2018-ESC-Guidelines-for-the-Management-of-Cardiovascular.pptx

Esc guidelines for cardiovascular disease in pregnanch

1. ESC Guidelines for the Management of Cardiovascular Diseases during Pregnancy Reporter: Ryan J. Pan, MD

2. “…pregnancies in the late reproductive years (or between ages of 40–50 years) are more frequently associated with an increasing prevalence of cardiovascular risk factors , especially diabetes, hypertension, and obesity.” Introduction

3. “In western countries, maternal heart disease is the major cause of maternal death during pregnancy.” Introduction

4. Plasma volume and CO increase to 40-50% above baseline (32 weeks AOG) Atrial and ventricular diameters increase while ventricular function is preserved Systemic and pulmonary vascular resistances decrease BP and CO increase during labor and postpartum Physiological Adaptations to Pregnancy

5. ECG, Echocardiography and an exercise test should be performed Complete aortic imaging by CT scanning or MRI (in cases of aortic pathology) A pregnancy exercise capacity >80% is associated with a favorable pregnancy outcome. Form a multidisciplinary team: Cardiologist, obstetrician, and anesthetist Pre-pregnancy Counseling

6. Assess the following first: Medical history Functional class Oxygen saturation Natriuretic peptide levels Echocardiographic assessment of ventricular and valvular function Intrapulmonary pressures and aortic diameters Exercise capacity Arrhythmias Risk of Maternal Cardiovascular Complications

7. Risk of Maternal Cardiovascular Complications

8. Obstetric Complications: Premature labor Preeclampsia Postpartum hemorrhage Fetal Complications: Congenital heart disease (18-30%) Neonatal mortality (1-4%) Risk of Obstetric and Offspring Complications

9. Risk of Obstetric and Offspring Complications Predictors of Maternal and Neonatal Events

10. ELECTROCARDIOGRAPHY During pregnancy: > Heart rotates to the left with a 15 to 20-degree leftward axis deviation > Transient ST-T wave changes > Q wave > Inverted T waves in lead III > Attenuated Q wave in lead aVF > Inverted T waves in V1, V2 and V3 Cardiovascular Diagnosis in Pregnancy

11. ECHOCARDIOGRAPHY The preferred imaging method in pregnancy During pregnancy: > Mild dilatation of cambers > Change in LV wall thickness > Increase in valve gradient EXERCISE TESTING Submaximal exercise testing ( 80% of predicted maximal heart rate ) in asymptomatic patients with suspected heart disease if already pregnant Cardiovascular Diagnosis in Pregnancy

12. CHEST RADIOGRAPHY Should only be performed if other methods fail to clarify the cause of symptoms COMPUTED TOPOGRAPHY Not recommended during pregnancy except in diagnosing Pulmonary embolism or Aortic pathology Cardiovascular Diagnosis in Pregnancy

13. CARDIAC CATHETERIZATION Can be necessary to guide interventional procedures Most electrophysiological studies should only be performed if arrhythmias are medically refractory and cause hemodynamic compromise MAGNETIC RESONANCE IMAGING Used if other non-invasive diagnostic measures are not sufficient for definitive diagnosis Its use should be avoided if possible, especially in the first trimester Excretion of contrast into breast milk is limited Cardiovascular Diagnosis in Pregnancy

14. Screening for Congenital Heart Disease: Nuchal fold thickness measurement (12 wks AOG) Fetal echocardiography (19-22 wks AOG) Suspected cardiac anomaly: Full fetal 2D echo Detailed scanning to identify associated anomalies Family history Maternal medical history Feta karyotype Fetal Growth Restriction: Determine umbilical artery and ductus venosus blood flow patterns Fetal Assessment

15. Percutaneous Therapy Ideal time: After the 4 th month in 2 nd trimester Maneuvers to minimize radiation: > Use echo guidance when possible > Place the source as distant as possible and the receiver as close as possible to the patient > Use only low-dose fluoroscopy > Favor anteroposterior projections > Avoid direct radiation of the abdominal region > Collimate as tightly as possible to the area of interest > Minimize fluoroscopy time > Utilize an experienced cardiologist Interventions in the Mother during Pregnancy

16. Cardiac Surgery with Cardiopulmonary Bypass Recommended only when medical therapy or interventional procedures fail and the mother’s life is threatened Ideal time: 13-28 weeks AOG When gestational age is ≥ 28 weeks, delivery before surgery should be considered (cesarean delivery) Interventions in the Mother during Pregnancy

17. Induction of labor should be considered at 40 weeks of gestation in all women with cardiac disease  reduces emergency CS by 12% and risk of stillbirth by 50% Timing of induction depends on: > Cardiac status > Obstetric evaluation including cervical assessment > Fetal well-being > Fetal lung maturity Pharmacologic method for induction of labor: > Misoprostol 25 ug (Prostaglandin E1) > Dinoprostone 10 mg (Prostaglandin E2) > Oxytocin infusion Mechanical method for induction of labor: > Cervical ripening balloon > Artificial rupture of membranes Timing and Mode of Delivery

18. Vaginal delivery Less blood loss and lower risk of infection Less risk for venous thrombosis and embolism Cesarean delivery Elective caesarean section carries no maternal benefit and results in earlier delivery and lower birthweight Indications for CS: > Obstetrics indication > Taking oral anticoagulants > Aggressive aortic pathology > Acute intractable heart failure > Severe forms of pulmonary hypertension Timing and Mode of Delivery

