View source for ACC-2017 Pregnancy - CHD

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{{Pregnancy -CHD - 2017}}
{{CMG}},{{AE}}{{AKK}}

==Management of Pregnancy in Patients With Complex Congenital heart Disease==

===Modified Who Classification of Maternal Cardiovascular Risk===

{| class="wikitable" style="width: 90%; text-align: justify;" 

! style="width:10%" | '''Who Pregnancy Risk Category'''
! style="width:30%" | '''Risk Description'''
! style="width:60%" | '''Maternal Risk Factors'''

|- 
| '''I''' || No detectable increase in maternal mortality and no/mild increase in morbidity risk || Uncomplicated small/mild pulmonary stenosis, PDA, mitral valve prolapse; 
Successfully repaired simple lesions (ASD, VSD, PDA, anomalous pulmonary venous drainage); Atrial or ventricular ectopic beats, isolated
|- 
| '''II''' || Small increase in maternal mortality and moderate increase in morbidity risk || If otherwise well and uncomplicated: Unoperated ASD, VSD; 
Repaired TOF; 

Most arrhythmias
|- 
| '''II–III''' || Moderate increase in maternal mortality morbidity risk || Mild LV impairment; 
Hypertrophic cardiomyopathy;  

Native or tissue valvular disease (not considered risk category I or IV);  

Marfan syndrome without aortic dilation; 

Aortic dilation <45 mm in bicuspid aortic valve aortopathy; 

Repaired coarctation
|- 
| '''IV''' || Extremely high maternal mortality or severe morbidity risk. Pregnancy is contraindicated. In the event of pregnancy, termination should be discussed. If pregnancy continues, care should follow class III recommendations. || Pulmonary arterial hypertension (of any cause); 
Severe systemic ventricular dysfunction (LV ejection fraction <30%, NYHA class III-IV); 

Previous peripartum cardiomyopathy with any residual impairment of LV function;  

Severe mitral stenosis, severe symptomatic aortic stenosis;  

Aortic dilation >45 mm in Marfan syndrome; 

Aortic dilation >50 mm in bicuspid aortic valve aortopathy; 

Native severe coarctation
|- 
| colspan="3" | '''AS''' indicates aortic stenosis; '''ASD,''' atrial septal defect; '''CHD''', congenital heart disease; '''LV''', left ventricular; '''NYHA''', New York Heart Association; '''PDA,''' patent ductus arteriosus; '''RV''', right ventricle; '''TOF''', tetralogy of Fallot; '''VSD''', ventricular septal defect; and '''WHO''', World Health Organisation. 
|}

===Medications During Pregnancy===

{| class="wikitable" style="width: 90%; text-align: justify;" 

