Dr Abdul Hadi bin Jaafar Head and Consultant Cardiology Cardiology Department, Tengku Ampuan Afzan Hospital Kuantan
2nd Trimester
3rd Trimester
Preconception Planning
1. 2. 3. 4. Dilated cardiomyopathy 15-60% MMR Primary pulmonary HTN 50% MMR Eisenmenger Syndrome 15-30% MMR Marfan Syndrome with aortic root dilatation 25-50% MMR 5. Coarctation of aorta 5% 6. Tetralogy of Fallot 12%
CLASS III
CLASS IV
Coarctation of the Aorta Univentricular circulation after Fontan Operation Prosthetic Valves on anti-coagulants Severe Mitral Regurgitation with NYHA class 1
PROFILE
Safe Safe
ADVERSE EFFECTS
Low Birth Weight Impairment of uterine blood flow, hyponatremia, thrombocytopenia, jaundice, bradycardia Skull ossification, IUGR, low birth weight, oligohydramnios, neonatal renal failure, limb contractures
ACE I
Use judiciously
Unsafe Use judiciously Use judiciously Fetal Bradycardia Fetal Distress due to maternal hypotension
DRUGS
Beta Blockers
PROFILE
Safe
ADVERSE EFFECTS
IUGR, bradycardia, apnea at birth, hypoglycaemia, hyperbilirubinaemia; may initiate uterine contraction None reported None reported High blood levels may cause fetal acidosis and CNS depression IUGR, prematurity, hypothyroidsm None reported Toxic dose may induce premature labor and damage to 8th cranial nerve
The timing and mode of Delivery Hemodynamic Monitoring Analgesia Antibiotic Prophylaxis
This is important to control the stress of labor An epidural is the technique of choice
patients
Ampicillin/Amoxycillin
Increase in venous return following delivery may result in worsening heart failure in patients with stenotic valves and impaired LV function
Patients with Eisenmengers syndrome decompensate in the early post partum period due to increase right to left shunting These patients should be monitored for about 48-72 hours and remain in hospital for about a week.
PROFILE
Safe Safe
COMMENTS
Amount ingested far < the pediatric dose Amount ingested far < the pediatric dose
Amount ingested far < the pediatric dose Excreted in significant amounts in milk Amount ingested far < the pediatric dose
No adverse effect Amount ingested far < the pediatric dose No adverse effect
Specific Conditions
Prosthetic Valves
Most patients with a normally functioning valve tolerate pregnancy well.
Patients with PHT usually die at the time of delivery or in the early post partum period This is due to shunt reversal with increased right to left shunting and resultant hypoxia and acidosis These patients should be admitted in the second trimester and the following considered: Anticoagulation till term and early post partum Continuous oxygen therapy, aiming at SaO2 > 90% Adequate hydration
Fetal complications
Spontaneous abortion Option I Combined heparin + warfarin Option II Heparin throughout Option III Warfarin throughout 24.8% Congenital anomalies 3.4%
Maternal complications
Thromboembolism 9.2% Death
4.2%
23.8%
0%-2.8%
33.3%
15%
24.7%
6.4%
3.9%
1.8%
Higher Risk
1st generation PHV (e.g., Starr-Edwards, Bjork Shiley) in the mitral position, atrial fibrillation, history of TE on anticoagulation
Warfarin (INR 2.53.5) for 35 weeks, followed by UFH (mid-interval aPTT 2.5) or LMWH (pre-dose anti-Xa 0.7) and ASA 80100 mg q.d.
OR
Lower Risk
2nd generation PHV (e.g., St. Jude Medical, Medtronic-Hall) any mechanical PHV in the aortic postion
UFH (aPTT 2.53.5) or LMWH (pre-dose anti-Xa 0.7) for 12 weeks, followed by warfarin (INR 2.53.5) to 35th week, then UFH (aPTT 2.5) or LMWH (pre-dose anti-Xa 0.7) and ASA 80100 mg q.d.
SC UFH (mid-interval aPTT 2.03.0) or LMWH (pre-dose anti-Xa 0.6) for 12 weeks, followed by warfarin (INR 2.53.0) for 35 weeks, then SC UFH (mid-interval aPTT 2.03.0) or LMWH (pre-dose anti-Xa level 0.6)
OR
SC UFH (mid-interval aPTT 2.03.0) or LMWH (pre-dose anti-Xa 0.6) throughout pregnancy
Elkayam U et al. Anticoagulation in pregnant women with prosthetic heart valve. J Cardiovasc Pharmacol Ther 2004;9:10715.
3.
4.
The score
Score of 0 Score of 1 Score of >1 5% risk 27% risk 75% risk