19. Delivery in anticoagulated women Vaginal delivery Moderate risk and high risk patients Can be converted to an infusion of UFH with regular checking of aPTT Infusion stops 4-6hrs prior regional anesthesia or anticipated deliver Low risk Therapeutic LMWH omitted 24hrs prior delivery Timing and Mode of Delivery

20. URGENT DELIVERY ON THERAPEUTIC ANTICOAGULATION High risk of maternal hemorrhage UFH and LMWH Give Protamine sulfate OAC CS Risk of intracranial hemorrhage Vitamin K 5-10mg FFP Timing and Mode of Delivery

21. HEMODYNAMIC MONITORING DURING DELIVERY Maternal BP Maternal Heart rate Arterial line Pulse oximetry Continuous ECG monitoring Right arterial pressure monitoring Timing and Mode of Delivery

22. ANESTHESIA/ANALGESIA Epidural analgesia • Side effect: Systemic hypotension Timing and Mode of Delivery

23. LABOR Mobilization Lateral decubitus position Delayed active phase of the 2nd stage of labor Assisted delivery with forceps Continuous electronic foetal heart rate monitoring Timing and Mode of Delivery

24. PERIMORTEM CESAREAN SECTION Immediate delivery 4 minutes Goal • Successfully resuscitating the mother • Improving fetal survival Timing and Mode of Delivery

25. POST-PARTUM CARE Slow IV infusion of Oxytocin 2U of oxytocin over 10mins after birth followed by 12mU/min for 4hrs Reduces risk of post partum hemorrhage Treatment: Sulprostone 100-500ug/h Misoprostol 200-1000ug Avoid Ergometrine Prostaglandin F analogues Elastic support stockings Early ambulation Timing and Mode of Delivery

26. BREAST FEEDING • Encourage in all cardiac patients low-risk of bacteraemia secondary to mastitis Timing and Mode of Delivery

27. Pulmonary Hypertension Elevation in mean Pulmonary arterial pressure (PAP) > 25mmHg at right heart catheterization Pulmonary arterial Hypertension (PAH) LV filling pressure < 15mmHg Pulmonary vascular resistance > 3 Wood units • Median age of survival: 2.8 years Females - pregnancy Congenital Heart Disease and Pulmonary Hypertension

28. Maternal risk Severity of PH • Late hospitalization • Use of general anesthesia Avoid pregnancy • If pregnancy occurs: Termination Greatest period risk • Puerperium • Early post-partum Cause of death • Pulmonary hypertensive crisis • Pulmonary thrombosis • Right sided HF Congenital Heart Disease and Pulmonary Hypertension

29. Offspring risk Fetal mortality: 0-30% Leads to: • Preterm delivery • Reduced maternal CO • Hypoxemia Congenital Heart Disease and Pulmonary Hypertension

30. Management • Echocardiography • Invasive right heart catherization • Full assessment every visit Oxygen saturation Assessment of RV function • Bed rest • Anticoagulation Thromboembolism Diuretics Treat iron deficiency Sildenafil Calcium channel blocker Congenital Heart Disease and Pulmonary Hypertension

31. Delivery Vaginal or Cesarean section Regional anesthesia Determinants of good outcome • Fluid balance • RV function Congenital Heart Disease and Pulmonary Hypertension

32. Maternal risk • Due to systemic vasodilation􀀀 dec pulmonary blood flow􀀀 dec CO Complications • Cyanosis • Right to left shunting • Paradoxical embolism Mortality: 20-50% • Termination of pregnancy Fetal risk Miscarriage Hypoxemia Eisenmenger’s Syndrome

33. Maternal risk • Due to systemic vasodilation􀀀 dec pulmonary blood flow􀀀 dec CO Complications • Cyanosis • Right to left shunting • Paradoxical embolism Mortality: 20-50% • Termination of pregnancy Fetal risk Miscarriage Hypoxemia Eisenmenger’s Syndrome

34. Management • Caution in antiplatelet or LMWH • Increased risk of thrombocytopenia • Sildenafil Eisenmenger’s Syndrome

35. Maternal risk • Repaired before pregnancy • Maternal complications HF Thrombosis Arrhythmias Endocarditis Maternal outcome Underlying condition Ventricular function CYANOTIC HEART DISEASE WITHOUT PULMONARY HYPERTENSION

36. Fetal risk • Oxygen saturation > 90%􀀀 better outcome • Oxygen saturation <85% Fetal restriction Prematurity Fetal death Pregnancy is discouraged CYANOTIC HEART DISEASE WITHOUT PULMONARY HYPERTENSION

37. Maternal risk Repaired: Tolerated Unrepaired ASD Complications Thromboembolism Atrial arrhythmias Offspring risk Preeclampsia Growth restriction Management Secundum Catheter device closure Antiplatelet therapy Compression stocks Minimizing bed rest Atrial Septal Defect

38. Maternal risk Low risk Offspring risk No evidence of increased risk Management Surveillance of development of PH Ventricular septal defect

39. Maternal risk • Repaired: Tolerated pregnancy • Arrhythmias • AV regurgitation • Offspring risk • Mortality: 6% • Management • Follow-up • Every trimester ATRIOVENTRICULAR SEPTAL DEFECT

40. Maternal risk • Repaired: Tolerated pregnancy • Unrepaired and Repaired with Systemic Hypertension, residual CoA or Aortic aneurysms • Aortic dissection • Aortic dilatation • Bicuspid aortic valve • Offspring risk • Pre-eclampsia • Miscarriage COARCTATION OF THE AORTA

