Professional Documents
Culture Documents
Heart Disease in Pregnancy
Heart Disease in Pregnancy
RHD
Developing
predominant : 56-
countries
89 %
Rutherford JD . Heart failure in pregnancy .Curr Heart Fail Rep , 2012 ;9:277-281
➢ Retrospective analysis , 207 pregnant women with cardiac disease who delivered at ≥28
weeks of gestation from June 1994 through December 2000 at AIIMS.
➢ Rheumatic heart disease ( 88%) with isolated mitral stenosis was the predominant
cardiac problem.
➢ Septal defects were the most common form of congenital heart disease
➢ 13.52% women, the diagnosis of cardiac disease was made during pregnancy.
➢ Cardiac complications were noted in 29.95% and fetal complications in 20.28%
pregnancies.
➢ Patients in NYHA class I/II had fewer maternal complications and their babies had a
higher birth weight than those in NYHA class III/IV .
➢ Maternal and fetal outcome was better in patients with prosthetic valves 97.4% of them
remained in NYHA class I/II. Surgical correction of the cardiac lesion prior to
pregnancy was associated with better pregnancy outcome.
➢ None of the newborns of mothers who had received anticoagulants had any congenital
malformation.
Morbidity and mortality
Leading cause of death in women of 25 to 44 years .
ICU admission rates – 6.4 per 1000 deliveries
Farr A ,outcomes and trends of peripartum maternal admissions to the ICU ,2017
During During
Post partum
pregnancy labour
Physiological changes during pregnancy
Cardiac output 40-50%
Plasma volume 40-50 %
stroke volume 30-50 %
heart rate 10-20 bpm
heart size upto 30 %
• Left axis deviation (15) • Straightening of left upper • Slightly increased EDV
• Sinus tachycardia cardiac border and ESV
• st segment and t wave • Horizontal positioning of • Slightly improved LV
changes in inferior leads heart function
• Small Q, inverted p or t • Increased lung marking • Enlargements of
wave in lead III • Small pleural effusion at ventricular dimensions
• Inverted t wave in lead V1 early postpartum • Slight enlargement of left
, V2 occasionally V3 atrial size
• Small pericardial effusion
• Increased tricuspid
annulus diameter
• Functional tricuspid
regurgitation
Uterine contractions
Auto transfusion of 300-500 ml blood
Maternal position
Cardiac output
Early labour : 15 % increase
Stage 1 : 25 % increase
European Heart Journal (2018)
Stage 2 : 50 % increase
Physiological changes post partum
• Cardiac output – increase by 80 %
reasons :
1)Uterine involution
2)Resorption of leg edema
Congestive
Pulmonary Sudden
heart failure
edema death
Danger period of cardiac decompensation
▪6-8 weeks : peripheral vasodilatation- CO increases by 20%
▪Between 28-32 weeks. pregnancy- induced hypervolemia and cardiac output
reach their maximum
▪Labor and delivery
▪Immediate post partum
▪4-5 days after delivery
Preterm delivery
Fetal Death
Method of termination
Approach to
Pregnancy and
pregnant
patients wit
heart disease
Risk of neonatal complications Cardiac surgery / percutaneous therapy Classify after history ,
examination ,investigations
Labour
and
delivery
Class
Previous peripartum cardiomyopathy with any residual impairment of left ventricular function
Aortic dilatation > 50 mm in aortic disease associated with bicuspid aortic valve
Siu et.al Circulation. 2001;104:515-521 ; Eur Heart J 2010;31:2124–2132. Khairy P et al Circulation 2006;113:517–524.
