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A review of the 2011 ESC guidelines on cardiovascular disease in pregnancy

An article from the e-journal of the ESC Council for Cardiology Practice.

Increasing prevalence of hypertension, obesity and diabetes, coupled with a rise in the age of expectant mothers, have contributed to increasing the burden of cardiac disease during pregnancy. The new ESC 2011 guidelines for the management of cardiovascular disease during pregnancy (1) provide physicians with new recommendations that come to update the 2003 ESC consensus document on this subject (2) and this paper aims to review its main recommendations.

Pregnancy and Heart Disease


I - General 

a- Childbearing age
cardiac disease 
   Risk assessment  

b- Pre-pregnancy 
In known or suspected congenital or acquired cardiovascular and aortic disease 
    Risk assessment and counseling

c- Pre-pregnancy and during pregnancy
cardiac disease 
    Risk assessment; with high risk patients to be treated in specialised centres by a multidisciplinary team 
In congenital heart disease or congenital arrhythmia, cardiomyopathies, aortic disease or genetic malformations associated with CVD  
    Genetic counseling

d- During pregnancy
in unexplained or new cardiovascular signs or symptoms
    Echocardiography; if echocardiography is insufficient for diagnosis gadolinium-free MRI to be considered

e- Delivery
in dilatation of the ascending aorta >45mm, severe aortic stenosis, Eisenmenger syndrome or severe heart failure 
    C-Section (Cesarean section) to be considered
in Marfan patients with an aortic diameter 40-45mm
    C-section may be considered; but avoiding prophylactic antibiotic therapy during delivery.

II - Pulmonary Arterial Hypertension (PAH)

PAH as described (5) includes 1) all idiopathic and heritable forms of the disease
and 2) pulmonary hypertension associated with congenital heart disease with or without previous corrective surgery.

a- Child-bearing age 
in pulmonary hypertension or in those with oxygen saturation below 85% at rest
    to be advised against becoming pregnant
in suspicion of pulmonary embolism as causing or suspected to partly having caused pulmonary hypertension
    associated anticoagulant treatment to be considered

b- During Pregnancy
In pulmonary arterial hypertension before becoming pregnant
    continuation to be considered after delivering information regarding associated teratogenic effects

III - Aortic Disease

Heritable disease such as Marfan syndrome, bicuspid aortic valve, Ehlers Danlos syndrome, Turner syndrome and other forms of congenital heart disease predispose to both aneurysm formation and aortic dissection.

a- Child-bearing age
    to be counseled on the risk of aortic dissection and the recurrence risk for the offspring

b- Pre-pregnancy
Marfan syndrome or other known aortic disease 
    imaging of the entire aorta (CT/MRI)
if ascending aorta >45mm 
    surgical treatment required
aortic disease associated with a bicuspid aortic valve when the aortic diameter is >50mm
    surgical treatment to be considered

c- Pregnancy
with ascending aorta dilatation
    echocardiographic imaging every 4-8 weeks
with dilatation of distal ascending aorta, aortic arch or descending aorta
    gadolinium-free MRI

d- Delivery
for patients with ascending aorta >45mm 
    C-section to be considered

IV - Acquired and congenital valvular heart disease

a- Child-bearing age
atrial fibrillation, left atrial thrombosis or prior embolism
    therapeutic anticoagulation
in 1) severe MS or 2) asymptomatic severe AS with symptoms development during exercise test or 3) severe aortic or mitral regurgitation and symptoms or impaired ventricular function or dilatation

b- Pregnancy
severe symptoms or systolic pulmonary artery pressure >50mmHg despite medical therapy
    percutaneous mitral commissurotomy to be considered
severe aortic stenosis  -symptomatic or LVEF<50%-
    intervention
in patients with mechanical valves - until the 36th week
OAC recommended from second trimester
    in patients with mechanical valves - after the 36th week and having stopped OAC
    dose- adjusted UFH or LMWH
LMWH to be replaced by iv UFH at least 36 hours before planned delivery.

