Mom and Baby: The Heart of the Matter

Eveleen R. Randall, MD Department of Medicine, Division of Cardiology Megan M. Schellinger, DO, MS Department of OB/GYN, Division of Maternal-Fetal-Medicine Objectives

• Briefly review CV physiology during pregnancy • Hypertension spectrum in pregnancy • Valvular heart disease during pregnancy – Native valve disease – Prosthetic valves • Aortopathies and pregnancy • Pulmonary hypertension and pregnancy • Congenital heart disease & the pregnant woman Maternal Physiology Review (Compliments Dr. Shroff)

- ↑Coag - ↑CO due to - ↓FRC/RV due factors/ fib - ↓ motility ↑HR, ↑SV & to ↑ diaphragm - 45% ↑ blood - ↓ LES tone + ↓PVR - No change in volume delayed gastric - Ute/Ov blood RR;↑TV and emptying  flow 450- min ventilation - ↑vascular GERD 650ml/min comp  ↑ - Chronic mild venous stasis resp alkalosis 4 Significant Hemodynamic Changes in Pregnancy • Plasma Volume Expansion – 40-50% increase in plasma volume • Increase normal cardiac output (30-50%) – Increase Stroke Volume – Increase Heart Rate • Systemic Vascular Resistance Falls • Procoagulant’s increase – (I, VII, VIII, IX, X and Fibrinogen) CV Physiology in Pregnancy

• Physiologic Changes noted per trimester – First trimester HypotensiveNormotensive • Meds +/- • Early as 7 weeks • Nadirs at 24-32 weeks – Second trimester/Third Trimester (24-32 weeks) • Pre-pregnancy blood pressures and higher noted • Medications + Maternal CV Risk – Risk Stratification Scores Hypertensive Disorders in Pregnancy

Chronic (pre-existing) BP >/= 140/90 before 20th week of hypertension pregnancy or persists longer than 12 weeks postpartum

Gestational hypertension Elevated BP 1st detected after 20 weeks in absence of proteinuria or other features of preeclampsia Hypertensive Disorders in Pregnancy

Preeclampsia without severe • New onset HTN + proteinuria features

Preeclampsia with severe • New onset HTN + end-organ features dysfunction ± proteinuria

Chronic HTN with ♀ w/ chronic HTN develops superimposed preeclampsia worsening HTN w/ new onset proteinuria or other features of preeclampsia Hypertensive Disorders in Pregnancy

Eclampsia • ± new onset HTN ± proteinuria • ± new onset HTN + end-organ dysfunction ± proteinuria • SEIZURE

Acute Fatty Liver TTP/HUS • ± new onset HTN ± proteinuria • ± new onset HTN + end-organ dysfunction ± proteinuria • Lab Abnormalities • History of preeclampsia • Multifetal gestation • Chronic Hypertension • Diabetes Type 1 or type 2 • Renal Disease • Autoimmune (SLE, RA)

“ACOG supports the recommendation to consider the use of low-dose aspirin (81 mg/day), initiated between 12 and 28 weeks of gestation, for the prevention of preeclampsia, and recommends using the high- risk factors as recommended by the USPSTF and listed above.” Prevention: Aspirin Therapy CV risk in ♀ with HTN during Pregnancy

• Twice as likely to develop HTN or pre-HTN in 12 months after delivery • At least annual lifelong measurement of BP • Recommend PCP to all patients with pre- eclampsia Supraventricular Arrhythmias during Pregnancy

• Arrhythmias are the most common cardiac complication in pregnancy. – ♀ w/ established arrhythmias or structural heart disease at highest risk • Incidence of PSVT (AVNRT, AVRT) > a fib, a flutter • Management of acute episodes: – Hemodynamic compromise: DCCV – Vagal maneuvers, adenosine w/ acute episodes of PSVT • Prophylaxis: digoxin, beta blockers, sotalol, flecainide • Radiofrequency catheter ablation for malignant arrhythmias Atrial fibrillation during Pregnancy

