CARPREG investigators.

Pregnant patients with heart disease

13% total events: pulmonary edema, arrythmia, stroke, cardiac death

Aortic stenosis•Etiology: Bicuspid aortic valve

•Mild and moderate AS tolerate pregnancy ok

•Severe AS:• Fixed outflow obstruction: can’t tolerate

increase in CO and stroke volume• CHF/pulmonary edema• Ventricular arrythmias• High rate of obstetric and fetal/neonatal

complications

•Symptomatic AS→Preconception balloon valvotomy if possible or tissue valve

•Diuretics

Mitral stenosis•Etiology: Rheumatic heart disease

•Mild MS probably ok

•Moderate or severe MS:• Tachycardia and increased CO→increased

LA pressure

• Pulmonary edema

• Atrial arrythmia

•Mitral Stenosis: balloon valvotomy if no concomitant MR

•Beta blockers and diuretics

Aortic regurgitation•Etiology: Bicuspid aortic valve

•Mild to moderate AI will do ok

•Severe AI with preserved EF and normal sized LV probably ok

•Symptomatic severe AI, reduced EF, or pulmonary HTN at high risk for CHF• tissue valve replacement prior to pregnancy

•Important to assess for aortopathy:• Marfan syndrome

• Ehlers Danlos

• Loeys-Dietz

Mitral regurgitation•Etiology: MVP, congenital disease, rheumatic heart disease

•Mild to moderate and asymptomatic severe MR ok

•Severe MR with reduced EF or elevated pulmonary pressures at risk

•MV repair or tissue MVR for high risk MR patients prior to conception

•Diuretics

Delivery plansStenotic lesions:◦ Minimize Valsalva◦ Induced labor with assisted second phase of labor◦ Consider CSX especially for aortopathy and aorta >4.5cm

or pulmonary HTN

Regurgitant lesions: ◦ Careful monitoring of volume status◦ Vaginal delivery generally ok unless there is pulmonary

hypertension

Arrythmias

Common arrythmias10% of palpitations in pregnancy will be an arrythmia

•PVCs

•Idiopathic VT

•PACs

•SVT→AVRT and AVNRT

•AF (less common)

Initial evaluation1. Ensure there is no underlying structural disease

with echocardiogram

2. Check for any underlying drivers such as elevated thyroid, anemia or dehydration

3. Monitoring for highly symptomatic patients

Management•Generally just monitor in absence of high risk features

•Identify high risk features:• Syncope or presyncope

• Long periods of arrythmia

• Structural heart disease→decreased EF

• Concerning family history

•Metoprolol first line for most arrythmias of pregnancy

•Digoxin can be used in AF

Metoprolol in pregnancy•Can decrease fetus weight if used for prolonged period in second and third trimester→atenolol is more implicated

•Can decreased fetal heart rate

•Can further lower blood pressure

Peripartum Cardiomyopathy

Peripartum Cardiomyopathy•Decreased LV function <45% in at end of pregnancy or within 5 months of delivery

•Incidence varies widely by geography→~1:1000 to 1:4000 in US

•Etiology: Unclear→oxidative stress, prolactin, impaired VGEF signaling, genetics, inflammatory response

Risk factors:◦ Age >30

◦ African American

◦ Multiple fetuses

◦ Hypertensive disorders of pregnancy/PEC in the past

◦ Cocaine use

Diagnosis•Recognizing symptoms: Shortness of breath, cough, edema

•TTE: Globally reduced EF, dilated LV

•Exclude other causes of heart failure:• Pre-existing cardiomyopathy: Idiopathic, HIV• Valvular disease• MI→abnormal ECG, wall motion abnormality• Pulmonary embolism• Thyroid disease, alcoholism

Management•Heart failure specialist

•Monitored setting:• Ventricular arrythmias

• Atrial fibrillation

•Standard Heart failure regimen:• BB: Metoprolol

• ACEI: Enalapril→ok to breastfeed

• Diuretics as needed

• O2

•Bromocriptine: Prolactin blocker so cannot breast feed→variablerecommendations

Prognosis•42/100 some recovery

• 23 complete

• 19 partial

•Better prognosis with better baseline EF

JACC. Volume 63, Issue 25, Part A, 1 July 2014.

Hypertensive disorders of pregnancySLIDES COURTESY OF DR. NATALIE BELLO

Peterson et al. MMWR. 2019

DuringPregnancy

Day ofDelivery

1-6 7-42 43-365

Number of days Postpartum

Hypertension

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Maternal Morbidity by Etiology & Time Relative to Delivery

Maternal mortality high in US

•Office Blood Pressure (measure at every prenatal visit)

•Hypertension:

• Systolic ≥140 mm Hg and/or Diastolic ≥90 mm Hg

•Severe Hypertension:

• Systolic ≥160 mm Hg and/or Diastolic ≥110 mm Hg

Diagnostic cut-offs for elevated out of office blood pressure on ambulatory

or home monitoring have not been established for pregnant women*

Diagnosis of HTN in pregnancy

Bello NA et al. Hypertension 2018

BP Lab

Spacelabs 90207

Welch Allyn QuietTrak

A&D UM-101

Dinamap ProCare 400

Microlife 3AS1-2

Nissei DS-400

Omron HEM-907

Omron MIT

Omron MIT Elite

Terumo ES-H51

Welch Allyn Vital Signs

Microlife 3BTO-A

Microlife WatchBP Home

Omron HEM 705 CP

Omron M7

Omron MIT

Omron MIT Elite

Omron T9P

Ambulatory Office or HomeOffice Home

How to Monitor BP

SBP ≥ 140 mm Hg

and/or

DBP ≥ 90 mm Hg

< 20 weeks gestation

or

Persistent >6 weeks postpartum

Chronic Hypertension

≥ 20 weeks gestation

Gestational Hypertension

(no target organ involvement)

