Cardiac disease in pregnancy overview: Difference between revisions
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{{ | {{Cardiac disease in pregnancy}} | ||
{{CMG}}; | {{CMG}}; {{AOEIC}} {{AC}}; {{LG}} | ||
==Overview== | ==Overview== | ||
Approximately 1-4% of pregnancies in the United States | Approximately 1-4% of pregnancies in the United States occur in women with maternal cardiovascular disease. In fact, pregnancy can "unmask" underlying cardiovascular disease, due to the hemodynamic changes associated with pregnancy. <ref name="pmid19329725">{{cite journal| author=Roos-Hesselink JW, Duvekot JJ, Thorne SA| title=Pregnancy in high risk cardiac conditions. | journal=Heart | year= 2009 | volume= 95 | issue= 8 | pages= 680-6 | pmid=19329725 | doi=10.1136/hrt.2008.148932 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19329725 }} </ref> With a careful pre-pregnancy evaluation, most women with cardiovascular disease can carry a pregnancy to term with proper care. | ||
==Physiology of Pregnancy== | |||
There are significant hemodynamic changes associated with pregnancy that begin early, reach their peak during the second trimester, and persist through delivery. These changes include a 40% increase in blood volume expansion, reductions in both the [[systemic vascular resistance]] and [[pulmonary vascular resistance]], a 30% rise in [[cardiac output]] and little change in the [[blood pressure]]. These changes can have a significant impact on both the mother and the fetus, particularly when there are maternal cardiac disorders. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Increasing numbers of women with [[Pregnancy and heart disease congenital heart disease|congenital heart disease]] are now reaching childbearing age, making [[Pregnancy and heart disease congenital heart disease|congenital heart disease]] the most common form of heart disease complicating pregnancy in the United States. [[Rheumatic heart disease]] is still prevalent in the developing world and in immigrant populations. Overall, maternal death during pregnancy in women with heart disease is rare, but certain conditions are associated with an increased mortality.<ref name="pmid11359761">{{cite journal| author=Siu SC, Colman JM| title=Heart disease and pregnancy. | journal=Heart | year= 2001 | volume= 85 | issue= 6 | pages= 710-5 | pmid=11359761 | doi= | pmc=PMC1729784 | url= }} </ref> | |||
==Disorders Associated with Cardiovascular Disease in Pregnancy== | ==Disorders Associated with Cardiovascular Disease in Pregnancy== | ||
Maternal cardiovascular disease includes (most commonly) | Maternal cardiovascular disease includes (most commonly) [[Pregnancy and heart disease congenital heart disease|congenital heart disease]]. Other cardiovascular disorders encountered during pregnancy include [[Pregnancy and heart disease cardiomyopathies|cardiomyopathies]], both [[dilated cardiomyopathy|dilated]] and [[hypertrophic obstructive cardiomyopathy|hypertrophic]], and [[Pregnancy and heart disease valvular heart disease|valvular heart disease]], such as [[bicuspid aortic valve]] and [[mitral valve prolapse]]. Less common cardiovascular disorders include [[Pregnancy and heart disease pulmonary hypertension|pulmonary hypertension]] and, rarely, [[Pregnancy and heart disease coronary artery disease|coronary artery disease]]. The above cardiovascular disorders require a strategy regarding the frequency of follow-up by the cardiologist and a plan for labor and delivery.<ref name="pmid15020530">{{cite journal| author=Thorne SA| title=Pregnancy in heart disease. | journal=Heart | year= 2004 | volume= 90 | issue= 4 | pages= 450-6 | pmid=15020530 | doi= | pmc=PMC1768170 | url= }} </ref> | ||
==Risk Factors== | ==Risk Factors== | ||
The following clinical characteristics are independent predictors of adverse outcomes in a risk score for maternal cardiac complications<ref name="pmid11479246">{{cite journal| author=Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC et al.| title=Prospective multicenter study of pregnancy outcomes in women with heart disease. | journal=Circulation | year= 2001 | volume= 104 | issue= 5 | pages= 515-21 | pmid=11479246 | doi= | pmc= | url= }} </ref>: | |||
* Prior cardiac events or [[arrhythmia]] | |||
