Hypertrophic cardiomyopathy management during pregnancy: Difference between revisions
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{{Hypertrophic cardiomyopathy}} | {{Hypertrophic cardiomyopathy}} | ||
'''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto: | '''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] | ||
==Overview== | ==Overview== | ||
Women with hypertrophic cardiomyopathy should be managed by a skilled cardiovascular specialist and a high-risk obstetrician during pregnancy. Any activity, drug or circumstance that increases left ventricular outflow obstruction, reduced left ventricular filling, or increases left ventricular afterload should be avoided. | Women with hypertrophic cardiomyopathy should be managed by a skilled cardiovascular specialist and a high-risk obstetrician during pregnancy. Any activity, drug or circumstance that increases left ventricular outflow obstruction, reduced left ventricular filling, or increases left ventricular afterload should be avoided. | ||
==Natural History, Complications And Prognosis In The Hypertrophic Cardiomyopathy Patient During Pregnancy== | |||
Among HCM patients who chronically have mild symptoms, pregnancy is generally well tolerated <ref name="pmid572730">{{cite journal | author = Oakley GD, McGarry K, Limb DG, Oakley CM | title = Management of pregnancy in patients with hypertrophic cardiomyopathy | journal = [[British Medical Journal]] | volume = 1 | issue = 6180 | pages = 1749–50 | year = 1979 | month = June | pmid = 572730 | pmc = 1599373 | doi = | url = | issn = }}</ref><ref name="pmid12446072">{{cite journal | author = Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P, Spirito P | title = Risk associated with pregnancy in hypertrophic cardiomyopathy | journal = [[Journal of the American College of Cardiology]] | volume = 40 | issue = 10 | pages = 1864–9 | year = 2002 | month = November | pmid = 12446072 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109702024956 | issn = }}</ref>. Although pregnancy causes vasodilation which should exacerbate the outflow gradient, pregnancy also causes fluid retention and an increase in plasma volume which increases preload and offsets the reduction in afterload. In a series of 100 HCM patients, only one of 28 asymptomatic patients developed NYHA Class III or IV [[heart failure]]. Among 12 previously symptomatic patients, 5 patients developed NYHA Class III or IV [[heart failure]]. It is notable that two [[sudden deaths]] occurred in this series of 100 patients. One of the two patients had a resting gradient of 115 mm Hg. The other patient had a markedly positive family history with 8 family members sustaining any early death, 5 of which were sudden death <ref name="pmid12446072">{{cite journal | author = Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P, Spirito P | title = Risk associated with pregnancy in hypertrophic cardiomyopathy | journal = [[Journal of the American College of Cardiology]] | volume = 40 | issue = 10 | pages = 1864–9 | year = 2002 | month = November | pmid = 12446072 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109702024956 | issn = }}</ref>. | |||
==Avoid Activities That Increase Left Ventricular Outflow Tract Obstruction== | ==Avoid Activities That Increase Left Ventricular Outflow Tract Obstruction== | ||
The following activities increase left ventricular outflow tract obstruction and should be avoided: | The following activities increase left ventricular outflow tract obstruction and should be avoided: | ||
*'''''Epidural Anesthesia Should Be Avoided''''' due to the potential for venous pooling. | |||
*[[Bleeding]] should be minimized. Blood should be crossed and typed in case a transfusion is needed for bleeding, which can exacerbate outflow obstruction. | |||
*[[Nausea]] and [[vomiting]] | *[[Nausea]] and [[vomiting]] | ||
*[[Dehydration]] | *[[Dehydration]] | ||
| Line 16: | Line 21: | ||
The following activities increase left ventricular [[afterload]] should be avoided: | The following activities increase left ventricular [[afterload]] should be avoided: | ||
*Intense isometric exercise | *Intense isometric exercise | ||
==Beta Blockade and Calcium Channel Blockade== | ==Beta Blockade and Calcium Channel Blockade== | ||
Although both [[beta blockers]] and [[verapamil]] may improve symptoms in the mother, the dosing should be limited to minimize the risk of fetal [[bradycardia]], [[growth retardation]] and [[hypoglycemia]]. There is more experience with the use [[beta blockers]] during pregnancy. | Although both [[beta blockers]] and [[verapamil]] may improve symptoms in the mother, the dosing should be limited to minimize the risk of fetal [[bradycardia]], [[growth retardation]] and [[hypoglycemia]]. There is more experience with the use [[beta blockers]] during pregnancy. | ||
