Hypertrophic cardiomyopathy management during pregnancy

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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.

Avoid Activities That Increase Left Ventricular Outflow Tract Obstruction

The following activities increase left ventricular outflow tract obstruction and should be avoided:

• 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

Management of the HCM Patient During Pregnancy

Among HCM patients who chronically have mild symptoms, pregnancy is generally well tolerated . 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 .

Although 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, and growth retardation. There is more experience with the use beta blockers during pregnancy.

Due to the potential for venous pooling, epidural anesthesia should be avoided.. Blood should be crossed and typed in case a transfusion is needed for bleeding, which can exacerbate outflow obstruction. Home delivery without IV access is not preferred. Vaginal delivery is usually successful.