* Poor functional class or [[cyanosis]] | |||
* [[Left ventricular outflow tract obstruction]] | |||
* [[Left ventricular systolic dysfunction]] | |||
[[Pulmonary hypertension]] is a well recognized risk factor during maternal pregnancy. In particular the presence of [[Eisenmenger syndrome]] places the mother particularly high risk. | |||
==Diagnosis== | ==Diagnosis== | ||
===History=== | |||
A history should be taken to assure that the patient does not have a condition that would place them at high risk during the pregnancy such as [[Marfan's syndrome]], [[Eisenmenger's syndrome]], [[congestive heart failure]], a prior history of [[peripartum cardiomyopathy]] or [[pulmonary arterial hypertension]]. | |||
===Symptoms=== | |||
Common symptoms present during pregnancy include: [[fatigue]], decreased exercise capacity, [[hyperventilation]], [[dyspnea]], [[tachycardia]] and [[palpitations]]. | |||
Secondary to [[IVC|inferior vena caval]] compression by the gravid uterus resulting in reduced [[venous return]] from the lower extremities, patients may even experience orthostatic [[lightheadedness]] and [[syncope]]. | |||
[[Pedal edema]] is often observed during the last trimester and may lead to an erroneous diagnosis of [[Congestive heart failure history and symptoms|heart failure]]. | |||
===Physical Examination=== | ===Physical Examination=== | ||
Normal physical exam signs of pregnancy include an "innocent" systolic flow murmur in 96% of patients due to the hyperdaynamic circulation, a diastolic murmur in 18% of patients, [[jugular venous distension]] and a displaced [[cardiac apex]] due to volume expansion, an S<sub>3</sub> in 84% of patients, an occasional S<sub>4</sub>, [[varicose veins]] and [[pedal edema]]. | |||
===ECG=== | ===ECG=== | ||
The common electrocardiographic findings that occur secondary to physiological changes during pregnancy include: [[tachycardia]], [[Electrocardiography#Shortened PR Interval|short PR interval]] and [[left axis deviation]]. | |||
===Echocardiography=== | ===Echocardiography=== | ||
Echocardiograhy does not carry the risk of fetal irradiation and is a safe and a preferred screening method to assess cardiac function and valvular lesions. | |||
===Chest X Ray=== | |||
Performance of routine chest x-rays should be avoided, especially in the first trimester of pregnancy. A chest x ray may be indicated in the pregnant patient with [[dyspnea]] <ref name="pmid15339791">{{cite journal |author= |title=ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy |journal=[[Obstetrics and Gynecology]] |volume=104 |issue=3 |pages=647–51 |year=2004 |month=September |pmid=15339791 |doi= |url= |accessdate=2012-04-17}}</ref> or [[cough]] <ref name="pmid15339791">{{cite journal |author= |title=ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy |journal=[[Obstetrics and Gynecology]] |volume=104 |issue=3 |pages=647–51 |year=2004 |month=September |pmid=15339791 |doi= |url= |accessdate=2012-04-17}}</ref>. Among patients with [[dyspnea]], a chest x-ray may be obtained to eavluate the patient for the presence of [[heart failure]] due to [[peripartum cardiomyopathy]]. In this scenario, the chest x ray may show [[cardiomegaly]], [[Kerley B lines]], [[pleural effusion]] and [[Congestive heart failure chest x ray#Cephalization|cephalization of blood vessels]]. | |||
===MRI=== | |||
There are no known safety hazards associated with the performance of an [[MRI]], especially after the first trimester.<ref name="pmid15556670">{{cite journal |author=De Wilde JP, Rivers AW, Price DL |title=A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus |journal=[[Progress in Biophysics and Molecular Biology]] |volume=87 |issue=2-3 |pages=335–53 |year=2005 |pmid=15556670 |doi=10.1016/j.pbiomolbio.2004.08.010 |url=http://linkinghub.elsevier.com/retrieve/pii/S0079-6107(04)00113-0 |accessdate=2012-04-18}}</ref> However, data evaluating the safety of MRI during pregnancy is limited and an MRI is indicated only when other imaging modalities such [[Cardiac disease in pregnancy chest x ray|chest x-ray]] and [[Cardiac disease in pregnancy echocardiography|echocardiography]] are inconclusive.<ref name="pmid15284433">{{cite journal |author=Shellock FG, Crues JV |title=MR procedures: biologic effects, safety, and patient care |journal=[[Radiology]] |volume=232 |issue=3 |pages=635–52 |year=2004 |month=September |pmid=15284433 |doi=10.1148/radiol.2323030830 |url=http://radiology.rsnajnls.org/cgi/pmidlookup?view=long&pmid=15284433 |accessdate=2012-04-18}}</ref> Currently, the [[FDA]] recommends prudent use of [[MRI]] during pregnancy. | |||