==Home Delivery Should Be Avoided== | ==Home Delivery Should Be Avoided== | ||
| Line 31: | Line 32: | ||
==Vaginal Delivery Versus C-Section== | ==Vaginal Delivery Versus C-Section== | ||
Vaginal delivery is usually successful. | Vaginal delivery is usually successful. | ||
==2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)<ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>== | |||
===Pregnancy/Delivery (DO NOT EDIT)<ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In women with HCM who are asymptomatic or whose symptoms are controlled with [[beta-blocking drug]]s, the drugs should be continued during pregnancy, but increased surveillance for [[fetal bradycardia]] or other complications is warranted<ref name="pmid19589432">{{cite journal |author=Bos JM, Towbin JA, Ackerman MJ |title=Diagnostic, prognostic, and therapeutic implications of genetic testing for hypertrophic cardiomyopathy |journal=J. Am. Coll. Cardiol. |volume=54 |issue=3 |pages=201–11 |year=2009 |month=July |pmid=19589432 |doi=10.1016/j.jacc.2009.02.075 |url=}}</ref><ref name="pmid19808347">{{cite journal |author=Hershberger RE, Cowan J, Morales A, Siegfried JD |title=Progress with genetic cardiomyopathies: screening, counseling, and testing in dilated, hypertrophic, and arrhythmogenic right ventricular dysplasia/cardiomyopathy |journal=Circ Heart Fail |volume=2 |issue=3 |pages=253–61 |year=2009 |month=May |pmid=19808347 |pmc=2927103 |doi=10.1161/CIRCHEARTFAILURE.108.817346 |url=}}</ref><ref name="pmid8102149">{{cite journal |author=Bascou V, Ferrandis J, Bauer V, Bouret JM, de Meeus JB, Magnin G |title=[Obstructive myocardiopathy and pregnancy] |language=French |journal=J Gynecol Obstet Biol Reprod (Paris) |volume=22 |issue=3 |pages=309–11 |year=1993 |pmid=8102149 |doi= |url=}}</ref><ref name="pmid19949785">{{cite journal |author=Fitzgerald-Butt SM, Byrne L, Gerhardt CA, Vannatta K, Hoffman TM, McBride KL |title=Parental knowledge and attitudes toward hypertrophic cardiomyopathy genetic testing |journal=Pediatr Cardiol |volume=31 |issue=2 |pages=195–202 |year=2010 |month=February |pmid=19949785 |doi=10.1007/s00246-009-9583-2 |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For patients (mother or father) with HCM, genetic counseling is indicated before planned conception. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In women with HCM and resting or provocable [[LVOT obstruction]] greater than or equal to 50 mm Hg and/or cardiac symptoms not controlled by medical therapy alone, pregnancy is associated with increased risk, and these patients should be referred to a high-risk obstetrician. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' The diagnosis of HCM among asymptomatic women is not considered a contraindication for pregnancy, but patients should be carefully evaluated in regard to the risk of [[pregnancy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women with HCM whose symptoms are controlled (mild to moderate), pregnancy is reasonable, but expert maternal/fetal medical specialist care, including cardiovascular and prenatal monitoring, is advised. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) | |||
|- | |||
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' For women with advanced [[heart failure]] symptoms and HCM, pregnancy is associated with excess morbidity/mortality. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
==References== | ==References== | ||
Latest revision as of 20:50, 28 October 2016
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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Women with hypertrophic cardiomyopathy should be managed by a skilled cardiovascular specialist and a high-risk obstetrician during pregnancy. Any activity, drug or circumstance that increases left ventricular outflow obstruction, reduced left ventricular filling, or increases left ventricular afterload should be avoided.
Natural History, Complications And Prognosis In The Hypertrophic Cardiomyopathy Patient During Pregnancy
Among HCM patients who chronically have mild symptoms, pregnancy is generally well tolerated [1][2]. Although pregnancy causes vasodilation which should exacerbate the outflow gradient, pregnancy also causes fluid retention and an increase in plasma volume which increases preload and offsets the reduction in afterload. In a series of 100 HCM patients, only one of 28 asymptomatic patients developed NYHA Class III or IV heart failure. Among 12 previously symptomatic patients, 5 patients developed NYHA Class III or IV heart failure. It is notable that two sudden deaths occurred in this series of 100 patients. One of the two patients had a resting gradient of 115 mm Hg. The other patient had a markedly positive family history with 8 family members sustaining any early death, 5 of which were sudden death [2].
