Cardiac disease in pregnancy and hypertrophic cardiomyopathy: Difference between revisions
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{{Cardiac disease in pregnancy }} | {{Cardiac disease in pregnancy }} | ||
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==Overview== | ==Overview== | ||
Patients with pre-existing [[Cardiomyopathy|cardiomyopathies]] such as [[dilated cardiomyopathy]] and [[HOCM|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|peripartum cardiomyopathy]]. | Patients with pre-existing [[Cardiomyopathy|cardiomyopathies]] such as [[dilated cardiomyopathy]] and [[HOCM|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|peripartum cardiomyopathy]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
[[Hypertrophic cardiomyopathy]] ([[HCM]]) is an autosomal dominant disease due to mutations of the cardiac sarcomere proteins, which result in asymmetric hypertrophy of the left ventricle, a nondilated left ventricular cavity, and preserved [[systolic function]] with impaired [[diastolic function]].<ref name="pmid12446072">{{cite journal| author=Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P et al.| title=Risk associated with pregnancy in hypertrophic cardiomyopathy. | journal=J Am Coll Cardiol | year= 2002 | volume= 40 | issue= 10 | pages= 1864-9 | pmid=12446072 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12446072 }} </ref> | [[Hypertrophic cardiomyopathy]] ([[HCM]]) is an autosomal dominant disease due to mutations of the cardiac sarcomere proteins, which result in asymmetric hypertrophy of the left ventricle, a nondilated left ventricular cavity, and preserved [[systolic function]] with impaired [[diastolic function]].<ref name="pmid12446072">{{cite journal| author=Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P et al.| title=Risk associated with pregnancy in hypertrophic cardiomyopathy. | journal=J Am Coll Cardiol | year= 2002 | volume= 40 | issue= 10 | pages= 1864-9 | pmid=12446072 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12446072 }} </ref> | ||
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[[Left ventricular outflow tract obstruction]] ([[LVOT]]) is present at rest in approximately 20% of patients.<ref name="pmid16735335">{{cite journal| author=Spirito P, Autore C| title=Management of hypertrophic cardiomyopathy. | journal=BMJ | year= 2006 | volume= 332 | issue= 7552 | pages= 1251-5 | pmid=16735335 | doi=10.1136/bmj.332.7552.1251 | pmc=PMC1471918 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735335 }} </ref> | [[Left ventricular outflow tract obstruction]] ([[LVOT]]) is present at rest in approximately 20% of patients.<ref name="pmid16735335">{{cite journal| author=Spirito P, Autore C| title=Management of hypertrophic cardiomyopathy. | journal=BMJ | year= 2006 | volume= 332 | issue= 7552 | pages= 1251-5 | pmid=16735335 | doi=10.1136/bmj.332.7552.1251 | pmc=PMC1471918 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735335 }} </ref> | ||
==Complications== | ==Natural History, Complications and Prognosis== | ||
Although most women with [[HCM]] with minimal or mild symptoms tolerate pregnancy well, the risks associated with pregnancy include:<ref name="pmid21757110">{{cite journal| author=Stergiopoulos K, Shiang E, Bench T| title=Pregnancy in patients with pre-existing cardiomyopathies. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 4 | pages= 337-50 | pmid=21757110 | doi=10.1016/j.jacc.2011.04.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21757110 }} </ref> | Although most women with [[HCM]] with minimal or mild symptoms tolerate pregnancy well, the risks associated with pregnancy include:<ref name="pmid21757110">{{cite journal| author=Stergiopoulos K, Shiang E, Bench T| title=Pregnancy in patients with pre-existing cardiomyopathies. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 4 | pages= 337-50 | pmid=21757110 | doi=10.1016/j.jacc.2011.04.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21757110 }} </ref> | ||
*[[Sudden death]], particularly in patients with severe outflow obstruction or other risk factors for [[sudden cardiac death]]. | *[[Sudden death]], particularly in patients with severe outflow obstruction or other risk factors for [[sudden cardiac death]]. | ||
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==Treatment== | ==Treatment== | ||
===Medical Therapy=== | |||
Management considerations during pregnancy, labor, and delivery include:<ref name="pmid21757110">{{cite journal| author=Stergiopoulos K, Shiang E, Bench T| title=Pregnancy in patients with pre-existing cardiomyopathies. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 4 | pages= 337-50 | pmid=21757110 | doi=10.1016/j.jacc.2011.04.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21757110 }} </ref> | Management considerations during pregnancy, labor, and delivery include:<ref name="pmid21757110">{{cite journal| author=Stergiopoulos K, Shiang E, Bench T| title=Pregnancy in patients with pre-existing cardiomyopathies. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 4 | pages= 337-50 | pmid=21757110 | doi=10.1016/j.jacc.2011.04.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21757110 }} </ref> | ||
*[[Beta-blockers]] and [[calcium channel blockers]] are safe in this population. | *[[Beta-blockers]] and [[calcium channel blockers]] are safe in this population. | ||
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*[[Epidural anesthesia]] should be avoided due to the potential for [[hypotension]]. | *[[Epidural anesthesia]] should be avoided due to the potential for [[hypotension]]. | ||
*[[Prostaglandins]] for the induction of labor is not advised, secondary to inherent vasodilatory effects. | *[[Prostaglandins]] for the induction of labor is not advised, secondary to inherent vasodilatory effects. | ||
*[[General anesthesia]] is often employed, and | *[[General anesthesia]] is often employed, and vasopressors and fluids can be given to treat [[hypotension]]. | ||
==Related Chapter== | ==Related Chapter== | ||
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==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[CME Category::Cardiology]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Obstetrics]] | [[Category:Obstetrics]] | ||
Latest revision as of 20:48, 29 July 2020
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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.
Pathophysiology
Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease due to mutations of the cardiac sarcomere proteins, which result in asymmetric hypertrophy of the left ventricle, a nondilated left ventricular cavity, and preserved systolic function with impaired diastolic function.[1]
Left ventricular outflow tract obstruction (LVOT) is present at rest in approximately 20% of patients.[2]
Natural History, Complications and Prognosis
Although most women with HCM with minimal or mild symptoms tolerate pregnancy well, the risks associated with pregnancy include:[3]
- Sudden death, particularly in patients with severe outflow obstruction or other risk factors for sudden cardiac death.
- Hemodynamic deterioration, particularly in those with moderate or severe symptoms before pregnancy.
Treatment
Medical Therapy
Management considerations during pregnancy, labor, and delivery include:[3]
- Beta-blockers and calcium channel blockers are safe in this population.
- Avoid decreases in preload (straining, dehydration, etc.).
- Avoid inotropes and vasodilators.
- Tachycardia and reduced preload from valsalva can both adversely affect the HCM patient, so labor should be in a high-risk center.
- Epidural anesthesia should be avoided due to the potential for hypotension.
- Prostaglandins for the induction of labor is not advised, secondary to inherent vasodilatory effects.
- General anesthesia is often employed, and vasopressors and fluids can be given to treat hypotension.
Related Chapter
- This section will primarily focus on hypertrophic cardiomyopathy (HCM) in pregnancy. For a more detailed discussion of hypertrophic cardiomyopathy, click here.
References
- ↑ Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P; et al. (2002). "Risk associated with pregnancy in hypertrophic cardiomyopathy". J Am Coll Cardiol. 40 (10): 1864–9. PMID 12446072.
- ↑ Spirito P, Autore C (2006). "Management of hypertrophic cardiomyopathy". BMJ. 332 (7552): 1251–5. doi:10.1136/bmj.332.7552.1251. PMC 1471918. PMID 16735335.
- ↑ 3.0 3.1 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.