41. Management • Close BP surveillance • To avoid placental hypoperfusion • Percutaneous intervention for re-CoA • Indication • Refractory hypertension • Maternal compromise • Fetal compromise COARCTATION OF THE AORTA

42. Maternal risk • Tolerated pregnancy • Severe PS • RV failure • Arrhythmias • Severe PR • Independent predictor of maternal complications • Offspring risk • No evidence of increased risk PULMONARY VALVE AND RIGHT VENTRICULAR OUTFLOW TRACT

43. Management • Mild and Moderate PS: low risk • Trimester • Severe PS • Monthly follow-up • Severe symptomatic PS • Percutaneous valvuloplasty PULMONARY VALVE AND RIGHT VENTRICULAR OUTFLOW TRACT

44. Maternal risk • Repaired: Tolerate pregnancy • Complications • HF • Arrhythmias • Thromboembolism • Endocarditis • Risk factors • Dysfunction of RV • Moderate to severe PR • Offspring risk • Fetal growth restriction • Maternal screening of 22q11 deletion prior pregnancy TETRALOGY OF FALLOT

45. Management • Follow-up: Every trimester • Severe PR: Monthly or bimonthly • RV failure during pregnancy • Diuretics • Bed rest • Early delivery • Transcatheter valve implantation TETRALOGY OF FALLOT

46. Management • Follow-up: Every trimester • Severe PR: Monthly or bimonthly • RV failure during pregnancy • Diuretics • Bed rest • Early delivery • Transcatheter valve implantation TETRALOGY OF FALLOT

47. Management • Follow-up: Every trimester • Severe PR: Monthly or bimonthly • RV failure during pregnancy • Diuretics • Bed rest • Early delivery • Transcatheter valve implantation EBSTEIN’S ANOMALY

48. Leads to Aneurysm formation and Aortic dissection • Risk factor • Hypertension • Advanced maternal age Aortic Diseases

49. MATERNAL RISK • Aortic dissection • 3rd trimester: 50% • Early post partum: 33% • Imaging of the entire aorta prior pregnancy • CT scan • MRI Aortic Diseases

50. Aortic dissection: 3% • Aortic size • Major determinant of risk • > 45mm: Avoid pregnancy • 40-45mm: Consider other factors such as family history of dissection and rate of aortic growth • Growth of 3mm during pregnancy MARFAN SYNDROME

51. Complications • Mitral regurgitation • Due to mitral valve prolapse • New arrhythmia • Heart failure • Due to ventricular dysfunction • Premature rupture of membrane MARFAN SYNDROME

52. Aortic dilation: 50% • Aortic dissection: Small • Occurs in distal ascending aorta • Not seen in 2d echo • Imaging before pregnancy: MRI or CT scan • Risk factors for dissection • Type of bicuspid aortic valve • Aortic dilation • Coarctation of aorta • Avoid pregnancy if aortic diameter: > 50mm BICUSPID AORTIC VALVE

53. Type IV Ehlers-Danlos Syndrome (Vascular) • Mortality • Uterine rupture • Aortic dissection • Pregnancy is not advised VASCULAR EHLERS-DANLOS SYNDROME

54. Leads to • Congenital heart disease • Aortic dilatation • Hypertension • Diabetes • Atherosclerotic events • Aortic dissection: Rare • Risk factor for aortic dissection • Aortic dilatation • Bicuspid aortic valve • Coarctation of aorta • Avoid pregnancy if aortic diameter: >25mm • Good BP control and DM management Turner Syndrome

55. Follow-up • High risk for dissection or severely dilated aorta: Monthly • Low risk for dissection or mild dilated aorta: every 12 weeks • 2D echo during pregnancy until 6 months post-partum Management

56. Medical therapy • Strict BP control • Antihypertensive • Beta blocker • Celiprolol • Ehlers-Danlos syndrome Type IV • Monitor fetal growth Management

57. Interventions • Before fetus is viable • Surgical treatment with fetus in uteru • Fetus is viable • CS then Aortic surgery Management

58. Interventions • Standford type A dissection • Surgical emergency • Delivery fetus by CS then repair of dissection • Uncomplicated Standford type B dissection • Conservative management • BP control • Complicated Standford type B dissection • Thoracic endovascular aortic repair Management

59. Delivery • Vaginal delivery (expedited second stage + epidural anesthesia) • Aorta size 40-45mm • Cesarean section • Aorta size >45mm • Ehlers-Danlos Type IV • Acute or chronic aortic dissection Management

60. Majority due to rheumatic heart disease Mechanical valve prostheses raise specific problems during pregnancy Valvular Heart Disease

61. increased CO causes an increase in transvalvular gradient of 50%, mainly between the first and second trimesters increases the risk of maternal and foetal complications Stenotic valve lesions

62. Maternal risk • Valve size • < 1.0cm2 􀀀 1/3 HF • < 1.5cm2 􀀀 ½ HF • NYHA >/= II • Systolic PAP > 30mmHg • Severe stenosis • Older age • Precipitate HF and thromboembolic events • Mortality: 0-3% MITRAL STENOSIS

63. Offspring risk • Prematurity􀀀 20-30% • Intrauterine growth retardation • Fetal death MITRAL STENOSIS

64. Diagnosis • Mitral valve area </= 1.5cm2 • Requires intervention prior pregnancy • Planimetry • Reference measurement of MS severity • Doppler derived pressure half time • Useful during pregnancy • Mean gradient and PAP • Assess hemodynamic consequence and prognosis • Exercise testing • Assess objective exercise tolerance • Before pregnancy MITRAL STENOSIS