Avoid Activities That Increase Left Ventricular Outflow Tract Obstruction
The following activities increase left ventricular outflow tract obstruction and should be avoided:
- Epidural Anesthesia Should Be Avoided due to the potential for venous pooling.
- Bleeding should be minimized. Blood should be crossed and typed in case a transfusion is needed for bleeding, which can exacerbate outflow obstruction.
- Nausea and vomiting
- Dehydration
- Hypovolemia (i.e., use diuretics with caution)
- Medications that reduce preload and left ventricular filling such as nitrates
Avoid Activities That Increase Afterload
The following activities increase left ventricular afterload should be avoided:
- Intense isometric exercise
Beta Blockade and Calcium Channel Blockade
Although both beta blockers and verapamil may improve symptoms in the mother, the dosing should be limited to minimize the risk of fetal bradycardia, growth retardation and hypoglycemia. There is more experience with the use beta blockers during pregnancy.
Home Delivery Should Be Avoided
Home delivery without IV access is not preferred.
Vaginal Delivery Versus C-Section
Vaginal delivery is usually successful.
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)[3]
Pregnancy/Delivery (DO NOT EDIT)[3]
| Class I |
| "1. In women with HCM who are asymptomatic or whose symptoms are controlled with beta-blocking drugs, the drugs should be continued during pregnancy, but increased surveillance for fetal bradycardia or other complications is warranted[4][5][6][7]. (Level of Evidence: C) " |
| "2. For patients (mother or father) with HCM, genetic counseling is indicated before planned conception. (Level of Evidence: C) " |
| "3. In women with HCM and resting or provocable LVOT obstruction greater than or equal to 50 mm Hg and/or cardiac symptoms not controlled by medical therapy alone, pregnancy is associated with increased risk, and these patients should be referred to a high-risk obstetrician. (Level of Evidence: C) " |
| "4. The diagnosis of HCM among asymptomatic women is not considered a contraindication for pregnancy, but patients should be carefully evaluated in regard to the risk of pregnancy. (Level of Evidence: C) " |
| Class IIa |
| "1. For women with HCM whose symptoms are controlled (mild to moderate), pregnancy is reasonable, but expert maternal/fetal medical specialist care, including cardiovascular and prenatal monitoring, is advised. (Level of Evidence: C) " |
| Class III (Harm) |
| "1. For women with advanced heart failure symptoms and HCM, pregnancy is associated with excess morbidity/mortality. (Level of Evidence: C) " |
References
- ↑ Oakley GD, McGarry K, Limb DG, Oakley CM (1979). "Management of pregnancy in patients with hypertrophic cardiomyopathy". British Medical Journal. 1 (6180): 1749–50. PMC 1599373. PMID 572730. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P, Spirito P (2002). "Risk associated with pregnancy in hypertrophic cardiomyopathy". Journal of the American College of Cardiology. 40 (10): 1864–9. PMID 12446072. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (2011). "2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): e212–60. doi:10.1016/j.jacc.2011.06.011. PMID 22075469. Retrieved 2011-12-19. Unknown parameter
|month=ignored (help) - ↑ Bos JM, Towbin JA, Ackerman MJ (2009). "Diagnostic, prognostic, and therapeutic implications of genetic testing for hypertrophic cardiomyopathy". J. Am. Coll. Cardiol. 54 (3): 201–11. doi:10.1016/j.jacc.2009.02.075. PMID 19589432. Unknown parameter
|month=ignored (help) - ↑ Hershberger RE, Cowan J, Morales A, Siegfried JD (2009). "Progress with genetic cardiomyopathies: screening, counseling, and testing in dilated, hypertrophic, and arrhythmogenic right ventricular dysplasia/cardiomyopathy". Circ Heart Fail. 2 (3): 253–61. doi:10.1161/CIRCHEARTFAILURE.108.817346. PMC 2927103. PMID 19808347. Unknown parameter
|month=ignored (help) - ↑ Bascou V, Ferrandis J, Bauer V, Bouret JM, de Meeus JB, Magnin G (1993). "[Obstructive myocardiopathy and pregnancy]". J Gynecol Obstet Biol Reprod (Paris) (in French). 22 (3): 309–11. PMID 8102149.
- ↑ Fitzgerald-Butt SM, Byrne L, Gerhardt CA, Vannatta K, Hoffman TM, McBride KL (2010). "Parental knowledge and attitudes toward hypertrophic cardiomyopathy genetic testing". Pediatr Cardiol. 31 (2): 195–202. doi:10.1007/s00246-009-9583-2. PMID 19949785. Unknown parameter
|month=ignored (help)