{| | |||
|-bgcolor="red" | |||
|'''[[MRI|Contrast MRI]] using [[gadolinium]] is ''contraindicated'' as [[gadolinium]] crosses the trans-placental membrane and exposes the fetus to [[teratogenicity]].''' | |||
|} | |||
===CT=== | |||
The preferable estimated fetal exposure from ionizing radiation should be '''below 50 mGy''' and with [[CT]], the exposed radiation is '''0.3 mGy''' and therefore '''''contra-indicated during pregnancy'''''.<ref name="pmid8349367">{{cite journal |author=van Hoeven KH, Kitsis RN, Katz SD, Factor SM |title=Peripartum versus idiopathic dilated cardiomyopathy in young women--a comparison of clinical, pathologic and prognostic features |journal=[[International Journal of Cardiology]] |volume=40 |issue=1 |pages=57–65 |year=1993 |month=June |pmid=8349367 |doi= |url= |accessdate=2012-04-18}}</ref> | |||
The '''''only exception''''' for the use of [[CT]] during pregnancy include to diagnosis [[pulmonary embolism]], for which a low-radiation [[CT]] is recommended.<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2012-04-18}}</ref><ref name="pmid12147847">{{cite journal |author=Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT |title=Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT |journal=[[Radiology]] |volume=224 |issue=2 |pages=487–92 |year=2002 |month=August |pmid=12147847 |doi= |url=http://radiology.rsnajnls.org/cgi/pmidlookup?view=long&pmid=12147847 |accessdate=2012-04-18}}</ref> | |||
==Treatment== | ==Treatment== | ||
===Labor and Delivery=== | |||
The preferred route of delivery is vaginal, but indications for a C-section include: | |||
*Traditional obstetric indications | |||
*[[Warfarin]] anticoagulation | |||
*Severe [[pulmonary hypertension]] | |||
*In the presence of fixed obstructive congenital lesions sudden BP changes may be dangerous | |||
*Unstable aorta | |||
==Radiation and Pregnancy== | |||
If a pregnant patient is radiated with less than five rads, then they can be reassured that there is a very low likelihood of risk. If a pregnant patient is exposed to more than 15 rads, termination of the pregnancy is recommended. A routine chest x-ray is associated with radiation of 20 millirads to the chest. Standard fluoroscopy delivers 1-2 rads per minute. Cineangiography delivers 5-10 rads per minute. Only 5% of the radiation delivered is absorbed by the fetus. A lead apron should be used over the mother's pelvis to minimize the risk of radiation exposure. With the use of nuclear medicine procedures the radiopharmaceuticals collect in the bladder which is in close proximity to the placenta and is directly across from the fetus. The expected radiation with thallium-201 or Tc imaging is less than one rad per examination. | |||
==Absolute and Relative Contraindications to Pregnancy== | |||
Absolute and relative contraindications to pregnancy include severe [[pulmonary arterial hypertension]]; severe fixed valve stenoses ([[AS]],[[MS]],[[PS]],[[HOCM]], [[coarctation]]; Class III or IV [[congestive heart failure]] with a [[left ventricular ejection fraction]] of < 40%; a history of [[peripartum cardiomyopathy]]; a dilated aorta such as in [[Marfan's syndrome]] with an aortic arch >40-45 mm; and severe [[cyanosis]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[CME Category::Cardiology]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Electrophysiology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Obstetrics]] | [[Category:Obstetrics]] | ||
Latest revision as of 20:48, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anjan K. Chakrabarti, M.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]
Overview
Approximately 1-4% of pregnancies in the United States occur in women with maternal cardiovascular disease. In fact, pregnancy can "unmask" underlying cardiovascular disease, due to the hemodynamic changes associated with pregnancy. [1] With a careful pre-pregnancy evaluation, most women with cardiovascular disease can carry a pregnancy to term with proper care.