65. Medical therapy • Symptoms or clinically significant PH ( echocardiographically systolic PAP > 50mmHg) • Restriction of activities • Beta blocker • Metoprolol • Bisoprolol • Diuretics • Given if symptoms still persist • Avoid high doses MITRAL STENOSIS

66. Medical therapy • Symptoms or clinically significant PH (systolic PAP > 50mmHg) • Anticoagulation • UFH • LMWH • Vit K antagonist • Indication: • Paroxysmal or persistent AF • Left atrial thrombus • Prior embolism • Sinus rhythm with significant MS • Spontaneous echocardiographic contrast in the left atrium • Large left atrium (>60ml/m2) • Congestive HF MITRAL STENOSIS

67. Medical therapy • Symptoms or clinically significant PH (systolic PAP > 50mmHg) • Anticoagulation • UFH • LMWH • Vit K antagonist • Indication: • Paroxysmal or persistent AF • Left atrial thrombus • Prior embolism • Sinus rhythm with significant MS • Spontaneous echocardiographic contrast in the left atrium • Large left atrium (>60ml/m2) • Congestive HF MITRAL STENOSIS

68. Percutaneous mitral commissurotomy • 20 weeks AOG • Indication • NYHA III/IV • Systolic PAP >50mmHg • Closed commissurotomy • Open heart surgery • Last option when all measures failed and mother’s life is threatened MITRAL STENOSIS

69. Follow-up during pregnancy • Clinical and 2D echo: Monthly or Bimonthly MITRAL STENOSIS

70. Labor and delivery • Vaginal delivery • Mild MS • MS NYHA class I/II without PH • Cesarean section • MS NYHA class III/IV • MS with PH • Percutaneous mitral commissurotomy cannot be performed or failed MITRAL STENOSIS

71. Labor and delivery • Vaginal delivery • Mild MS • MS NYHA class I/II without PH • Cesarean section • MS NYHA class III/IV • MS with PH • Percutaneous mitral commissurotomy cannot be performed or failed MITRAL STENOSIS

72. Main cause: • Bicuspid aortic valve • Rheumatic heart disease • Maternal risk • HF • Symptomatic before pregnancy • Arrythmias􀀀 rare • Aortic dissection • Rare if aortic diameter is < 50mm • Mortality􀀀 rare AORTIC STENOSIS

73. Main cause: • Bicuspid aortic valve • Rheumatic heart disease • Maternal risk • HF • Symptomatic before pregnancy • Arrythmias􀀀 rare • Aortic dissection • Rare if aortic diameter is < 50mm • Mortality􀀀 rare AORTIC STENOSIS

74. Diagnosis • Severity • Flow dependent indices • Valve area • Exercise testing • Indication: Asymptomatic patients before pregnancy • Purpose: • Evaluate exercise tolerance • BP response • Arrhythmias • Aortic diameter should be assessed before and during pregnancy AORTIC STENOSIS

75. Medical therapy • Medical treatment • Restriction of activities • Diuretics AORTIC STENOSIS

76. Interventions • Surgery pre-pregnancy • All symptomatic patients with severe AS • Asymptomatic patients with impaired LV function • Pathologic exercise test • Pregnancy is not discourage • Asymptomatic patients with severe AS • Normal LV size and function • Normal exercise test • Severely symptomatic during pregnancy • Percutaneous valvuloplasty • Valve replacement • After early delivery by CS • Transcatheter aortic valve implantation AORTIC STENOSIS

77. Follow-up • Severe AS: Month or Bimonthly AORTIC STENOSIS

78. Labor and Delivery • Cesarean delivery • Severe symptomatic AS • Vaginal delivery • Non severe AS AORTIC STENOSIS

79. Labor and Delivery • Cesarean delivery • Severe symptomatic AS • Vaginal delivery • Non severe AS AORTIC STENOSIS

80. Maternal Risk • HF: 20-25% Offspring Risk • Intrauterine growth restriction: 5-10% MITRAL AND AORTIC REGURGITATION

81. Diagnosis • Assessment of symptoms • Comprehensive echocardiographic evaluation • Regurgitation severity • LV dimensions • Function • Ascending aortic diameter MITRAL AND AORTIC REGURGITATION

82. Medical therapy • Symptoms of fluid overload can be managed medically Interventions • Pre-pregnancy • Valvular repair • Indication: • Severe aortic or mitral regurgitation • Symptoms of impaired ventricular function • Impaired ventricular dilatation • During pregnancy • Delivery + Cardiac surgery MITRAL AND AORTIC REGURGITATION

83. Follow-up • Mild/moderate regurgitation • Every trimester • Severe regurgitation • Monthly or Bimonthly MITRAL AND AORTIC REGURGITATION Labor and Delivery • Vaginal delivery with epidural anesthesia MITRAL AND AORTIC REGURGITATION

84. Secondary TR is more frequent • Endocarditis • Ebstein’s anomaly • Maternal risk • Left sided valve disease • PH • Symptomatic TR • RV dysfunction • Complications: Arrhythmias TRICUSPID REGURGITATION