! style="width:12%" | ''' '''
! style="width:12%" | '''Common Examples'''
! style="width:10%" | '''FDA Pregnancy Category'''
! style="width:12%" | '''Teratogenic risks (First Trimester)'''
! style="width:14%" | '''Other Pregnancy Concerns (Second and Third Trimesters)'''
! style="width:14%" | '''Suggested Evaluation'''
! style="width:14%" | '''Lactation'''
! style="width:12%" | '''Notes'''
|- 
| colspan="8" | Antihypertensives
|- 
| β-Blockers || Metoprolol Propranolol Carvedilol Atenolol || C C C D || None reported || Possible association with fetal growth restriction in second and third trimesters (atenolol, propranolol), neonatal bradycardia (esmolol, nadolol) || Consider serial fetal sonography to assess interval fetal growth in second and third trimesters || Except for atenolol, probably safe ||
|- 
| Combined α-/β- blockers || Labetalol || C || None reported || No ||  || Yes ||
|- 
| Calcium channel blockers || Nifedipine Verapamil Diltiazem || C || None reported || Caution if used in combination with magnesium sulfate ||  || Yes ||
|- 
| ACE inhibitors || Captopril Enalapril Lisinopril || C ( first trimester) D (second and third trimesters) || || Fetal renal dysplasia, oligohydramnios, growth restriction, and intrauterine demise reported in second and third trimesters || Consider fetal echocardiography with  rst trimester exposure, serial sonography to assess interval fetal growth and amniotic  fluid volume in second and third trimesters || Yes (captopril and enalapril) Unknown (lisinopril) || Avoid if possible during pregnancy
|- 
| α2- Adrenergic agonists || Methyldopa Clonidine || B C || None reported || Induction of positive indirect Coombs testing (methyldopa), rare neonatal hypertension (clonidine) ||  || Yes (methyldopa) Probably safe (clonidine) ||
|- 
| Vasodilators || Hydralazine Epoprostenol Nitroprusside Nitroglycerin Isosorbide dinitrate Sildenafil || C B  B || None reported || Possible transient fetal bradycardia (nitroprusside) ||  || Yes (hydralazine) Probably safe (nitroglycerin) Unknown (epoprostenol, nitroprusside, isosorbide dinitrate, sildenafil) ||
|- 
| colspan="8" | Diuretics
|- 
| Thiazide diuretics || Hydrochlorothiazide || B || None reported || Possible increased risk of neonatal hypoglycemia and thrombocytopenia || Consider neonatal blood count and electrolyte evaluation  || Yes (AAP) No (WHO) || Maintenance therapy permissible, but therapy not usually started during pregnancy
|- 
| Loop of Henle diuretics || Furosemide || C || None reported || Possible association with neonatal PDA and sensorineural hearing loss || Maternal electrolyte monitoring  || No ||
|- 
| Potassium- sparing diuretics || Spironolactone (not recommended) || C || None reported || || || Yes (probably safe; (not recommended) ||
|- 
| colspan="8" | Anticoagulants
|- 
| Heparin (including LMWHs) || Heparin Enoxaparin Dalteparin || C || None reported || Possible maternal osteoporosis, heparin-induced thrombocytopenia, and bleeding || Maternal platelet and coagulation status monitoring (as appropriate) || Yes ||
|- 
| Vitamin K antagonists || Warfarin || X || Fetal warfarin syndrome (craniofacial and skeletal anomalies) with exposure in weeks 6–9; fetal intracranial hemorrhage in second and third trimesters || || Comprehensive fetal sonography at 18–20 wk of gestation || Yes || Teratogenicity appears to be related to doses >5 mg daily
|- 
| Antiplatelet agents || Aspirin (full dose) Clopidogrel || D (third trimester) B || None reported || Premature closure of fetal ductus arteriosus at ≥32 wk of gestation || Empirical recommendation to discontinue clopidogrel 7 d in advance of anticipated delivery  || Unknown (AAP) No (WHO) || Low-dose aspirin (≤100 mg/d) does not appear to have deleterious effects
|- 
| Direct thrombin inhibitors || Argatroban || B || None reported || || || Unknown ||
|- 
| Indirect factor Xa inhibitors || Fondaparinux || B || None reported || Possible neonatal factor Xa inhibition || || Unknown ||
|- 
| Direct factor Xa inhibitors || Rivaroxaban || C || None reported || Theoretical risk of maternal hemorrhage || || Unknown ||
|- 
| Fibrinolytics || Streptokinase || C || None reported || || || Unknown ||
|- 
| colspan="8" | Inotropic/vasopressors
|- 
| Cardiac glycosides || Digoxin Digitalis || C || None reported || || || Yes ||
|- 
| Adrenergic agents || Epinephrine Norepinephrine Phenylephrine Dopamine Isoproterenol || C || Possible association with gastroschisis or hemifacial microsomia (phenylephrine) || || || Probably safe (dopamine) Unknown (epinephrine, norepinephrine, phenylephrine, isoproterenol) ||
|- 
| colspan="8" | Antiarrhythmics
|- 
| β-Blockers || Metoprolol Propranolol Carvedilol Atenolol || C C C D || None reported || Association with fetal growth restriction in second and third trimesters (atenolol, propranolol), neonatal bradycardia (esmolol, nadolol) || Consider serial fetal sonography to assess interval fetal growth in second and third trimesters || Except for atenolol, probably safe ||
|- 
| Class 1A || Quinidine Procainamide || C C || None reported || || || Yes ||
|- 
| Class 1C || Flecainide || C || None reported || || || Yes ||
|- 
| Class III || Sotalol Amiodarone || B D || None reported || Thyroid dysfunction || || No  No WHO)/ (AAP Yes) ||
|- 
| Purine nucleosides || Adenosine || C || None reported || || || Unknown ||
|- 
| colspan="8" | AAP indicates American Academy of Pediatrics; ACE, angiotensin-converting enzyme; FDA, US Food and Drug Administration; LMWH, low-molecular- weight heparin; PDA, patent ductus arteriosus; and WHO, World Health Organisation.
|}