Physiology of Pregnancy
There are significant hemodynamic changes associated with pregnancy that begin early, reach their peak during the second trimester, and persist through delivery. These changes include a 40% increase in blood volume expansion, reductions in both the systemic vascular resistance and pulmonary vascular resistance, a 30% rise in cardiac output and little change in the blood pressure. These changes can have a significant impact on both the mother and the fetus, particularly when there are maternal cardiac disorders.
Epidemiology and Demographics
Increasing numbers of women with congenital heart disease are now reaching childbearing age, making congenital heart disease the most common form of heart disease complicating pregnancy in the United States. Rheumatic heart disease is still prevalent in the developing world and in immigrant populations. Overall, maternal death during pregnancy in women with heart disease is rare, but certain conditions are associated with an increased mortality.[2]
Disorders Associated with Cardiovascular Disease in Pregnancy
Maternal cardiovascular disease includes (most commonly) congenital heart disease. Other cardiovascular disorders encountered during pregnancy include cardiomyopathies, both dilated and hypertrophic, and valvular heart disease, such as bicuspid aortic valve and mitral valve prolapse. Less common cardiovascular disorders include pulmonary hypertension and, rarely, coronary artery disease. The above cardiovascular disorders require a strategy regarding the frequency of follow-up by the cardiologist and a plan for labor and delivery.[3]
Risk Factors
The following clinical characteristics are independent predictors of adverse outcomes in a risk score for maternal cardiac complications[4]:
- Prior cardiac events or arrhythmia
- Poor functional class or cyanosis
- Left ventricular outflow tract obstruction
- Left ventricular systolic dysfunction
Pulmonary hypertension is a well recognized risk factor during maternal pregnancy. In particular the presence of Eisenmenger syndrome places the mother particularly high risk.
Diagnosis
History
A history should be taken to assure that the patient does not have a condition that would place them at high risk during the pregnancy such as Marfan's syndrome, Eisenmenger's syndrome, congestive heart failure, a prior history of peripartum cardiomyopathy or pulmonary arterial hypertension.
Symptoms
Common symptoms present during pregnancy include: fatigue, decreased exercise capacity, hyperventilation, dyspnea, tachycardia and palpitations.
Secondary to inferior vena caval compression by the gravid uterus resulting in reduced venous return from the lower extremities, patients may even experience orthostatic lightheadedness and syncope.
Pedal edema is often observed during the last trimester and may lead to an erroneous diagnosis of heart failure.
Physical Examination
Normal physical exam signs of pregnancy include an "innocent" systolic flow murmur in 96% of patients due to the hyperdaynamic circulation, a diastolic murmur in 18% of patients, jugular venous distension and a displaced cardiac apex due to volume expansion, an S3 in 84% of patients, an occasional S4, varicose veins and pedal edema.
ECG
The common electrocardiographic findings that occur secondary to physiological changes during pregnancy include: tachycardia, short PR interval and left axis deviation.
Echocardiography
Echocardiograhy does not carry the risk of fetal irradiation and is a safe and a preferred screening method to assess cardiac function and valvular lesions.
Chest X Ray
Performance of routine chest x-rays should be avoided, especially in the first trimester of pregnancy. A chest x ray may be indicated in the pregnant patient with dyspnea [5] or cough [5]. Among patients with dyspnea, a chest x-ray may be obtained to eavluate the patient for the presence of heart failure due to peripartum cardiomyopathy. In this scenario, the chest x ray may show cardiomegaly, Kerley B lines, pleural effusion and cephalization of blood vessels.
