Cardiac disease in pregnancy risk factors: Difference between revisions
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{{Pregnancy and heart disease}} | {{Pregnancy and heart disease}} | ||
{{CMG}}; | {{CMG}}; {{AOEIC}} {{AC}} | ||
==Overview== | ==Overview== | ||
Women with acquired or congenital heart disease have a higher risk of cardiac complications during pregnancy than the general population. In general, a full evaluation including history, physical examination, echocardiogram, and electrocardiogram should be considered | Women with acquired or [[congenital heart disease]] have a higher risk of cardiac complications during pregnancy than the general population. In general, a full evaluation including history, physical examination, echocardiogram, and electrocardiogram should be considered in the patient maternla patient with underlying heart disease. Further risk stratification and monitoring are dictated by a number of factors, including the presence of prior cardiac events, [[heart failure]], [[valvular heart disease]], and systolic or diastolic dysfunction. | ||
==Risk | ==Cardiac Risk Score in Pregnancy== | ||
A prospective study performed by Siu and colleagues identified four predictors of maternal cardiac events.<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> These include: | A prospective study performed by Siu and colleagues identified four predictors of maternal cardiac events.<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> These include: | ||
*A prior cardiac event (e.g., heart failure, transient ischemic attack, or stroke before pregnancy | *A prior cardiac event (e.g., [[heart failure]], [[transient ischemic attack]], [[arrhythmia]] or [[stroke]]) before pregnancy | ||
*A baseline New York Heart Association (NYHA) class higher than Class II or cyanosis | *A baseline [[New York Heart Association (NYHA) class]] higher than Class II [[heart failure]] or [[cyanosis]] | ||
*A left-sided heart obstruction (mitral valve area smaller than 2 | *A left-sided heart obstruction ([[mitral valve area]] smaller than 2 cm², [[aortic valve area]] less than 1.5 cm², or peak [[left ventricular outflow tract]] gradient more than 30 mm Hg by echocardiography | ||
*Reduced systemic ventricular systolic function (ejection fraction less than 40% | *Reduced left (or systemic) ventricular systolic function ([[ejection fraction]]) less than 40% | ||
Based on this study of approximately 600 patients, the estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively. The authors recommended that those with a low cardiac risk of 0 could safely be delivered in a community hospital, but those at intermediate or high cardiac risk (risk score of 1 or more) should be delivered at a regional center. | Based on this study of approximately 600 patients, the estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively. The authors recommended that those with a low cardiac risk of 0 could safely be delivered in a community hospital, but those at intermediate or high cardiac risk (risk score of 1 or more) should be delivered at a regional center. | ||
[[File:Pregnancy risk factors.PNG|Center|500px]] | |||
It should be noted that severe [[pulmonary hypertension]] is associated with a 30-50% risk of maternal mortality. | |||
==High Risk Valvular Lesions== | |||
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines designate the following valvular lesions as high risk during pregnancy<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>: | |||
*Severe [[aortic stenosis]] | |||
*Symptomatic [[mitral stenosis]] | |||
*[[Aortic regurgitation]] or [[mitral regurgitation]] with [[NYHA class]] III to IV symptoms | |||
*Aortic and/or mitral valve disease with [[left ventricular dysfunction]] ([[left ventricular ejection fraction]] < 40%) | |||
*Aortic and/or mitral valve disease with severe [[pulmonary hypertension]] ([[pulmonary artery]] (PA) pressure > 75% of systemic pressure) | |||
*[[Marfan syndrome]] | |||
*Mechanical [[prosthetic valve]] requiring [[anticoagulation]] | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[CME Category::Cardiology]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Obstetrics]] | [[Category:Obstetrics]] | ||
[[Category: | [[Category:Cardiology board review]] | ||
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]
Overview
Women with acquired or congenital heart disease have a higher risk of cardiac complications during pregnancy than the general population. In general, a full evaluation including history, physical examination, echocardiogram, and electrocardiogram should be considered in the patient maternla patient with underlying heart disease. Further risk stratification and monitoring are dictated by a number of factors, including the presence of prior cardiac events, heart failure, valvular heart disease, and systolic or diastolic dysfunction.
Cardiac Risk Score in Pregnancy
A prospective study performed by Siu and colleagues identified four predictors of maternal cardiac events.[1] These include:
- A prior cardiac event (e.g., heart failure, transient ischemic attack, arrhythmia or stroke) before pregnancy
- A baseline New York Heart Association (NYHA) class higher than Class II heart failure or cyanosis
- A left-sided heart obstruction (mitral valve area smaller than 2 cm², aortic valve area less than 1.5 cm², or peak left ventricular outflow tract gradient more than 30 mm Hg by echocardiography
- Reduced left (or systemic) ventricular systolic function (ejection fraction) less than 40%
Based on this study of approximately 600 patients, the estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively. The authors recommended that those with a low cardiac risk of 0 could safely be delivered in a community hospital, but those at intermediate or high cardiac risk (risk score of 1 or more) should be delivered at a regional center.
It should be noted that severe pulmonary hypertension is associated with a 30-50% risk of maternal mortality.
High Risk Valvular Lesions
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines designate the following valvular lesions as high risk during pregnancy[2]:
- Severe aortic stenosis
- Symptomatic mitral stenosis
- Aortic regurgitation or mitral regurgitation with NYHA class III to IV symptoms
- Aortic and/or mitral valve disease with left ventricular dysfunction (left ventricular ejection fraction < 40%)
- Aortic and/or mitral valve disease with severe pulmonary hypertension (pulmonary artery (PA) pressure > 75% of systemic pressure)
- Marfan syndrome
- Mechanical prosthetic valve requiring anticoagulation
References
- ↑ 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.
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.