c- Delivery
If delivery starts while in OAC
    C-section

V - Coronary Artery Disease

a- Pre-Pregnancy 
in known CAD
    pregnancy may be considered in the absence of residual ischemia and LV dysfunction

b- During pregnancy (9):
ACS is rare and strongly related to the major CAD risk factors
chest pain, 
    ECG and troponin levels to be taken
STEMI, 
    coronary angioplasty is preferred reperfusion therapy
non ST-elevation ACS without risk criteria, 
    conservative management is to be considered

VI - Acquired and inherited cardiomyopathies and heart failure

a- Child-bearing age
    information to be delivered on the risk of deterioration of the condition during gestation and peripartum

b- During pregnancy
intracardiac thrombus, detected by imaging, or with evidence of systemic embolism
    Anticoagulation
hypertrophic cardiomyopathy (HCM)
with atrial fibrillation
    therapeutic AC with LMWH or oral vitamin K antagonists, according to the stage of pregnancy
with persistent AF
    cardioversion to be considered

c- During pregnancy and after delivery
Peripartum cardiomyopathy (PPCM) is a form of dilated CM presented as heart failure with LV systolic dysfunction towards the end of pregnancy or in the months following delivery. It is a diagnosis of exclusion (10).
    heart failure treatment according to general guidelines for the treatment of acute and chronic heart failure, - while avoiding ACE inhibitors, angiotensin II receptor blockers and rennin inhibitors

d- Delivery
In hypertrophic cardiomyopathy.
    Delivery under Beta-blocker protection

VII - Arrhythmias

a- Before or during pregnancy
Ventricular tachycardia (VT)(11):
    implantation of an ICD, if clinically indicated

b- During pregnancy
Episodes of tachyarrhythmia 
    DC conversion to restore sinus rhythm - all antiarrhythmic drugs to be considered toxic for the fetus
Atrial flutter and fibrillation in relation with structural heart disease leading to haemodynamic instability 
    electrical cardioversion
haemodynamicaly stable patients 
    pharmacological treatment to be considered

supraventricular tachycardia (12):
acute conversion of paroxysmal SVT 
    vagal maneuvre followed by i.v. adenosine
acute treatment of any tachycardia with haemodynamic instability
    Immediate electrical cardioversion
pharmacological conversion of paroxysmal SVT i.v.
    metoprolol or propranolol to be considered
pharmacological conversion of paroxysmal SVT i.v. 
    verapamil to be considered

sustained, unstable and stable VT
    immediate electrical cardioversion with implantation of permanent pacemaker or ICD with echocardiographical guidance to be considered, especially if the foetus is beyond 8 weeks gestation
drug-refractory and poorly tolerated tachycardias
    catheter ablation to be considered

VIII - Hypertensive Disorders

Includes (13) 1) Pre- pregnancy hypertension:  BP>140/90 mmHg or developing before 20 weeks of gestation 2) Gestational hypertension -  Develops after 20 weeks’ gestation and resolves in most cases within 42 days postpartum 3) pre-eclampsia - when associated with significant proteinuria 4) Pre-existing hypertension with further worsening of BP and protein excretion >3g/day in 24 hour urine collection after 20 weeks’ gestation 5) Antenatal unclassifiable hypertension. When BP is first recorded after 20 weeks of gestation and hypertension is diagnosed.

a- During pregnancy (14): 
SBP of 140-150 mmHg or DBP of 90-99mmHg  
    non-pharmacological management
SBP>170mmHg 
    emergency hospitalisation
In pre-eclampsia associated with pulmonary edema, 
    infusion i.v. nitroglycerine
In severe HT
    drug treatment with i.v. labetalol or oral methyldopa or nifedipine
With continued pre-pregnancy HT 
    pre-pregnancy medication to be continued- while ACE inhibitors, angiotensin II antagonists and direct renin inhibitors are strictly contra-indicated.