Approach to pregnant patients with
cardiac disease
Chest x ray ( only in special
Examination
History
Investigations
Dyspnea : NYHA classification ,
Cyanosis circumstances)
onset Clubbing Cardiomegaly,
Prior events : heart failure , Systolic murmur grade 3/6 Pulmonary vascular markings
TIA , stroke or more Enlargement of pulmonary
Associated Symptoms & sign
disease ( anaemia , of Left sided failure:
Diastolic murmur veins
Easy fatigability,
thyrotoxicosis , hypertension ) shortness of breath, Orthopnoea, PND, Pulmonary
Cardiomegaly ECG
congestion,
Drugs : ( kind Cardiac
, compliance ) asthma,Persistent
B/L rales.split S2 Cardiac chamber hypertrophy
Arrythmia Symptoms & sign of RightPersistent sided failure :
arrhythmia Arrhythmia
Weight gain, dependant edema,
Fever with arthalgia
hepatomegaly,
Persistent neck vein JVP (increases) Myocardial ischemia and
Recurrent cyanosis distention infarction
Past history Equivocal enlargement of Conduction abnormalities
heart(X-ray) ECHO
Family history
Presence of arrhythmias ,
atrial fibrillation or flutter
Classify patients - NYHA classification
• Uncomplicated – no limitation of physical activity
Class I
Patient history
• Cardiac events prior to pregnancy
• Baseline NYHA functional class
• No cardiac intervention prior to pregnancy
Specific lesions
• Mechanical valves
• Coronary artery disease
• High risk aortopathy
Imaging • High risk left sided valve lesion / left ventricular outflow tract obstruction
• Pulmonary hypertension
Other variables •
•
•
Other maternal comorbidities : advanced maternal age , hypertension , obesity
MRI and cardio pulmonary testing
Fertility therapy and patients access to care and therapy
Predictors of maternal cardiovascular events Predictors of neonatal events
• Prior cardiac events ( heart failure , transient ischemic • NYHA class III / IV , cyanosis during baseline prenatal visit
attack , stroke , arrythmia ) • Maternal left heart obstruction
• NYHA class III/IV • Smoking during pregnancy
• Left heart obstruction ( moderate to severe ) • Low maternal oxygen saturation < 90 %
• Reduced systemic ventricular systolic function ( ejection • Multiple gestation
fraction < 40 % ) • Use of anticoagulation throughout pregnancy
• Reduced sub pulmonary ventricular function ( TAPSE <16 • Mechanical valve prosthesis
mm) • Maternal cardiac event during pregnancy
• Systemic atrioventricular valve regurgitation ( moderate to • Maternal decline in cardiac output during pregnancy
severe )
• Pulmonary atrioventricular valve regurgitation ( moderate
to severe )
• Pulmonary artery hypertension
• Cardiac medication before pregnancy
• Cyanosis ( O2 saturation <90 % )
• Smoking history
• Mechanical valve prosthesis
• Repaired / unrepaired cyanotic heart disease
• NT – pro BNP > 128 pg/ml at 20 weeks predictive of event
later in pregnancy
Fetal assessment
• A full fetal echocardiography to evaluate cardiac structure
• NT /NB scan around 12 weeks to r/o and function, arterial and venous flow, and rhythm.
GCA and chromosomal anomalies • Detailed scanning of the fetal anatomy to look for
associated anomalies (particularly the digits and bones).
• NT/NB scan has sensitivity and • Family history to search for familial syndromes.
specificity of 85 [95% confidence • Maternal medical history to identify chronic medical
interval (CI) 78–90%] and 99% (95% CI disorders, viral illnesses, or teratogenic medications.
98–100%), respectively in detecting • Fetal karyotype (with screening for deletion in 22q11.2
CHD when cono-truncal anomalies are present).
• Referral to a maternal–fetal medicine specialist, paediatric
• The incidence of congenital heart cardiologist, geneticist, and/or neonatologist to discuss
disease with normal nuchal fold prognosis, obstetric, and neonatal management, and
thickness is about 1/1000 options
•
• Offer fetal ECHO at 19-22 weeks ,45% of Delivery at an institution that can provide neonatal cardiac
care, if needed
all congenital cardiac malformations
identified Eleftheriades M, Tsapakis E, Sotiriadis A, Manolakos E, Hassiakos D, Botsis D. Detection of congenital heart
defects throughout pregnancy; impact of first trimester ultrasound screening for cardiac abnormalities. J
Matern Fetal Neonatal Med 2012;25:2546–2550.
