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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.
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.
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
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
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
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
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
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
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
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).
Full text of guidelines are available here.
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.
Rafael Ferreira M.D., PhD, FESC Member of the task force of the GL on the management of CV disease during pregnancy.
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