The parturient with cardiac disease PD Dr. med Daniel Tobler Leiter angeborene Herzfehler (GUCH) Universitätsspital Basel ! www.heartdiseaseandpregnancy.com Cause of death in pregnancy 7th report of the Confidential Enquiries into Maternal Deaths in the UK. London: Royal College of Obstetrics and Gynaecology, 2007 Increase of maternal death from cardiac disease Roos-Hesselink, Heart 2009 Reasons for cardiac death unknown disease known disease Roos-Hesselink, Heart 2009 Acute Myocardial Infarction in Pregnancy James A. et al, Circulation 2006 Acute Myocardial Infarction in Pregnancy Nevertheless a rare event: 6.2 per 100‘000 deliveries James A. et al, Circulation 2006 Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7% Ischemic heart disease 2% ROPAC registry, EHJ 2012 Congenital heart disease Changing prevalence Baumgartner H. EHJ 2014 Complex congenital heart disease Transposition of the Great Arteries Tricuspid atresia Hypoplastic left heart syndrome TGA - atrial switch Subaortic right ventricle Mustard vs Senning procedure Fontan palliation Single ventricle physiology Coutesy of Prof. R. Pretre Failing Fontan Failing Mustard Congenital heart disease Cardiac morbidity in Pregnancy Drenthen et al. JACC 2007 Special considerations for anesthesia in GUCH patients Hardware Special considerations for anesthesia in GUCH patients Access Special considerations for anesthesia in GUCH patients Shunts Don‘t forget the air filters! Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7% Ischemic heart disease 2% ROPAC registry, EHJ 2012 Valvular heart disease in pregnancy Valvular heart disease in pregnancy Patients with Heart failure and VHD Ruys et al. ROPAC registry, Heart 2013 Mitral stenosis in Pregnancy Silversides et al. Am J Cardiol 2003 Aortic stenosis in pregnancy Hemodynamic changes during pregnancy Thorne, Heart 2009 Timing of heart failure in pregnancy Ruys et al. Heart 2013 Timing of heart failure in pregnancy Ruys et al. Heart 2013 Mechanical valves and pregnancy Mechanical valves and pregnancy Drenthen et al. EHJ 2010 Mechanical valves and pregnancy Elkayam et al. JACC 2012 Mechanical valves and pregnancy Yinon et al. Am J Cardiol 2009 Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7% Ischemic heart disease 2% ROPAC registry, EHJ 2012 Dilated Cardiomyopathy in pregnancy Risk factors for cardiac events Grewal et al. JACC 2010 Outcome in Dilated Cardiomyopathy Pregnancy as risk factor Grewal et al. JACC 2010 Counseling a woman with heart disease • ‚Should a woman with heart disease marry?‘ – „the answer to the friends or relatives of the patient must be ‚No‘“ ! Manual of Midwifery 1905 Jellett ! • „Don’t fall in love!“ Jane Sommerville Kovacs et al. JACC 2008 Maternal risk scores Siu et al. Circulation 2001 Modified WHO classification ESC Guidelines, EHJ 2011 High risk pregnancy - team work! High risk obstetrics Obstetric Anesthesia Cardiac and fetal imaging Nurse specialists Multidisciplinary team Neonatology 35% decrease in mortality Eldrodt G, Crit Pathw Cardiol 2007 Other medical specialists Congenital heart disease Interventional/Surgical Availability Multidisciplinary team - Cardiologist • • • • • Hemodynamic goals Anticoagulation NYHA classification Expected problems Limitations (air, fluid) Multidisciplinary team - Cardiologist • Draw a picture! Delivery recommendations Vaginal delivery • Vaginal delivery 1st choice in most patients (Class I) – associated with less change in cardiac output – associated with less blood loss – associated with less infection risk – associated with less risk of venous thrombosis and thrombo-embolism ESC Guidelines, EHJ 2011 Delivery recommendations Caesarean section Roos-Hesselink et al, EHJ 2012 Delivery recommendations Caesarean section • In general, CS is reserved for obstetric indications ! • CS should be considered (Class IIa): – dilatation of ascending aorta >45 mm – severe aortic stenosis – pre-term labour while on oral anticoagulants – Eisenmenger syndrome – Severe heart failure ! • CS may be considered (Class IIb): – Marfan syndrome with aortic diameters 40-45 mm ESC Guidelines, EHJ 2011 Anesthetic management of women with heart disease The Toronto experience • 657 pregnancies (602 NYHA I/II, 55 NYHA III/IV) in 1986-2004 – 0.4% of all deliveries – epidural analgesia: 84% vs 83% – CS 29% vs 31 % • 192 cesarian deliveries, 110 (57%) unplanned) • 82 planned CS deliveries, only 5 for maternal cardiac indications Goldszmidt et al, Int J Cardiol 2010 Optimizing vaginal delivery hemodynamics • • • • • Epidural placed early No supine positioning Local anesthetics without epinephrine Minimize/titrate postpartum Oxytocin administration Aim: to minimize change of cardiac output <10% Arendt KW et al, Expert Rev. Obstet. Gynecol 2012 Take home message ! ! ! • Management of high risk pregnancy in patients with cardiac disease is multidisciplinary team work! Thank you
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