Subsequent management :
Antepartum care – medical management
Multidisciplinary team : cardiologist , obstetrician , NYHA class III OR IV
fetal medicine specialist , paediatrician
Hospitalisation for bed rest
Intensive close monitoring
Cardiac intervention , surgery
NYHA CLASS I OR II
• Limit strenuous activities Or
• Adequate rest terminate pregnancy
• Iron and vitamin supplementation to avoid
anaemia
• Salt restriction if ventricular dysfunction
• Regular cardiac and obstetric evaluation
• Stop / change teratogenic drugs used previously
Identify and treat early : • Switchover of anticoagulants at 1st trimester and
Infections , anaemia , hypertension , after 36 weeks
hyperthyroidism , arrhythmias • Endocarditis prophylaxis
Teratogenicity of cardiac drugs
options LMWH
throughout
Begin with 1mg/kg
enoxaparin BD
Antifactor Xa level 4-6 hr after
dose b/w 0.8-1.2 U/ml
Miscarriage rates :12.2
%
Pregnancy Or dalteprin 100U/kg Pre dose level >0.6U/ml,
BD Weekly monitored
Low molecular Unfractioned UFH or LMWH in Heparin infusion Same as above for heparins; Fetal loss rate : 22.7 %
weight heparin heparin 1st trimester and Warfarin daily INR for warfarin
again at 35–36
Dose – 1mg/kg body wk, warfarin
from 14-36 wk
weight
Less Higher incidence of
thrombocytopenia OAC throughout INR of 3.0 (2.5–3.5) embryopathy in 0.6-
thrombocytopenia , pregnancy for warfarin 10%
less frequent dosing monitored weekly < 5 mg- 0.45-0.9 %
due to longer half life 0.7-2%- risk of
, less osteoporosis ACCP guidelines fetopathy in 2nd and 3rd
trimester
advice UFH to be Miscarriage rates : 28.6
administered twice %
daily with aPTT
monitoring six hourly Aspirin added to No longer Maternal bleeding
all above recommended complications
increased
Xu Z, Fan J, Luo X, Zhang WB, Ma J, Lin YB, Ma SH, Chen X, Wang ZP, Ou JS, Zhang X.
Anticoagulation regimens during pregnancy in patients with mechanical heart valves:
ESC guidelines2018:European Heart Journal (2018) A systematic review and meta-analysis. Can J Cardiol 2016;32:1248.e1–1248.e9.
9th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2012;126(suppl):627S– 44S
Women on high dose VKA ( warfarin >5 mg , Women on low dose VKA ( warfarin <5 mg ,
phenprocoumon > 3 mg , acenocoumorol > 2 phenprocoumon < 3 mg , acenocoumorol <2
mg ) mg )
Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth
Analg 2009;108:777–785.
Obstetrical management
Frequency of visits
USG
Hospital admission
Labour
Frequency of visits : two weekly
During visits :
•Routinely question and examine about signs and symptoms of cardiac
failure
•Monitor vital signs and weight gain
•Obtain anaesthesia consultation prior to delivery
•Discuss contraception
USG :
If there is increased risk of IUGR :
Monitor by USG – 2 to 4 weekly
Fetal surveillance -32-34 weeks
General medical objectives of treatment
• Shunts : avoid favoring R to L shunting, lower PA pressure ,avoid
hypoxemia , avoid prolonged valsalva
• Obstructive lesions: Beta blockers, avoid volume depletion maintain
preload
• CHF – diuretics (only with pulmonary edema), reduce afterload(NTG ,
Hydralazine)
• Arrhythmias : Rate and rhythm control , anticoagulation as necessary,
higher dose digoxin
• Marfan’s , Aortic dissection: Beta blockers
Admission criteria
ELECTIVE
EMERGENCY
European society of cardiology guidelines for management of cardiovascular diseases during pregnancy , 2018
recommends elective induction at 40 weeks POG
Reduces risk of caesarean by 12 %
Mishanina E ,Use of labour induction and risk of cesarean delivery: A systematic review and
Stillbirth risk : reduced by 50 % meta-analysis, CMAJ ,2014
Indications for elective LSCS:
❑ Any obstetric indications
Should be considered in
➢ Aortic dissection, acute or chronic ,
Mode of delivery ➢ on oral anticoagulants (OACs) in pre-
term labour ( decrease risk of
intracranial hemorrhage in baby)
• Vaginal delivery is safer except certain situation
➢ acute & unless
intractable there
heart failure.
➢ Severe forms of pulmonary
is an obstetric indication of CS hypertension ( includes Eisenmenger’s
• Induction done for obstetric reasons syndrome)
➢ Marfan syndrome with dilated aortic
root (>4.5cm)
➢ Taken warfarin within 2 weeks of labor
Method of induction
➢ Aortic aneurysm
➢ Endocarditis needing- emergency valve
Bishop favourable Oxytocin and artificial rupture of
membrane replacement at or near term
➢ Severe AS
Both misoprostol and dinoprostone can be ➢ History of recent MI
used safely
May be considered
Active CVD ➢ Marfan patients with an aortic
Dinoprostone contraindicated
Cyanosis ( drop in SVR detrimental ) Foley catheter preferreddiameter 40–45mm.
