Cardiac disease in pregnancy and dilated cardiomyopathy

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Cardiac disease in pregnancy Microchapters

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Overview

Pathophysiology

Epidemiology and Demographics

Risk Factors

Diagnosis

History and Symptoms

Physical Examination

Electrocardiogram

Exercise Testing

Radiation Exposure

Chest X Ray

Echocardiography

MRI

CT

Catheterization:

Pulmonary artery catheterization
Cardiac catheterization
Cardiac Ablation

Treatment

Cardiovascular Drugs in Pregnancy

Labor and delivery

Resuscitation in Late Pregnancy

Contraindications to pregnancy

Special Scenarios:

I. Pre-existing Cardiac Disease:
Congenital Heart Disease
Repaired Congenital Heart Disease
Pulmonary Hypertension
Rheumatic Heart Disease
Connective Tissue Disorders
II. Valvular Heart Disease:
Mitral Stenosis
Mitral Regurgitation
Aortic Insufficiency
Aortic Stenosis
Mechanical Prosthetic Valves
Tissue Prosthetic Valves
III. Cardiomyopathy:
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Peripartum Cardiomyopathy
IV. Cardiac diseases that may develop During Pregnancy:
Arrhythmias
Acute Myocardial Infarction
Hypertension

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anjan K. Chakrabarti, M.D. [2]

Overview

Patients with pre-existing cardiomyopathies such as dilated cardiomyopathy and hypertrophic cardiomyopathy, often have significant difficulty dealing with the physiologic and hemodynamic changes that occur during pregnancy, labor, and delivery. In addition to these patients, there is a subset of patients who will develop peripartum cardiomyopathy.

Epidemiology and Demographics

Incidence

Currently, DCM is responsible for "approximately 10,000 deaths and 46,000 hospital stays each year in the United States and is the most common indication for cardiac transplantation."[1]

Cause

The cause often remains unknown, in up to 50% of cases.[2]

Reasons why Women with Dilated Cardiomyopathy are Advised to Avoid Pregnancy

  • Dilated cardiomyopathy has been associated with A-type lamin gene defects, which are associated with a high rate of heart failure and life-threatening arrhythmias, as predicted by NYHA functional class[3]
  • The increase in intravascular volume and cardiac output during pregnancy leads to a greater risk for complications in women with dilated cardiomyopathy, especially in the 3rd trimester
  • A history of cardiac events including previous episodes of heart failure, atrial fibrillation or atrial flutter, transient ischemic attack, or a history of cardiac events before pregnancy is predictive of negative pregnancy-related cardiac outcomes[4]

Treatment

Medical Therapy

Management of Heart Failure

The following should be considered when managing heart failure during pregnancy:[5]

Management during Labor and Delivery

Finally, the following should be considered during labor and delivery:[5]

  • Multi-disciplinary approach is crucial.
  • Careful maternal continuous monitoring should be employed, including EKG monitoring, non-invasive blood pressure monitoring, and right heart catheterization/arterial line monitoring if necessary.
  • No official recommendation on timing of delivery is established; coordination between the obstetrician and cardiologist is necessary to deem what is safest for the patient.
  • Vaginal delivery generally poses less cardiovascular risk than cesarian section (less blood loss).
  • Induction of labor with an unfavorable cervix should be avoided; induction with a favorable cervix can be achieved with oxytocin and artificial rupture of membranes.
  • Epidural anesthesia, can produce changes in preload and afterload that can be advantageous in the setting of reduced ventricular function, and should be considered along with intravenous opiates to provide analgesia and reduce the hemodynamic demands that accompany significant pain.
  • When in labor, the patient should be placed in a left lateral decubitus position to avoid IVC compression by the gravid uterus, and the first stage of labor should occur without maternal assistance to avoid the hemodynamic effects of the valsalva maneuver.
  • The second stage of labor can be shortened via assistance with low forceps or by vacuum extraction as needed.

Related Chapter

This section will primarily focus on dilated cardiomyopathy (DCM) in pregnancy. For a more detailed discussion of dilated cardiomyopathy, click here.

References

  1. Manolio TA, Baughman KL, Rodeheffer R, Pearson TA, Bristow JD, Michels VV; et al. (1992). "Prevalence and etiology of idiopathic dilated cardiomyopathy (summary of a National Heart, Lung, and Blood Institute workshop". Am J Cardiol. 69 (17): 1458–66. PMID 1590237.
  2. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL; et al. (2000). "Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy". N Engl J Med. 342 (15): 1077–84. doi:10.1056/NEJM200004133421502. PMID 10760308.
  3. Pasotti M, Klersy C, Pilotto A, Marziliano N, Rapezzi C, Serio A; et al. (2008). "Long-term outcome and risk stratification in dilated cardiolaminopathies". J Am Coll Cardiol. 52 (15): 1250–60. doi:10.1016/j.jacc.2008.06.044. PMID 18926329.
  4. Siu SC, Colman JM, Sorensen S, Smallhorn JF, Farine D, Amankwah KS; et al. (2002). "Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease". Circulation. 105 (18): 2179–84. PMID 11994252.
  5. 5.0 5.1 Stergiopoulos K, Shiang E, Bench T (2011). "Pregnancy in patients with pre-existing cardiomyopathies". J Am Coll Cardiol. 58 (4): 337–50. doi:10.1016/j.jacc.2011.04.014. PMID 21757110.


Cardiology