Preexisting Cardiovascular Disease Aggravated by Pregnancy

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1 Preexisting Cardiovascular Disease Aggravated by Pregnancy Prof. Vera Regitz-Zagrosek Director, Institute of Gender in Medicine (GiM), & Center Cardiovascular Research, & DHZB Charité U N I V E R S I T Ä T S M E D I Z I N B E R L I N

2 No conflicts of interest Regitz-Zagrosek, Gohlke-Baerwolf, Geibel-Zehender, Haas, Kaemmerer, Kruck, Nienaber, Heart Disease in Pregnancy, Guidelines, German Cardiac Society, Clin Res Cardioloy, 2008;97:

3 CVD during pregnancy O.2-4 % of all pregnancies in industrialized nations are complicated by CVD Estimated women in Germany are affected, about 6000 Newborns are harmed CVD is the main cause of maternal death during pregnancy

4 Pre-existing CVD aggravated by pregnancy Hypertension, 6-8 % of pregnancies, serious complications infrequent Congenital most frequent cause of cardiac complications in pregnancy in the Western world (75-82 %), only 9-19 % outside Europe and NA Valvular 15 % in industrialized countries, dominant in developing countries (56-89 %), among those rheumatic diseases: 90 %, Mitral stenosis most frequent Coronary HD rare, but increasing Myocardial Disease, cardiomyopathies (CMP): rare, but severe complications. Strong variation according to country

5 Physiological changes in pregnancy Mechanisms that increase CV risk Increases in hemodynamic load: HR bpm, CI: %, Cardiac hypertrophy, up to 30 %, changes in gene expression Decrease in systemic resistance and diastolic blood pressure, may reverse in 3rd trimester Metabolic changes: increase in glucose and lipids Drug metabolism: mainly increased CK and CK mb are expressed in uterus and placenta (not troponins) Hemostatic changes: pro-coagulatory state

6 Load induced by delivery and indication for Cesarian delivery Load induced by Delivery O2 consumption of mother increases 3 fold BP up to 200 Cardiac output: increases in early labour 15%, 50 % by pushing Indications for cesarian section Heart failure (III-IV) Cyanotic states Severe aortic stenosis Aortic dilatation Preterm labour in patients on OAC

7 Cardiac hypertrophy in pregnancy in a mouse model Eghbali et al., Circ. Res. 2005

8 Increase in diameters, but no significant changes in cardiac function

9 Classical markers of cardiac hypertrophy are not upregulated in pregnancy

10 Maternal high risk conditions Greatest cardiovascular risk in Pulmonary hypertension Severe MS Severe (symptomatic AS) Marfan syndrome Resulting complications Heart failure, arrhythmia, aortic rupture

11 Maternal Risk predictors Predictors of CV events in the mother: Prior cardiac event(hf, TIA, stroke, arrhythmia) NYHA > II or cyanosis Left heart obstruction Reduced ventricular function Smoking Mechanical valve prosthesis Use of cardiac medication

12 Conditions that make pregnancy un-advisable Severe Pulmonary arterial hypertension of any cause Severe systemic ventricular dysfunction (LVEF < 30%) and heart failure (NYHA III-IV) Previous peripartum cardiomyopathy with any residual impairment of left ventricular function Severe left ventricular outflow tract obstruction (Native severe coarctation, severe AS) Severe mitral or aortic stenosis Aortic dilatation Marfan syndrome, others > 45/50 mm) Cyanotic heart disease (O2- saturation below 80 %)

13 Diagnosis in the mother History, physical examination, ECG, Echo, TEE is safe Exercise testing is safe If absolutely needed: Chest X-ray MRT Cardiac catheterization

14 Radiation exposure Normal exposure: 3.6 mgray Exposure above 50 mg may be associated with increased risk for congential malformations, growth restriction, CNS impairment Risk for malformations probably increased above 100 mg Dose mother child (mg) Chest x ray 0.1 <0.01 CT chest Coronary a PCI 15 3

15 absolute Fallzahl Fetal risk predictors Damage to the fetus by maternal factors, Germany Schädigung des Feten und Neugeborenen durch mütterliche , Faktoren und based durch Komplikationen on bei Schwangerschaft, male and Wehentätigkeit und Entbindung female life births insgesamt männlich weiblich Jahr

16 Fetal testing First trimester ultrasound Early detection of multiple pregnancy and malformations Second trimester ultrasound Particularly in women with congenital HD Cardiac anatomy and function arterial and venous flow, rhyth Third trimester ultrasound: Detect growth retarded fetus Doppler velocimetry in in the umbilical artery Fetal biophyical profile (movements, tone, breathing, amniotic fluid volume) will allow interventions that prevent adverse fetal sequelae

17 Heritable heart diseases and genetic counseling Higher transmission rates if mother is affected Risk clearly defined in autosomal dominant inheritage (Marfan, Noonan, LQTS), not in others Higher risk when left sided heart disease, other family members affected, patient has dysmorphic features

18 Heritable heart diseases

19 Specific conditions: Stenotic valvular lesions: sharp increase in transvalvular gradient MS, AS: risks: HF, pulmonary edema, arrhythmia Chronic regurgitation: reduction of systemic vascular resistance reduces regurgitant volume (relatively well tolerated) Diagnosis: regular follow up, exercise test Measure aortic diameter in AR, Marfan and related syndromes, control rhythm

20 Mitral valve diseases severity Maternal complications Fetal /neonatal complications Recommendations MR moderate Slightly elevated: Arrh. Medical, anti-arrhythmic severe Arrh, HF, PE, TE, IE Growth retardation, reduced birth weight,death Surgery pre- Pregnancy recommended MS moderate Arrh, HF, PE, IE Growth retardation, reduced birth weight, severe Arrh, HF, PE, IE Growth retardation, reduced birth weight, death Heart rate control, valvuloplasty before or during pregnancy (symptomatic) Valvuloplasty before pregnanc, or during pregnancy, if sypmptomatic

21 Aortic valve diseases severity Maternal complications Fetal problems Recommendations AR moderate (rare (arrhythmia, HF) Growth retardation, reduced birth weight, Medical, anti-arrhythmic severe Arrh, HF, IE Growth retardation, reduced birth weight, AS moderate Arrh, HF, Growth retardation, reduced birth weight, death Surgery pre-pregnancy recommended Heart rate control, valvuloplasty before or during pregnancy (symptomatic) severe Arrh, HF, sudden death Growth retardation, reduced birth weight, death Valvuloplasty/Surg before pregnanc, possible during Pregnancy, if symptomatic sectio

22 Spontaneous dissection of coronary arteries Group of young women is the only cohort with increasing number of MI Infarkt-Häufigkeit bei jungen Frauen Frauen 2007 Frauen 0 40 bis bis bis bis bis 64

23 Coronary artery disease Risk factors for classical CAD Diabetes, hypertension, HLP, Obesity, positive family history Hyperhomocysteinaemia Non-obstructive CAD Local thrombosis Persisting spasms? Spontaneous dissection Last trimenon and up to 3 mo post partum Infiltration of eosinophile cells in the adventitia Treat with intervention and bare metal stent

24 Summary CVD are the most frequent causes of maternal death in western societies Interdisciplinary care for young women with heart disease based on a team of gynecologists, cardiologists, and others is recommended Patients with severe stenotic HD should undergo surgery or catheter intervention before pregnancy In spontaneous dissection, catheter intervention and stent implantation may be preferable to thrombolysis