• More common in ♀ w/ structural heart disease – But, evaluate for other possible causes (ie hyperthyroidism) • Management: – DCCV if hemodynamically unstable – Rhythm control preferred to rate control – If an episode of a fib > 48 hours  TEE + DCCV, anticoagulation 3 weeks then DCCV – Digoxin, beta blocker, non-dihydropyridine CCB for rate control – Thromboembolism prophylaxis- ASA vs. anticoagulant Native Valvular Heart Disease and Pregnancy Mitral Stenosis in Pregnancy

• MS is tolerated poorly because of: ↑ blood volume, ↑ cardiac output, ↑ heart rate • Pregnant women at risk for pulmonary edema, atrial arrhythmias (1º A. Fib), ↓ functional NYHA class • Women at highest risk of maternal cardiac complications: – moderate to severe MS (valve area < 1.5 cm2) – baseline NYHA Class III or IV – h/o cardiac complications prior to pregnancy – central cyanosis – LV systolic dysfunction Mitral Stenosis- Preconception intervention

Symptomatic w/ Percutaneous mitral moderate or severe valvuloplasty MS

ASx w/ moderate or Percutaneous mitral severe MS valvuloplasty *

* If a woman has normal PA pressures, exercise testing 1st to eval for exercise-induced PA HTN • If excellent exercise capacity  do NOT routinely intervene Antepartum Care in Woman w/ Mitral Stenosis

• Multi-disciplinary approach involving OB, cardiology, perinatology • F/u frequency determined by risk level: – Moderate or severe MS: monthly or bimonthly – Mild MS: every trimester • Medical management • Echo assessment: 1st antepartum visit and again during 3rd trimester, clinical ∆ Management of MS during Pregnancy Medical Management

• Small doses of furosemide ♀ w/ mild, • Restriction of activities moderate, or • Beta blockers (avoid Atenolol- a/w severe MS low birthweight) • Digoxin (↑ renal clearance) • Anticoagulation (VKA, UFH, LMWH)

If despite medical management, a ♀ has severe Sx or HF: • Percutaneous mitral valvotomy (using abdominal shielding) • Timing: > 20 weeks BUT prior to mid-late 3rd trimester Prosthetic Heart Valves in Pregnancy • Most common life-threatening complication = valve thrombosis • All forms of anticoagulation increase risk of spontaneous abortion, retroplacental bleeding, stillbirth, and fetal death

Bioprosthetic Heart Mechanical Heart Valves Valves Continue low-dose aspirin • Low-dose aspirin (75- (75-100mg/day) 100mg/day) • Vitamin K antagonist or LMWH Anticoagulation Options for Mechanical Valves • Without RF for valve thrombosis

1st Trimester 2nd/3rd Trimester

• Warfarin dose

• Warfarin dose > 5mg/d: dose- • If mom chooses to avoid fetal adjusted BID SC LMWH risk assoc w/ VKA, therapeutic SC LMWH is reasonable alternative Anticoagulation Options for Mechanical Valves

• Peripartum management: – A plan for anticoagulation should be agreed to by OB, anesthesia, and cardiology – At 36 weeks: VKA  dose-adjusted BID SC LMWH – Continue low-dose ASA up until planned delivery – Prior to induction of labor or C-section: Women with SC LMWH can be switched to dose- adjusted IV UFH or receive PPX doses of LMWH Heart Failure and Pregnancy Heart Failure and Pre- Pregnancy Counseling

• Ideally, counseling should occur prior to pregnancy

• Risk of maternal mortality is very high during pregnancy for ♀ w/ dilated CMY w/ LVEF < 20% – Avoidance of pregnancy is advised – If a ♀ becomes pregnant, termination of pregnancy should be discussed Medical Management of HFrEF in Pregnancy