85. Maternal Risk • HF: 20-25% Offspring Risk • Intrauterine growth restriction: 5-10% TRICUSPID REGURGITATION

86. • Management: Medical • Surgery • Left sided valve lesions • Moderate TR with annular dilatation > 40mm • Severe symptomatic TR􀀀 pre-pregnancy TRICUSPID REGURGITATION

87. AF is common among MS • Treatment: • Anticoagulation • LMWH • Therapeutic dose in 1st and 3rd trimester • VKA or LMWH • 2nd trimester • Non-VKA OAC are contraindicated • Rate controller • Beta blocker • Digoxin ATRIAL FIBRILLATION IN NATIVE HEART VALVE DISEASE

88. CHOICE OF VALVE PROSTHESIS • Mechanical valve • Hemodynamic stable • Long term durability • Need anticoagulated • Increases maternal and fetal mortality • Bioprosthetic valves • Structural valve deterioration • Catheter valve implantation • Especially in pulmonary valve • Ross procedure: aortic valve PROSTHETIC VALVES

89. Offspring risk • Anticoagulation • Causes: • Hemorrhage • Retroplacental bleeding • Results: • Premature birth • Fetal death MECHANICAL PROSTHESES AND ANTICOAGULATION

90. Offspring risk • Anticoagulation • VKA • 1st trimester • Miscarriage • Limb defects • Nasal Hypoplasia • 2nd and 3rd trimester • Ocular abnormalities • Central nervous system abnormalities • Intracranial hemorrhage • Vaginal delivery is contraindicated • Intracranial bleeding MECHANICAL PROSTHESES AND ANTICOAGULATION

91. Offspring risk • Anticoagulation • LMWH and UFH • Does not cross placenta MECHANICAL PROSTHESES AND ANTICOAGULATION

92. Offspring risk • Anticoagulation • LMWH and UFH • Does not cross placenta MECHANICAL PROSTHESES AND ANTICOAGULATION

93. Medical therapy • VKA • Most effective regimen to prevent valve thrombosis • More adverse effects • INR monitoring 2 weeks • Preferred therapy in 2nd and 3rd trimester until 36th week • Discontinued at 36th week gestation and shift to UFH ( aPTT > 2x control) or LMWH MECHANICAL PROSTHESES AND ANTICOAGULATION

94. Medical therapy • LMWH • Given from weeks 6-12 • Starting dose: • Enoxaparin 1mg/kg BW BID SQ • Dalteparin 100IU/kg BID SQ • Dose adjusted: • Daily: • Based on peak anti- Xa levels • Target: 4-6hrs post dose • Aortic valve prosthesis: 0.8- 1.2IU/ml • Mitral and right sided valve prosthesis: 1.0-1.2IU/ml MECHANICAL PROSTHESES AND ANTICOAGULATION

95. Medical therapy • LMWH • Dose adjusted: • Daily: • Based on trough (pre-dose) anti- Xa level • Target: 0.6 IU/mL • Weekly • Target anti- Xa level achieved MECHANICAL PROSTHESES AND ANTICOAGULATION

96. Medical therapy • UFH • aPTT monitoring weekly • Prolonged >2x control MECHANICAL PROSTHESES AND ANTICOAGULATION

97. MECHANICAL PROSTHESES AND ANTICOAGULATION

98. MECHANICAL PROSTHESES AND ANTICOAGULATION

99. MECHANICAL PROSTHESES AND ANTICOAGULATION

100. Diagnosis of valve thrombosis • Transthoracic echocardiography • Transesophageal echocardiography • Fluoroscopy MECHANICAL PROSTHESES AND ANTICOAGULATION

101. Management of valve thrombosis • Comparable with non-pregnant patients • Anti-coagulation • IV • Oral • Non critically ill patients • Surgery • If anticoagulation fails • High risk of fetal loss MECHANICAL PROSTHESES AND ANTICOAGULATION

102. Management of valve thrombosis • Fibrinolysis • Indication • Critically ill patients when surgery is not available • Right sided prosthetic valve thrombosis • Pass placenta (<1000kDa) • Steptokinase • Urokinase • Does not pass placenta • Alteplase • Risk of subplacental bleeding MECHANICAL PROSTHESES AND ANTICOAGULATION

103. Delivery • Vaginal delivery • Switch to IV heparin • Cesarean section • Do not use Epidural anesthesia • Indication • High risk valve thrombosis • Labor onset while on VKA • Labor less than 2 weeks after discontinuation of VKA MECHANICAL PROSTHESES AND ANTICOAGULATION

104. Pregnancy increases risk of Acute MI • Risk factors • Smoking • Maternal age: 40 years old • Hypertension • Diabetes • Obesity • Dyslipidemia • Pre-eclampsia • Thrombophilia • Transfusion • Post-partum infection • Cocaine use • Multiparity • Post partum hemorrhage CORONARY ARTERY DISEASE

105. Mechanism • Pregnancy related spontaneous coronary artery dissection (PSCAD) • Most common cause • Late pregnancy or Early post partum • Involves left sided coronaries • Multivessel involvement • Rationale: • Fluctuating estrogen/progesterone􀀀 Structural changes in coronary vasculature • Increased coronary shear stress during labor CORONARY ARTERY DISEASE

106. Mechanism • Angiographically normal coronary arteries • Rationale: • Transient coronary spasm􀀀 increased vascular reactivity • Coronary thrombosis • Rationale: • Hypercoagulability􀀀 Embolization CORONARY ARTERY DISEASE