➢ In patients with high risk of valve
ESC guidelines2018 :European Heart Journal (2018 ) thrombosis
Labour in cardiac disease
Decubitus
During labour, the mother with significant heart disease
Position should be kept in a semi recumbent position with lateral tilt
Place of epidural analgesia
Systemic vasodilation
Decrease CO 25-45% even in normal patients
Well tolerated (often beneficial):
• AR ,MR, L to R Shunts
Poorly tolerated:
• Limited ability to increase SV
• R to L shunts
• AS, MS
• Hypertrophic CM
• Pulmonary hypertension without ASD
First stage
Should be confined to bed with lateral recumbent position to minimize aorta – caval compression
O2 by mask
Fluid infusion should not be more than 75ml/hr to prevent pulmonary edema , concentrated syntocinon
augmentation
Careful watch of pulse & resp. rate every 15 mins frequent chest auscultations every 30 mins
Cardiac monitoring and pulse oximetry can detect arrhythmias & hypoxia ( indicative pulmonary edema )
Increases in Pulse rate much above 100bpm or respiratory rate above 24 per min, particularly when associated with dyspnea,
may suggest impending ventricular failure
Second stage
Delay in 2nd stage of labour to be curtailed by forceps/ventouse application under pudendal and
/ or perineal block
It is preferable to administer oxytocin in an i.v drip to all cases who are not in failure and simultaneously furosemide
20 mg i.v. to relieve volumetric load
Slight blood loss is beneficial and if in excess Oxytocin infusion may be continued.
If resp. distress develops secondary to pulm, congestion, should be treated aggressively as pulm edema in I.C.U
PPH control and postpartum
A slow i.v. infusion of oxytocin (2 U/min), which avoids systemic hypotension, is administered after placental delivery to prevent maternal
haemorrhage.
Prostaglandin F analogues are useful to treat post-partum haemorrhage, unless an increase in pulmonary artery pressure (PAP) is undesirable.
Methylergonovine is contraindicated because of the risk (10%) of vasoconstriction and hypertension. de Labriolle A, Genee O, Heggs LM, Fauchier L.
Acute myocardial infarction following oral methyl-ergometrine intake. Cardiovasc Toxicol 2009;9:46–48
Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of thrombo-embolism.
Delivery is associated with important haemodynamic changes and fluid shifts, particularly in the first 12–24 h, which may precipitate heart
failure in women with structural heart disease.
Pts. on warfarin should be allowed to breast feed as secretion through breast milk is extremely small
Jakes AD, Coad F, Nelson-Piercy C. A review of contraceptive methods for women with cardiac
disease. The Obstetrician & Gynaecologist.
2018;20:21–9.
Urgent delivery during full anticoagulation
• Warfarin reversed with FFP & vit –K ( 5-10 mg i.v ) and UFH with
protamine sulfate
• In case of LMWH : repeated dose of protamine sulfate required ( due
to longer half life of LMWH and slow subcutaneous absorption
• If a fully anticoagulated patient required CS, GA should be
administered &wound drains and interrupted skin sutures to be
considered
• Four factor prothrombin concentrate gives better reversal than FFP
and should be given prior to delivery to achieve INR </- 1.5
Infective endocarditis prophylaxis
• Overall annual incidence of I.E.:
1 per 1000 patients with congenital heart disease
3-12 per 1000 in patients with prosthetic valves
• Incidence higher in drug addicts
• Efficacy to prevent IE questionable
• Administer intra-partum to at risk patients only in
presence of suspected bacteraemia or active
infection
• Prophylactic antibiotic therapy during vaginal or
caesarean delivery is not recommended.( level of
evidence C, class 3 recommendation)
ACOG: Use of prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011a
Prevention of Infective Endocarditis: Guidelines From the AHA:, Circulation. 2007;116:1736-1754
Regimen for I.E. Prophylaxis
Situation Agent Single dose 30 to 60 min Before
Procedure
Oral Amoxicillin 2g
Others
Congenital
Acquired arrhythmia infective
Cyanotic ( r to l ) ( tetrology of endocarditis
Rheumatic heart disease Obstructive (mitral stenosis ,
fallot , tricuspid atresia , ebsteins
aortic stenosis , pulmonary marfan’s syndrome
Ischaemic heart disease anamoly ,tga , tapvc )
stenosis , coarctation of aorta ) mitral valve prolapse
Cardiomyopathies Acyanotic ( l to r)
( ASD,VSD,PDA) pulmonary hypertension
