Pregnancy and Heart Disease:Congenital Heart Disease: Difference between revisions
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==Overview== | |||
Given that more patients with congenital heart disease are living into adulthood, congenital heart disease is now rapidly becoming the most common cardiac problem among pregnant patients. There are also improved diagnostic techniques to aid in the management of these patients. Outcomes clearly linked to functional status pre-pregnancy. | |||
Children of affected mothers at increased risk of having similar lesions. | |||
===Congenital Heart Disease in Pregnancy=== | |||
====Classification of disease==== | |||
'''Can classify lesions into 3 classes:''' | |||
=====Volume Overload (L-->R shunt) ===== | |||
*[[ASD]], [[VSD]], and [[PDA]] well tolerated if [[pulmonary hypertension]] not present | |||
**PVR and SVR falls to same degree | |||
**Degree of shunting does not change | |||
*[[Eisenmenger’s Syndrome]] | |||
**Maternal and fetal mortality ≥50% | |||
:*Consider termination if detected early | |||
:*Careful medical management | |||
::-Supplemental O2 during pregnancy | |||
::-Hospitalization at 20 weeks gestation | |||
::-Prompt treatment of [[CHF]] | |||
::-Avoid shifts in preload/afterload | |||
::Atrial Septal Defect (ASD): Arrhythmias, thromboembolism may develop among pregnant women with an ASD. However, there is no available evidence to suggest that pregnant patients should be managed differently from nonpregnant patients with respect to the indications for ASD closure are no different in pregnant women compared to non-pregnant women. | |||
=====Pressure Overload===== | |||
*[[AS]], [[MS]] | |||
*Pulmonic Stenosis | |||
**Degree of obstruction determines outcome | |||
**Gradient >80 mm Hg mandates correction | |||
*[[Coarctation]] of the aorta | |||
**Accounts for 9% of all congenital disease in adults | |||
**Class I or II patients usually do well | |||
**Overall 3.5% mortality in unoperated patients ([[aortic dissection]]/rupture, CVA, [[CHF]], [[endocarditis]]) | |||
**[[HTN]] needs careful management | |||
*[[HOCM]] | |||
**Early to mid pregnancy, C.O. and end-diastolic dimension ↓ outflow tract obstruction (counteracted by SVR) | |||
::*Avoid Valsalva | |||
::*Encourage left lateral decubitus position | |||
**Maximum risk period during delivery when blood loss can result in increased gradient + systemic hypotension | |||
::*Keep well hydrated | |||
::*Avoid [[digoxin]], simpathomimetics and excessive diuretics | |||
=====Cyanotic Heart Disease (R-->L shunt)<ref>Presbitero P. et al. Circulation 1994;89:2673-6.</ref>===== | |||
*Poor prognosticators: | |||
**Hematocrit > 60% | |||
**O2 sat<85% | |||
::*Livebirth 12% vs. 92% is sat >90% | |||
**Systemic RV pressures | |||
**h/o recurrent [[syncope]] | |||
*[[Tetralogy of Fallot]] most common unrepaired defect | |||
**Drop in SVR leads to increased shunting, deeper [[cyanosis]] and rising HCT | |||
**Need to avoid Valsava during delivery | |||
**Maternal mortality more than 4% | |||
==Specific Disease States== | |||
===[[Aortic Stenosis]]=== | |||
* Most commonly bicuspid valve | |||
* Fixed [[cardiac output]] in response to stress | |||
* Patients with mild to moderate severity do very well | |||
* Severe cases have maternal mortality up to 17% and fetal mortality up to 32% | |||
* Critical cases need surgery / valvuloplasty | |||
* Any reduction in [[preload]] can lead to [[myocardial ischemia|cardiac]] / [[cerebral ischemia]] and compromised uterine flow | |||
===[[Marfan's Syndrome]]=== | |||
* Autosomal dominant inheritance pattern (counseling is essential) | |||
* Major risk is [[aortic dissection]] | |||
:* Most common in 3rd trimester or 1st stage of labor | |||
:* Increases with enlarging aortic root diameter | |||
::* Surgery recommended pre-conception if root diameter >40 mm | |||
::* Surgery recommend during gestation if > 55 mm | |||
:* Prophylactic [[Beta-blockers]] appear to be helpful | |||
* Close follow-up with serial echo | |||
===[[Mitral Stenosis]]=== | |||
====Overview==== | |||
* Most hemodynamically important valvular problem during pregnancy | |||
* Physiologic changes result in increased pulse and C.O. with augmentation of diastolic gradient | |||
* [[Atrial fibrillation]] can lead to rapid deterioration | |||
* Volume shifts during delivery can result in [[pulmonary hypertension]] or [[pulmonary edema]] | |||
====Management of MS in Pregnancy==== | |||
* Restriction of physical activity and salt intake. Avoid supine position | |||
* [[Beta-blockade]] to lengthen disatolic filling period | |||
* Diuretics if necessary (gentle) | |||
* Consideration of invasive monitoring | |||
* Replace blood losses during delivery carefully | |||
* Percutaneous Balloon Mitral Valvuloplasty can be performed during pregnancy if necessary (Class III,IV) | |||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Revision as of 01:28, 20 May 2010
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Overview
Given that more patients with congenital heart disease are living into adulthood, congenital heart disease is now rapidly becoming the most common cardiac problem among pregnant patients. There are also improved diagnostic techniques to aid in the management of these patients. Outcomes clearly linked to functional status pre-pregnancy. Children of affected mothers at increased risk of having similar lesions.