107. Third trimester • STEMI: 25% • NSTEMI: 32% • Post-partum • STEMI: 45% • NSTEMI: 52% • Clinical presentation: Chest pain • ECG changes • Serum troponin • 2D echo PRESENTATION AND DIAGNOSIS

108. Complications • Heart failure/Cardiogenic shock • Arrhythmias • Recurrent angina/AMI • Maternal mortality • Fetal death PRESENTATION AND DIAGNOSIS

109. Similar in general population • Cardiac arrest • Resuscitation and delivery should be performed PRESENTATION AND DIAGNOSIS

110. Effect of ionizing radiation should not prevent primary PCI when indicated • Conservative management • NSTEMI with low risk • Primary coronary angioplasty • STEMI • Invasive approach • NSTEMI with high risk • Drug-eluting stents (DES) • Antiplatelet after stenting INTERVENTION

111. Leads to: • Maternal mortality • Adverse Fetal outcome • Pregnancy can be considered in known CAD • Absence of residual ischemia • LV dysfunction • Pregnancy is suggested after 12 months post ACS • Breastfeeding is not recommended in mothers who take antiplatelets other than low dose aspirin PRE-EXISTING CAD

112. Delivery postponed (if possible) at least 12 weeks post ACS • Vaginal delivery LABOR AND DELIVERY

113. PERIPARTUM CARDIOMYOPATHY Risk factors • Multiparity • African ethnicity • Smoking • Diabetes • Pre-eclampsia • Malnutrition • Advanced age • Teenage pregnancy • Rationale • Inflammation • Angiogenic imbalance • Vascular damage • Increase in 16kDa prolactin • Soluble fms -like tyrosine kinase 1 (sFlt1) CARDIOMYOPATHIES AND HEART FAILURE

114. PERIPARTUM CARDIOMYOPATHY DIAGNOSIS • Heart failure secondary to LV systolic dysfunction • EF < 45% • End of pregnancy or months following delivery • Imaging of choice: 2D echo • Worse prognosis • LVEF < 30% • Marked LV dilatation (LV EDD > 6.0cm) • RV involvement • Counselling • EF not recovered to >50-55%􀀀 Discourage pregnancy • Tx: Bromocriptine PERIPARTUM CARDIOMYOPATHY

115. Risk factors • Prior viral infection • Drugs • Ischemia • Idiopathic􀀀 50%; Hereditary 20-35% • Known case of DCM or present with de novo • Headache • Visual disturbance • Abdominal pain • Low platelet • Abnormal liver function DILATED CARDIOMYOPATHY

116. Predictors of mortality • NYHA III/ IV • EF < 40% • Mitral regurgitation • RV failure • Atrial fibrillation • Hypotension • Pre-pregnancy management • Avoid ACEi , ARB, ARNI, MRA and Ivabradine • Beta blockers DILATED CARDIOMYOPATHY

117. HEMODYNAMIC INSTABILITY AND CARDIOGENIC SHOCK • Transfer to facility where mechanical circulatory support teams are available • Urgent delivery by CS • Avoid beta-adrenergic agonist • Levosimendan 􀀀 preferred inotrope MANAGEMENT OF HEART FAILURE DURING PREGNANCY

118. ACUTE/SUBACUTE HEART FAILURE • Avoid ACEi , ARB, ARNI, MRA and Atenolol • Pulmonary congestion • Loop diuretics􀀀 reduction in placental central blood flow • Thiazides • Hydralazine • Nitrates • Beta blockers • High resting heart rate􀀀 predictor adverse • Duration: 6 months • After full recovery of LV function • Gradual tapering MANAGEMENT OF HEART FAILURE DURING PREGNANCY

119. MANAGEMENT OF HEART FAILURE DURING PREGNANCY

120. MANAGEMENT OF HEART FAILURE DURING PREGNANCY

121. BROMOCRIPTINE AND PERIPARTUM CARDIOMYOPATHY • Addition to standard HF therapy • Dose: • Uncomplicated: 2.5mg OD x 1 week • EF < 25% and or cardiogenic shock: 2.5mg BID x 2 weeks then 2.5mg OD for 6 weeks • Accompanied by anticoagulation • Heparin (LMWH or UFH) • Prophylactic dose MANAGEMENT OF HEART FAILURE DURING PREGNANCY

122. DEVICES AND TRANSPLANTATION • Wearable Cardioverter defibrillator (WCD) • Indication: • Severe LV dysfunction of 6-12 months duration despite optimal medical therapy • Cardiac resynchronization therapy • Indication: • Severe LV dysfunction of 6-12 months duration despite optimal medical therapy • Left bundle branch block • QRS > 130ms • Cardiac transplantation • Indication: • Mechanical support is not possible or desirable MANAGEMENT OF HEART FAILURE DURING PREGNANCY

123. ANTICOAGULATION • LMWH or Vitamin K antagonist • Choice of anticoagulant depends on the stage of pregnancy and patient preference • Indication • Intracardiac thrombus detected by imaging • Evidence of systemic embolism MANAGEMENT OF HEART FAILURE DURING PREGNANCY

124. DELIVERY • Cesarean section • Advanced EF • Hemodynamic instability • Central neuraxial anesthesia • Vaginal delivery • Stable Congestive HF • Spinal/Epidural analgesia MANAGEMENT OF HEART FAILURE DURING PREGNANCY

125. Tolerate pregnancy well • Increased risk of premature birth • High risk profile • Diastolic dysfunction • Severe LV outflow tract obstruction • Arrythmia HYPERTROPHIC CARDIOMYOPATHY

