Thanks so much to Dr. Nisha Soneji, a new local expert in Cardio-Obstetrics! She joined SMGR in the fall and gave us a great presentation this week that was very family medicine friendly-- on the overlap of cardiovascular disease (hypertension, pre-E, valvular disease) and the peripartum time. It's a great presentation, and she is going to be an awesome resource to have here in our community.
"Pregnancy itself is a major stress test-- you are basically on a treadmill all the time".
US has a shocking rate of maternal mortality-- the highest among developed countries, 49.5/100K live births (highest for black women in the US) and CVD is the major contributor to maternal mortality. Significant racial and ethnic disparities are seen: black women 2.6x risk of death compared to white women. Advancing maternal age increases risk of maternal mortality (87.1 death/100K births)
CVD accounts for 33% of all maternal deaths. Whereas infectious risk of maternal mortality have decreased over the last decade, CVD related deaths are increasing, 2/3rds are considered preventable.
Most common cause of CVD death:
- congenital heart disease
- ischemic heart disease
- valvular heart disease (esp stenotic disease: aortic stenosis, mitral stenosis)
- hypertensive heart disease
- congestive heart failure (peripartum cardiomyopathy, esp post partum)Contributing factors; delayed response to warnings (pregnancy symptoms mimic CVD), ineffective care, misdiagnosis, lack of continuity post partum (risk continues up to 6 months after delivery)
CV changes during pregnancy: "Pregnancy itself is a major stress test-- you are basically on a treadmill all the time". If you are at risk for CVD, in can present in pregnancy or post partum.
See image below:
Normal findings in pregnancy: systolic murmur, elevated JVP, displaced apex, edema, increase in chambers on TTE, small pericardial effusion
NOT normal in pregnancy: S4, diastolic murmur, fixed splitting second heart sound, moderate to large pericardial effusionNOTABLY Unchanged in pregnancy: LVEF, REF, PASP
American College Cardiology
Who should be referred to Cardio-OB?
change in functional status
asthma not responsive to therapy
palpitations
chest pain/tightness that doesn't improve
syncope
SBP not controlled on med
oxygen saturation <90%
hx chemo can lead to HF in pregnant women (10% risk)
existing cardiac conditions: valvular disease, CHF
Risk Assessment:
Modified WHO 2.0 risk calculator
CARPREG
Who doesn't need referral: isolated sinus tachycardia, benign ectopy, mild hypertension managed on meds, normal BNP or TTE. If in doubt, refer!
Preconception counseling: high risk patients should get preconception counseling when risk of death is so high that they really should NOT get pregnant.
Assess risk
medication review (cannot use ACE/ARB)
genetic consultation (if CHD, increased risk of fetal CHD)Testing:
TTE: echo is first line monitoring tool
Troponin, BNP not routinely monitor, but good idea to check baseline if risk factors and/or symptoms. Can then compare post partum to antepartum BNP. Troponin can be ordered routine at the lab.BNP>200 can be normal in pregnancy
BNP >300 VERY suggestive of heart failure
CXR for shortness of breath
Treadmill stress tests in pregnancy can be done safely
Zio/holter
CT chest with angiogram can be considered if benefit>> risk
Hypertension in pregnancy
Chronic hypertension (<20 weeks), gestational hypertension (>20 weeks), preE (+organ dysfunction, Pre-Eclampsia with severe features, Eclampsia (with seizures)
BP Goal <140/90
Daily low dose ASA during pregnancy for preE/eclampsia prevention >12 weeks EGA in moderate to high risk patients
Benefit>>Risk
Pre E: 71% increased risk CVD, 2.5 risk CAD, 4x risk HF
Meds for BP: labetolol (shouldn't be used in asthma, decompensated cardiac function), can use nifedipine
Arrythmias
pregnancy increases aryrthmias due to increased blood flow and hormonal changes. Most common CV complication. Increases with age >41 years.
Preventable
SVT: vagal maneuvers, beta blockers, calcium channel blockers, digoxin (can be added if BB don't work) flecainide
Defer ablation to post partum (due to risk)
Afib: BB, digoxin, 2nd line calcium channel blockers, can be safely cardioverted
Can get implanted devices if need pacemaker
Heart Failure should be treated during pregnancy, cannot be deferred to post partum
-bad outcomes for moms and babies
Peripartum Cardiomyopathy
diagnosis of exclusion
new EF <45% without reversible cause
RF: maternal age, htn, preE, prior cardiomyopathy
present in 3rd trimester to 1 month (up to 6 months PP)
20% recurrence rate, contraception is important
risk of death 5-10% at 1 year
most people with recover EF, but future pregnancy brings higher risk
Meds: loop diuretic, hydralazine, isosorbide dinitrite, digoxin, beta blocker, ((IV dobutamine can be used), AVOID: ACE/ARB/ARNI, SGLT2
Vaginal delivery is recommended unless cardiogenic shock (safer than LTCS)
Valvular Disease
preconception counseling important, especially with L side valve disease (even if asymptomatic)
send to cardiology, need to get stress test pre-conception
TTE q trimester for mild-mod valve disease
R sided valvular disease (e.g. TR), need fetal echo, rarely need intervention>> vaginal delivery preferred
L sided valvular disease: regurgitation well-tolerated, stenotic disease NOT well tolerated in pregnancy (e.g. AS or MS, even if mild). At high risk for atrial arrhthmias
CAD in pregnancy
1/10K hospitalizations after pregnancy
Risk increases 3x
RF: age, black race, eclampsia/preE, known CAD, traditional risk factors (e.g. DM)
Spontaneous dissection (SCAD) most common cause of pregnancy-related MI (conservative tx recommended)