b- For delivery
in gestational HT with proteinuria with adverse conditions
    Induction

IX - Venous thromboembolism including pulmonary embolism

a- Pre-pregnancy and early pregnancy
     risk factors for VTE to be assessed - mainly previous history of unprovoked DVT or PE and thrombophilias forming high, intermediate and low risk groups
    - high risk
to receive antenatal profilaxis with LMWH as well as 6 weeks postpartum 
    - intermediate risk
postpartum prophylaxis with LMWH to be given for at least 7 days or longer, if >3 risk factors persist

b- During pregnancy
in suspected VTE
   D-Dimer measurement and compression ultrasonography
in acute VTE
    pregnancy UFH is in high risk and LMWH in non-high risk patients

c- During pregnancy and puerperium
increased incidence of venous thromboembolism (VTE) and its clinical manifestations (PE).

Conclusion:

  1. Suspected cardiac disease in childbearing age should prompt physician to offer counseling and special care
  2. Cardiac disease during pregnancy to be managed by interdisciplinary teams
  3. High risk patients to be sent for treatment in specialised centers
  4. Diagnostic procedures and interventions to be performed by specialists with great expertise in the individual techniques
  5. Registries and prospective studies to be implemented to improve current state of knowledge.

Full text of guidelines are available here.

References


1. Regitz-Zagrosek V, Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular disease during pregnancy. Eur Heart J. 2011 Aug 26. [Epub ahead of print]
2. Oakley C, Child A, Jung B, et al. Expert consensus document on the management of cardiovascular disease during pregnancy of the European Society of Cardiology. Eur Heart J 2003;24:761-81.
3. Pierpont ME, Basson CT, Benson DW,Jr et al. Genetic basis for congenital heart defects: current knowledge.Circulation 2007;115:3015-38.
4. Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010;31:2124-32.
5. Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension. Eur Heart J 2009;30:256-65.
6. Pacini L, Digne F, Boumendil A, et al. Maternal complications of pregnancy in Marfan syndrome. Int J Cardiol 2009;136:156-61.
7. Yap SC, Drenthen W, Pieper PG,et al. Risk of complications during pregnancy in women with congenital aortic stenosis. Int J Cardiol 2008;126:240-6.
8. ElKayam U, Bitar F. Valvular heart disease and pregnancy: part II: prosthetic valves. J Am Coll Cardiol 2005;46:403-10.
9. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol 2008;52:171-80.
10. Sliwa K, Hilfiker-Kleiner D, Petrie MC,et al. Current state of knowledge on aetiology, diagnosis, management and therapy of peripartum cardiomyopathy. Eur J Heart Fail 2010;12:767-78
11. Nakagawa M, Katou S, Ichinose M, et al. Characteristics of new-onset ventricular arrhythmias in pregnancy. J Electrocardiol 2004;37:47-53.
12. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias – executive summary. J Am Coll Cardiol 2003;42: 1493-1531.
13. Helewa ME, Burrows RF, Smith J, et al. Report of the Canadian Hypertension Society consensus conference: I- definitions, evaluation and classification of hypertensive disorders in pregnancy. CMAJ 1997;157:715-25.
14. McDonald SD, Malinowski A, Zhou Q, et al. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analysis. Am Heart J 2008;156:918-30.
15. Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum : a 30-year population based study. Ann Intern Med 2005;143:697-706.
16. Marik DE, Plante LA. Venous thromboembolic disease in pregnancy. N Engl J Med 2008 ;359 :2025-33.
17. Nijkenter M, Ginsberg JS, Huisman MV. Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost 2006;4:496-500.
18. Bates SM, Greer IA, Pabinger I, et al. Venous thromboembolism, thrombophilia, antithrombotic therapy and pregnancy. Chest 2008 133(suppl 6):844S-886S.

VolumeNumber:

Vol10 N°3

Notes to editor


Rafael Ferreira M.D., PhD, FESC
Member of the task force of the GL on the management of CV disease during pregnancy.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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