126. Management • Beta blocker • Verapamil • Cardioversion • Poorly tolerated persistent AF • Therapeutic anticoagulation • Paroxysmal or persistent arrhythmias HYPERTROPHIC CARDIOMYOPATHY

127. Delivery • Vaginal delivery • Low risk • Cesarean section • Severe LV outflow tract obstruction􀀀 avoid Epidural or spinal anesthesia􀀀 hypovolemia • Preterm labor while on OAC • Severe HF HYPERTROPHIC CARDIOMYOPATHY

128. Delivery • Vaginal delivery • Low risk • Cesarean section • Severe LV outflow tract obstruction􀀀 avoid Epidural or spinal anesthesia􀀀 hypovolemia • Preterm labor while on OAC • Severe HF ARRHYTHMIAS

129. Atrial fibrillation􀀀 increase mortality risk • Supraventricular tachycardia and ventricular tachycardia • Catheter ablation prior pregnancy • Bradyarrhythmia and conduction disturbances􀀀 favorable outcome MATERNAL RISK

130. Paroxysmal SVT􀀀 worse obstetric and fetal outcome • Severe maternal morbidity • Cesarean delivery • Low birth weight • Pre-term labor • Fetal stress • Fetal abnormalities OBSTETRIC AND OFFSPRING RISK

131. Paroxysmal SVT • AV nodal re-entry tachycardia • AV re-entry tachycardia • Acute management • IV administration of adenosine • Prevention • Beta-blockers (except Atenolol) • Verapamil SUPRAVENTRICULAR TACHYCARDIA

132. Focal atrial tachycardia • Drug resistance • Tachycardia induced cardiomyopathy • Long term management • Beta-blockers and Verapamil 􀀀 prevention of SVT in patients without pre-excitation on ECG • Flecainide or Propafenone􀀀 prevention of SVT in patients with WPW syndrome • Catheter ablation􀀀 drug refractory or poorly tolerated SVT SUPRAVENTRICULAR TACHYCARDIA

133. Acute management • Electrical cardioversion • Hemodynamically unstable • Congenital heart disease + Atrial flutter • Ibutilide or Flecainide • Stable patients with structurally normal heart • Long term management • Beta blocker • Digoxin and Verapamil􀀀 rate control if Beta blocker fails • Cardioversion should be preceded by anticoagulation ATRIAL FIBRILLATION AND ATRIAL FLUTTER

134. Peripartum cardiomyopathy (PPCM) • Should be ruled out in new onset VT during last 6 weeks of pregnancy or early post-partum period • Idiopathic RV outflow tract tachycardia􀀀 most frequent type of VT VENTRICULAR TACHYCARDIA

135. Acute management • Cardioversion • Sustained Unstable VT • Sustained Stable VT • Sustained, hemodynamically stable, monomorphic VT • Beta blocker • Sotalol, Flecainide, Procainamide • Ventricular pacing VENTRICULAR TACHYCARDIA

136. Long term management • ICD implantation • One chamber • Prior pregnancy • With indication during pregnancy: < 8 weeks AOG • Beta blockers • During pregnancy and post partum • Indication: • Long QT syndrome • Catecholaminergic polymorphic VT • Prevention of idiopathic sustained VT VENTRICULAR TACHYCARDIA

137. SINUS NODE DYSFUNCTION • Supine hypotensive syndrome of pregnancy • Symptomatic bradycardia • Tx: • Changing the position of the mother to left lateral decubitus position • Pacemaker BRADYARRHYTHMIAS

138. ATRIOVENTRICULAR BLOCK • Isolated congenital complete heart block • Favorable outcome: Narrow QRS • Temporary ventricular pacing during delivery • Symptomatic patients BRADYARRHYTHMIAS

139. ELECTRICAL CARDIOVERSION • Safe in all phases of pregnancy • Fetal heart rate should be controlled after cardioversion BRADYARRHYTHMIAS

140. CATHETER ABLATION • Second trimester • Indication • Drug refractory AV nodal re-entry tachycardia • Drug refractory AV re-entrant tachycardia • Drug refractory focal AT • Cavotricuspid isthmus dependent atrial flutter • Benign right sided VT Interventions

141. IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR AND PACING • Prior pregnancy in patient with high risk for sudden cardiac death • Can still be done during pregnancy in < 8 weeks AOG Interventions

142. IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR AND PACING • Prior pregnancy in patient with high risk for sudden cardiac death • Can still be done during pregnancy in < 8 weeks AOG Interventions

143. Interventions

144. Interventions

145. Interventions

146. BLOOD PRESSURE MEASUREMENT Sitting position • During labor: Left lateral recumbent • Appropriate sized arm cuff • At level of the heart • Korotkoff V for Diastolic BP • Mercury sphygmomanometers > Automatic • Ambulatory BP monitoring HYPERTENSIVE DISORDERS

147. Ultrasound of adrenals, plasma and urinary fractionated metanephrine assays • PHEOCHROMOCYTOMA • Doppler ultrasound of uterine arteries • < 20 weeks AOG • Diseases: • Gestational Hypertension • Pre-eclampsia • Intrauterine growth retardation • sFlt1 to placental growth factor (sFlt1:PIGF) ratio < 38 • Exclude pre-eclampsia LABORATORY TESTS