Drugs to use: Drugs/drug classes to avoid: • Diuretic • Angiotensin inhibition • β blockers (ACEi, ARBs, AR-neprilysin • Hydralazine + inhibitor)- ↑ risk isosorbide dinitrate - embryopathy vasodilator therapy in ♀ w/ • Ivarbardine – lack of Sx of HF evidence of safety during • If persistent Sx, add pregnancy digoxin • Aldosterone antagonists Delivery in Setting of HFrEF

• Multi-disciplinary approach involving OB, Anesthesia, and Cardiology • Highlights – Push or pull ? vs CD – ICU – Maternal telemetry – Recovery in ICU – Echocardiogram (24-48 hours after delivery) Peripartum Cardiomyopathy (PPCM)

• Diagnostic Criteria – LVEF < 45% – In absence of previous heart disease – Occurs in last month of pregnancy OR during first 5 months after delivery Peripartum Cardiomyopathy (PPCM)- Etiology • Pathophysiology unknown – Is pregnancy the original insult? – Is pregnancy the aggravating factor in ♀ susceptible to cardiomyopathy? – Active myocarditis? – Stress of pregnancy unmasks or unveils a process that would have occurred later in life? Risk Factors of PPCM

• Advanced Maternal Age • African-American • History of multiple pregnancies • Hypertension • Genetics- initial manifestation or de novo familial dilated CMY Peripartum Cardiomyopathy Management • Co-management with cardiology –Medical Management –Echocardiogram • Follow-up with MFM and Cardiology Postpartum • BIRTH-CONTROL • Genetic Counseling/Genetic Testing • Subsequent pre-conceptual counseling with MFM/Cardiology Counseling in PPCM

Recovery in LVEF At risk for recurrence in subsequent pregnancies

Persistent LV Avoid pregnancy dysfunction (LVEF < - due to risk of HF 50%) or LVEF ≤ 25% progression & death Marfan Syndrome (MFS) and Pregnancy

Counseling (ideally prior to conception)

• risk of Aortic dissection/rupture and aortic regurgitation  screening TTE, CTA/MRA  multidisciplinary approach: MFM, cardiology, geneticist  risk is difficult to quantify- limited data - Ao root diameter 40 mm or rapidly ↑ Ao root size:  ‘increased risk’ Management of MFS during Pregnancy

Intervention Monitoring Medical Therapy during Pregnancy • Serial TTEs • β-Blockers- ↓ Ao • Ao diameter ≥ • q4-8 weeks if Ao dilation and ↓ 50mm + ↑ root > 40mm risk of Ao rapidly (ESC, dissection ACC/AHA/AATAS) • Strict BP control Postpartum Marfan’s Syndrome

• ↑ risk of Ao dissection postpartum • Expert consensus: – ‘monitoring ♀ with MFS for complications during the first 4-6 weeks postpartum.’ – Monitoring is individualized and determined by ♀’s risk of dissection Acute MI in Pregnancy

• Manage patient aggressively to save patient and pregnancy • Mortality 7% - due to reluctance to Tx patients aggressively • RF: h/o chronic HTN, DM, ↑ maternal age, eclampsia/pre- eclampsia • Initial Tx: Heparin, ASA, β blocker, nitrates • BMS preferred over DES*; thrombolysis if LHC/PCI not available – *do not have great data on use of P2Y12 inhibitors in pregnancy Pulmonary Hypertension One of the LEAST well-tolerated conditions in pregnancy

• STRONGLY counsel against At the time of pregnancy diagnosis of PAH • Initiate & provide appropriate contraceptive measure

Honest discussion about If a patient were to therapeutic termination of become pregnant pregnancy Congenital Heart Disease and Pregnancy • Multi-disciplinary approach: – OB – Cardiology – Maternal Fetal Medicine (aka perinatology) – Anesthesia Consultation • Regular follow-up in clinic • Serial echocardiograms over pregnancy • Level II Ultrasound – Serial Fetal Ultrasounds for growth – Antenatal testing at 34 weeks • Fetal Echocardiogram at 20-24 weeks • Delivery planning and timing – Clinical stable vs. “functionally significant CHD” Delivery Timing Late Preterm Steroids Counseling