Congenital Heart Disease in Pregnancy
Classification of disease
Can classify lesions into 3 classes:
Volume Overload (L-->R shunt)
- ASD, VSD, and PDA well tolerated if pulmonary hypertension not present
- PVR and SVR falls to same degree
- Degree of shunting does not change
- Maternal and fetal mortality ≥50%
- Consider termination if detected early
- Careful medical management
- -Supplemental O2 during pregnancy
- -Hospitalization at 20 weeks gestation
- -Prompt treatment of CHF
- -Avoid shifts in preload/afterload
- Atrial Septal Defect (ASD): Arrhythmias, thromboembolism may develop among pregnant women with an ASD. However, there is no available evidence to suggest that pregnant patients should be managed differently from nonpregnant patients with respect to the indications for ASD closure are no different in pregnant women compared to non-pregnant women.
Pressure Overload
- Pulmonic Stenosis
- Degree of obstruction determines outcome
- Gradient >80 mm Hg mandates correction
- Coarctation of the aorta
- Accounts for 9% of all congenital disease in adults
- Class I or II patients usually do well
- Overall 3.5% mortality in unoperated patients (aortic dissection/rupture, CVA, CHF, endocarditis)
- HTN needs careful management
- Early to mid pregnancy, C.O. and end-diastolic dimension ↓ outflow tract obstruction (counteracted by SVR)
- Avoid Valsalva
- Encourage left lateral decubitus position
- Maximum risk period during delivery when blood loss can result in increased gradient + systemic hypotension
- Keep well hydrated
- Avoid digoxin, simpathomimetics and excessive diuretics
Cyanotic Heart Disease (R-->L shunt)[1]
- Poor prognosticators:
- Hematocrit > 60%
- O2 sat<85%
- Livebirth 12% vs. 92% is sat >90%
- Systemic RV pressures
- h/o recurrent syncope
- Tetralogy of Fallot most common unrepaired defect
- Drop in SVR leads to increased shunting, deeper cyanosis and rising HCT
- Need to avoid Valsava during delivery
- Maternal mortality more than 4%
Specific Disease States
Aortic Stenosis
- Most commonly bicuspid valve
- Fixed cardiac output in response to stress
- Patients with mild to moderate severity do very well
- Severe cases have maternal mortality up to 17% and fetal mortality up to 32%
- Critical cases need surgery / valvuloplasty
- Any reduction in preload can lead to cardiac / cerebral ischemia and compromised uterine flow
Marfan's Syndrome
- Autosomal dominant inheritance pattern (counseling is essential)
- Major risk is aortic dissection
- Most common in 3rd trimester or 1st stage of labor
- Increases with enlarging aortic root diameter
- Surgery recommended pre-conception if root diameter >40 mm
- Surgery recommend during gestation if > 55 mm
- Prophylactic Beta-blockers appear to be helpful
- Close follow-up with serial echo
Mitral Stenosis
Overview
- Most hemodynamically important valvular problem during pregnancy
- Physiologic changes result in increased pulse and C.O. with augmentation of diastolic gradient
- Atrial fibrillation can lead to rapid deterioration
- Volume shifts during delivery can result in pulmonary hypertension or pulmonary edema
Management of MS in Pregnancy
- Restriction of physical activity and salt intake. Avoid supine position
- Beta-blockade to lengthen disatolic filling period
- Diuretics if necessary (gentle)
- Consideration of invasive monitoring
- Replace blood losses during delivery carefully
- Percutaneous Balloon Mitral Valvuloplasty can be performed during pregnancy if necessary (Class III,IV)
- ↑ Presbitero P. et al. Circulation 1994;89:2673-6.