148. HYPERTENSION • Based on office or in hospital BP • BP 140/90mmHg • Mild: 140-159/90-109mmHg • Severe: >160/110mmHg • PRE-EXISTING HYPERTENSION • Hypertension < 20 weeks AOG • Hypertension > 42 days post-partum • GESTATIONAL HYPERTENSION • Hypertension > 20 weeks AOG • Hypertension resolves within 42 days post-partum LABORATORY TESTS

149. PRE-ECLAMPSIA • Gestational hypertension • Plus of the following features: • >0.3g in proteinuria in 24hr urine collection • ACR > 30mg/ mmoL • Common in • First pregnancy • Multiple pregnancy • Hydatidiform mole • Antiphospholipid syndrome • Pre-existing hypertension • Renal disease • Diabetes • Associated with fetal growth restriction (due to placental insufficiency) • Tx: Delivery Pre-eclampsia

150. MODERATE RISK (> 1) • First pregnancy • Age > 40yrs old • Pregnancy interval of more than 10 years • BMI > 35kg/m2 at first visit • Family history of pre-eclampsia • Multiple pregnancy Prevention

151. HIGH RISK (At least 1) • Hypertensive disease during pregnancy • Chronic kidney disease • Autoimmune disease such as Systemic Lupus erythematosus or Antiphospholipid syndrome • Type 1 or Type 2 Diabetes • Chronic Hypertension Prevention

152. Aspirin • Dose: 100-150mg OD from week 12 to week 36-37 • Calcium supplementation • Dose: 1.5-2g/day • Started at first antenatal clinic • Vitamin C and E • Reduce risk of BW <2.5kg Prevention

153. NON-PHARMACOLOGIC • Regular exercise • Obese women (BMI > 30kg/m2) • Avoid weight gain of more than 6.8kg Management

154. SEVERE Emergency (requires hospitalization) Avoid ACEi , ARB and Direct renin inhibitors Labetalol Oral Methyldopa Nifedipine Uradipil Sodium nitroprusside - last choice Adverse effect: Fetal cyanide poisoning Nitroglycerin DOC pre-eclampsia + pulmonary edema Dose: 5ug/min Increased every 3-5min to maximum dose 100ug/min Management

155. MILD • Methyldopa • Labetalol • Adverse effect: • Fetal bradycardia • Growth retardation • Hypoglycemia • Nifedipine • Magnesium sulfate • Prevention of eclampsia • Treatment of seizures • Not given with CCB (Nifedipine)􀀀 Hypotension Management

156. Delivery is indicated in pre-eclampsia with visual disturbances or haemostatic disorders, and at 37 weeks in asymptomatic women DELIVERY

157. Delivery is indicated in pre-eclampsia with visual disturbances or haemostatic disorders, and at 37 weeks in asymptomatic women VENOUS THROMBO-EMBOLIC DISEASE DURING PREGNANCY AND PUERPERIUM

158. Pulmonary embolism or Deep venous thrombosis • Risk factors • Previous unprovoked recurrent VTE • Previous VTE unprovoked or estrogen related • Prevention • Low molecular weight heparin • Less bone loss • Dose: 0.5IU/kg (BW at first antenatal appointment) VENOUS THROMBO-EMBOLIC DISEASE DURING PREGNANCY AND PUERPERIUM

159. Clinical presentation: • Dyspnea • Chest pain • Tachycardia • Hemoptysis • Collapse • Tachycardia PULMONARY EMBOLISM

160. Diagnosis • High index of suspicion • D-dimer • Compression ultrasonography • MRI • Low dose CT scan PULMONARY EMBOLISM

161. Clinical Presentation • Leg swelling􀀀 Left sided • Rationale: Compression of the Left iliac vein and Left iliac artery and the Gravid uterus • > 2cm calf circumference • First trimester allowed a negative predictive value of 100% ACUTE DEEP VEIN THROMBOSIS

162. Diagnosis • D-dimer • Compression ultrasound leg vein imaging • Specific for proximal DVT • Serial ultrasound on days 0, 3, 7 in pregnancy • Negative ultrasound􀀀 MRI ACUTE DEEP VEIN THROMBOSIS

163. Diagnosis • D-dimer • Compression ultrasound leg vein imaging • Specific for proximal DVT • Serial ultrasound on days 0, 3, 7 in pregnancy • Negative ultrasound􀀀 MRI ACUTE DEEP VEIN THROMBOSIS

164. Low molecular weight heparin • Indication: VTE • Enoxaparin 1mg/kg BW BID • Dalteparin 100IU/kg BW BID • Tinzaparin 175IU/Kg • Target: 4-6h peak in anti- Xa 0.6-1.2IU/ml • Unfractionated heparin • Indication: Acute treatment for massive pulmonary emboli • Thrombolysis • Indication: Severe hypotension or shock • After thrombolysis􀀀 UFH 18U/kg/h􀀀 LMWH • Fondaparinux • Indication: Allergy or adverse response to LMWH • Dose: 7.5mg OD TREATMENT

165. ON THERAPEUTIC LMWH: Delivery at 39 weeks • Toxicity: Protamine sulfate • HIGH RISK WOMEN ON THERAPEUTIC LMWH • LMWH converted to UFH at least 36hrs prior to delivery • Infusion stopped 4-6hrs prior to delivery • LOW RISK WOMEN ON LMWH OR HIGH RISK ON HIGH DOSE PROPHYLAXIS • Evening LMWH dose omitted then induction or CS performed the next morning • Regional Anesthesia: > 24hrs from last dose LMWH RECOMMENDATIONS

166. THANK YOU