Preeclampsia/Eclampsia

(target organ involvement)

~25%

>40%

ACOG Practice Bulletin Nos. 202 and 203. Jan 2019; USPSTF. October 2014

Classifying HTN in Pregnancy

ASA 81mg daily after 12week for those at risk for developing PEC

PEC Risk Factors

ACOG Committee Opinion 743

Blood pressure • SBP 140 mm Hg and/or DBP 90 mm Hg on two occasions at least 4 hours apart after 20 weeks of

gestation in a woman with a previously normal blood pressure

• SBP 160 mm Hg and/or DBP 100 (confirmed over 15 min)

AND

Proteinuria• 300 mg per 24 hour urine collection

• Protein/creatinine ratio 0.3 mg/dL

• Dipstick reading of 2+ (if quantitative methods are not available)

OR

Thrombocytopenia (<100k)

• Renal insufficiency (Cr >1.1 mg/dL or 2x Cr in the absence of other renal disease)

• Impaired liver function (transaminases >2x ULN)

• Pulmonary edema

• New-onset headache or visual symptoms

ACOG Practice Bulletin No. 202. Jan 2019

Severe Features

Diagnosis of Preeclampsia

Whelton PK, et al 2017 High Blood Pressure Clinical Practice Guideline

Management of CHTN

Chronic HTN Gestational HTN Preeclampsia

ACOG* (2013/2015/2019)

*2017 ACC/AHA Guideline

refers to this document

StartSBP ≥ 160 mm Hg

DBP ≥ 110 mm Hg

SBP ≥ 160 mm Hg

DBP ≥ 110 mm Hg

GoalSBP 120-160 mm Hg

DBP 80-110 mm Hg

ESC/ESH (2018)Start

Gestational HTN, chronic HTN superimposed by gestational HTN, HTN

with target organ damage or symptoms: SBP > 140 mm Hg or DBP >90

mm Hg

All others: SBP ≥ 150 mm Hg or DBP ≥ 95 mm Hg

Goal

HTN Canada (2018)Start SBP ≥ 140 mm Hg OR DBP ≥ 90 mm Hg

Goal DBP 85 mm Hg

NICE (2010)

Start SBP ≥ 150 mm Hg OR DBP ≥ 100 mm Hg

Goal

SBP <150 mm Hg

DBP 80-100 mm Hg

If target organ damage:

SBP <140 mm Hg

DBP 80-90 mm Hg

SBP <150 mm Hg

DBP 80-100 mm Hg

Pregnancy HTN Goals

First Line

•Labetalol 100-200mg BID, increase Q2-3d; max 2400 mg/24h

•Nifedipine ER 30-60mg QD, increase Q7-14d; max 120 mg/24h

•Methyldopa 250 mg BID-TID, increase Q2d; max 3000 mg/24h

Second Line

•Hydralazine* 10mg QID, increase Q2-5d; max 200 mg/24h

•Thiazide diuretics

CONTRAINDICATED: ACEI/ARB, Renin Inhibitors, mineralocorticoid receptor antagonists

*Hydralazine should not be used in isolation due to reflex tachycardia

ACOG Practice Bulletin Nos. 202 and 203. Obstet Gynecol, 2019

Medical management

ACOG Practice Bulletin Nos. 202 and 203. Obstet Gynecol, 2019

Avoid Nifedipine with MgSO4 (synergistic hypotension)

Emergent BP Control•Labetalol: 10-20 mg IV, then 20-80mg IV Q 20-30 min to max 300mg or

1-2 mg/min IV gtt

•Nifedipine: 10-20mg PO repeat x1 in 30 min, then 10-20mg Q2-6h

•Hydralazine: 5 mg IV or IM, then 5-10 mg IV Q 20-40min or 0.5-10

mg/h IV gtt

Nitro gtt: can be used for pulmonary edema

Magnesium Sulfate: to prevent eclampsia and treat seizures in

women with severe preeclampsia or eclampsia

Medication Class Preferred Agents

Calcium Channel

Blockers

Nifedipine, Verapamil, Diltiazem

B-blockers Labetalol, Metoprolol, and Propranolol are preferred,

Atenolol may be used but concentrates in breast milk

ACE-I Captopril, Enalapril, Quinipril

Diuretics Safe, can decrease mild production

Methyldopa Caution! May exacerbate postpartum depression

ARBs Insufficient data to recommend their use during breast

feeding

Newton et al. Clin Obstet Gynecol. 2015

Safety for Breastfeeding

•Headache or visual changes in association with hypertension raise suspicion for postpartum preeclampsia

•Pregnancy related hypertension should resolve within 6 weeks.

•Women with gestational HTN and preeclampsia have:

• >2x higher rates of developing chronic HTN in 1-5 years

• 2-3 x increased risk of CVD in their lifetime

Black et al. J Hypertens. 2016; Stuart et al. Ann Int Med. 2018

The Fourth Trimester

2017

ACOG Committee Opinion No. 736, May 2018

Post-partum Care

Columbia’s Mothers Center

Outpatient: 844-MOM-CNTR (844-666-2687).

Inpatient: 800-NYP-STAT

Take Home Points1. Preconception counseling with cardiology and MFM is key for any

preexisting heart disease

2. Severe stenotic or regurgitant valve lesions should be addressed prior to pregnancy

3. Arrythmias of pregnancy in STRUCTURALLY NORMAL hearts is usually benign and does not need treatment

4. Peripartum cardiomyopathy should be on the differential when there is SOB or edema after 36 weeks or in the early post partum period

5. Hypertensive disorders of pregnancy are common and dangerous if not addressed

6. Refer patients with heart disease to specialized centers