“You said I can’t get pregnant, not that I shouldn’t get pregnant.” Preconception Counseling

• CHD start as a teenager – LARCs • Complex CHD preconception counseling • Recommendations should be individualized – Multiple Medications – Baseline Creatinine – Baseline Cardiac Function – Co-Morbidities • Genetic Counseling-recurrence risk stratified by type of lesion • Anesthesia consultation Rates of Complications According to Degree of Renal Insufficiency (%)

Creatinine PTD Preeclampsia HTN FGR Perinatal Live birth Decline in mortality renal function

< 1.4 20 11 25 24 9 >90 16

1.4-2.8 36-60 42 56 31-37 7 >90 50

2.8 73-86 42 56 43-57 36 N/A 40

Dialysis 48-84 86 100 50-80 60 40-50 N/A

Renal 52-75 20-37 47-63 20-99 7 74-80 14 Transplant Question A 30 year old female with a history of mitral stenosis status post mechanical mitral valve replacement presents to your clinic because she recently found out that she is pregnant. She is currently 8 weeks pregnant. She takes warfarin 4mg daily for anticoagulation, and her INR has been therapeutic on her current regimen.

Now that she is pregnant, how do you manage her anticoagulation for the remainder of the first trimester?

(a) Hospitalize the patient and start IV heparin

(b) Start apixaban 10mg BID for anticoagulation

(c) Continue only aspirin 81mg daily (d) Continue her current regimen of warfarin 4mg daily, maintaining INR 2.5-3.5 (e) Discontinue warfarin, start enoxaparin adjusting the dose by following aPTT.

Heart Failure with Preserved Ejection Fraction

• Β blockers • HR-limiting CCB • Digoxin is not indicated to treat HFpEF Aortic Stenosis in Pregnancy

• Most commonly due to congenital bicuspid AoV • Maternal cardiac morbidity related to AS severity + Sx • Complications a/w AS: HF and/or arrhythmias – In ASx ♀ w/ mild or moderate AS: Pregnancy is usually well-tolerated – ASx ♀ with severe AS may tolerate pregnancy- need close f/u • Management: Multidisciplinary approach • In w/ ♀ moderate to severe AS, need to f/u w/ cardiology post pregnancy Anticoagulation Options for Mechanical Valves

• With RF for prosthetic valve thrombosis: – Reducing maternal risk: • Continue VKA with close INR monitoring through pregnancy until 36 weeks

– Minimize fetal risk: • BID subQ LMWH with monitoring of anti-Xa levels Peripartum Cardiomyopathy

Elkayam U et al. N Engl J Med 2001;344:1567-1571. Marfan Syndrome- Elective repair prior to conception

• What do the guidelines say?

European Society of ACC/AHA/AATS (2010) Cardiology (2011) Ao root ≥ 45 mm (or > Ao root > 40 mm 27mm/m2) MFS and Delivery

AAo Diameter < 40 AAo Diameter ≥ 40 AAo Diameter > 45 mm mm, but ≤ 45 mm mm • Vaginal delivery • Vaginal delivery • C-section using epidural anesthesia • Expedited 2nd stage or delayed pushing (minimize Valsalva) Pulmonary Hypertension

• One of the LEAST well-tolerated conditions in pregnancy – RV failure, worsening cyanosis/hypoxia, ↑ pulmonary arterial resistance, thrombosis • Maternal mortality is exceptionally high: 30-50% • Rates of spontaneous abortions ~ 40-50%; fetus at risk for IUGR and preterm delivery • Multidisciplinary approach for these patients- OB, pulmonary HTN specialist (cardiology &/or pulmonary), anesthesia – and close monitoring • Goal of management: optimize RV preload & RV systolic function, and ↓ PVR