Dr. Christa Gohlke-Baerwolf,
Read the ESC Practice guidelines on Pregnancy and CVD
Prof. Vera Regitz-Zagrosekfrom Berlin, Germany, who chaired the taskforce, outlined the goal and aims of the guidelines, and particularly the new aspects since the publication of the first ESC Expert consensus document on this topic in 2003. The scope of the guidelines were markedly widened by including the obstetrician in the task force, represented by Prof. Foidart from Liège, thus assuring a multidisciplinary approach in the development of the guidelines as well as adding new topics, like genetic testing, fetal assessment, mode and timing of delivery and venous thromboembolism and a chapter on drugs. All recommendations are graded according to class and level of evidence. Due to the lack of randomised or prospective studies in this field, the level of evidence for the recommendations is mostly C.
from Rotterdam, The Netherlands, focused on the identification of high risk patients, in whom pregnancy should be discouraged or is contra-indicated. This group comprises patients with pulmonary hypertension, severely impaired left ventricular function (LVEF less than 30 %), severely symptomatic patients, severe mitral stenosis, symptomatic aortic stenosis, Marfan syndrome with dilated aorta > 45 mm or more than 50mm in patients with a bicuspid valve. Because of early sexual activity of adolescents, timely risk assessment and counselling is of special importance. 4 modes of risk assessment are available, whereby the WHO system is favoured by the taskforce. High risk patients should be treated in specialized centres by a multidisciplinary team (IC).
from Uppsala, Sweden discussed in depths the treatment of arrhythmias, most of which are of low risk and do not require treatment. Tachycardias resulting in morbidity, particularly hemodynamic impairment, incessant tachycardias or those associated with disease and states leading to an increased risk of sudden death require treatment. This should follow the available guidelines with respect for contra-indications to certain drugs, investigations and catheter ablation. For acute conversion of paroxysmal supraventricular tachycardia, vagal manoeuvre followed by i.v.adenosine is recommended (Class I C recommendation). Immediate electrical cardioversion is recommended for acute treatment of any tachycardia with hemodynamic instability (IC). Catheter ablation may be considered in the case of drug – refractory and poorly tolerated tachycardias (IIb C). In this case, referral to a specialized ablation center is advised.
from Groningen, The Netherlands, focused on the indication for anticoagulation during pregnancy and the selection process for the type of anticoagulant in the various clinical situations. Oral anticoagulants are the safest for the mother to prevent thrombosis of a mechanical valve, yet at the cost of embryopathy. This risk correlates with the dose required to maintain the INR in the therapeutic range. A dosis of warfarin of less than 5mg is associated with a risk of embryopathy of 0 % -5 % and doses over 5 mg with a risk of 5 to 10 %. In patients with mechanical valves and low dose requirement oral anticoagulation should be given throughout pregnancy until the 36th week (IIaC), when a switch to low molecular weight heparin (LMWH) or unfractionated heparin is recommended. In patients with a higher than 5 mg dose requirement LMWH should be considered during weeks 6 to 12 (IIaC), followed by oral anticoagulants in the 2nd and third trimester. LMWH, even when given only during the first trimester is associated with an increased risk of valve thrombosis. It should only be used when regular monitoring of anti-Xa levels is available. Informing the mother and her partner on the risks associated with the different anticoagulant regimes is mandatory. Venous thromboembolism occurs in 0,05-0,2 % of pregnancies and represents an important cause of mortality and morbidity. Assessment of risk factors for venous thromboembolism is recommended in all women prior to or in early pregnancy (IC). This allows identification of patients with high, intermediate and low risk and the application of preventive measures accordingly.
The current guidelines on the management of cardiovascular disease in pregnancy comprise an interdisciplinary effort of adult and paediatric cardiologists, obstetricians and colleagues from other medical specialties who all contributed to their development. They provide all physicians involved in the care of women in childbearing age with a comprehensive guidance for counselling and practical management of those with cardiovascular disease prior to and during pregnancy, delivery and postpartum. The taskforce hopes that these guidelines will stimulate the urgently needed studies to fill the still existing gaps in knowledge in this field and compliance with the guidelines will contribute to a decrease in pregnancy related complications for mothers and children.
ESC Guidelines for the management of cardiovascular diseases during pregnancy.
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