MRI
There are no known safety hazards associated with the performance of an MRI, especially after the first trimester.[6] However, data evaluating the safety of MRI during pregnancy is limited and an MRI is indicated only when other imaging modalities such chest x-ray and echocardiography are inconclusive.[7] Currently, the FDA recommends prudent use of MRI during pregnancy.
| Contrast MRI using gadolinium is contraindicated as gadolinium crosses the trans-placental membrane and exposes the fetus to teratogenicity. |
CT
The preferable estimated fetal exposure from ionizing radiation should be below 50 mGy and with CT, the exposed radiation is 0.3 mGy and therefore contra-indicated during pregnancy.[8]
The only exception for the use of CT during pregnancy include to diagnosis pulmonary embolism, for which a low-radiation CT is recommended.[9][10]
Treatment
Labor and Delivery
The preferred route of delivery is vaginal, but indications for a C-section include:
- Traditional obstetric indications
- Warfarin anticoagulation
- Severe pulmonary hypertension
- In the presence of fixed obstructive congenital lesions sudden BP changes may be dangerous
- Unstable aorta
Radiation and Pregnancy
If a pregnant patient is radiated with less than five rads, then they can be reassured that there is a very low likelihood of risk. If a pregnant patient is exposed to more than 15 rads, termination of the pregnancy is recommended. A routine chest x-ray is associated with radiation of 20 millirads to the chest. Standard fluoroscopy delivers 1-2 rads per minute. Cineangiography delivers 5-10 rads per minute. Only 5% of the radiation delivered is absorbed by the fetus. A lead apron should be used over the mother's pelvis to minimize the risk of radiation exposure. With the use of nuclear medicine procedures the radiopharmaceuticals collect in the bladder which is in close proximity to the placenta and is directly across from the fetus. The expected radiation with thallium-201 or Tc imaging is less than one rad per examination.
Absolute and Relative Contraindications to Pregnancy
Absolute and relative contraindications to pregnancy include severe pulmonary arterial hypertension; severe fixed valve stenoses (AS,MS,PS,HOCM, coarctation; Class III or IV congestive heart failure with a left ventricular ejection fraction of < 40%; a history of peripartum cardiomyopathy; a dilated aorta such as in Marfan's syndrome with an aortic arch >40-45 mm; and severe cyanosis.
References
- ↑ Roos-Hesselink JW, Duvekot JJ, Thorne SA (2009). "Pregnancy in high risk cardiac conditions". Heart. 95 (8): 680–6. doi:10.1136/hrt.2008.148932. PMID 19329725.
- ↑ Siu SC, Colman JM (2001). "Heart disease and pregnancy". Heart. 85 (6): 710–5. PMC 1729784. PMID 11359761.
- ↑ Thorne SA (2004). "Pregnancy in heart disease". Heart. 90 (4): 450–6. PMC 1768170. PMID 15020530.
- ↑ Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC; et al. (2001). "Prospective multicenter study of pregnancy outcomes in women with heart disease". Circulation. 104 (5): 515–21. PMID 11479246.
- ↑ 5.0 5.1 "ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy". Obstetrics and Gynecology. 104 (3): 647–51. 2004. PMID 15339791. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ De Wilde JP, Rivers AW, Price DL (2005). "A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus". Progress in Biophysics and Molecular Biology. 87 (2–3): 335–53. doi:10.1016/j.pbiomolbio.2004.08.010. PMID 15556670. Retrieved 2012-04-18.
- ↑ Shellock FG, Crues JV (2004). "MR procedures: biologic effects, safety, and patient care". Radiology. 232 (3): 635–52. doi:10.1148/radiol.2323030830. PMID 15284433. Retrieved 2012-04-18. Unknown parameter
|month=ignored (help) - ↑ van Hoeven KH, Kitsis RN, Katz SD, Factor SM (1993). "Peripartum versus idiopathic dilated cardiomyopathy in young women--a comparison of clinical, pathologic and prognostic features". International Journal of Cardiology. 40 (1): 57–65. PMID 8349367. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". European Heart Journal. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2012-04-18. Unknown parameter
|month=ignored (help) - ↑ Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT (2002). "Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT". Radiology. 224 (2): 487–92. PMID 12147847. Retrieved 2012-04-18. Unknown parameter
|month=ignored (help)