eisenmenger syndrome
Mitral stenosis
Pre pregnancy Maternal risk Obstetric and
•Assess cardiac function , optimise medical therapy offspring risk
•Consider surgical correction
•Decide on Comissurotomy vs replacement
• Less thrombogenic , associated with high risk of structural • Durable , but more thrombogenic
valve deterioration ~ 50 % women < 30 years 10 years post • Requires anticoagulation
implantation
• Valve deterioration more in aortic and mitral than in
pulmonary or tricuspid
Aortic regurgitation
Normal aortic root diameter – 1 % • High risk of uterine rupture • Prevalence of cardio vascular • ~ 50 % of patients with bicuspid
risk of dissection • So is a contraindication for malformation – 25-50 % aortic valve and aortic stenosis
4 cm a/w increase d risk of pregnancy have aortic root dilatation
dissection • Turner syndrome alone with • Perform pre pregnancy MRI /
> 45 mm , discourage pregnancy • Prophylactic surgery : not pregnancy does not increase CT to look for distal aortic
40 – 45 mm , risk factors for useful complication dilatation not visible
dissection ( rapid growth , family adequately in ECHO
history ) • Higher risk if associated with • If aortic root >50 mm, consider
Following replacement – risk of bicuspid aortic valve , pre pregnancy surgery
disease in residual aorta coarctation of aorta ,
hypertension
• Thoracic aortic diameters
should be evaluated in terms of
body surface area , as they
have short stature
• Aortic diameter index > 27
mm/m2
• a/w high risk of dissection ,
prophylactic surgery considered
Congenital heart disease
Maternal high risk conditions ( WHO III- Maternal low and moderate risk
IV ) conditions ( WHO class I , II, III )
• Atrial septal defect
• Pulmonary hypertension • Ventricular septal defect
• Patients with eisenmengers • Atrioventricular septal defect
syndrome • Coarctation of aorta
• Pulmonary valve stenosis and regurgitation
• Severe left ventricular outflow • Aortic stenosis
tract obstruction • Tetrology of fallot
• Ebstein anomaly
• Transposition of great arteries -
• Corrected TGA
• Fontan circulation
Pulmonary hypertension
Pre natal / antenatal visits • High maternal mortality risk • Neonatal risk : 87-89 %
•Counsel against pregnancy • 16-30 % in patients Bedard E , 2009
•Sterilization if required ( Mandalenakis Z ,2017 ) • Increased fetal and neonatal mortality : 0-
•Thromboembolism prophylaxis , hospital 30%
admission and monitor spo2 • Death occurs in last trimester of pregnancy
•Treat pulmonary hypertension – prostacyclin or first few months after delivery
analogues , bosentan , PDE inhibitors sildenafil ,
inhaled nitric oxide • Risk factors for maternal death :
• Late hospitalisations
• Severity of pulmonary hypertension
• General anaesthesia
Pre natal • 20 – 50 % mortality rate • Live birth unlikely ( < 12% ) if saturation
•Same as above • Occuring in peripartum and post < 85 %
partum period Presbitero P, 2014
• Fetal and neonatal risks increased and
relate to maternal cardiac output and
Labour , delivery , post partum degree of cyanosis
•Monitor volume status , look for signs
and symptoms of right heart failure
Cyanotic heart disease without pulmonary hypertension
Pre natal • pregnancy is well tolerated • Prematurity , SGA babies occur more
• Same as routine management , unless • Closure of hemodynamically significant frequently
patient has complications like ASD , to be performed before
arrythmia , pulmonary hypertension pregnancy
• Screen fetus for congenital heart defect • 5 % risk of thromboembolic
complication
Pre natal • Morbidity related to size of VSD and • No evidence of increased obstetric risk
•Screen fetus for CHD pulmonary hypertension
• High risk of complications in large VSD
• Small perimembranous VSD ( without
Labour , delivery , post partum left heart dilatation ) –low risk of
•Antibiotics prophylaxis ( unless patient complications during pregnancy
has uncomplicated vaginal delivery ,
defect is repaired ) prior to ceserean
•Spontaneous vaginal delivery is
appropriate
•Postnatal : early ambulation careful fluid
balance , screen for CHD
Fallots tetralogy
Pre natal • Repair indicated before pregnancy • Increased risk of offspring complication
• Uncorrected lesions – consider • Repaired TOF ( Class II ) • Maternal screening for 22q11 deletions
termination • 12% patents have cardiac complications pre pregnancy recommended
• Rest and oxygen supplementation
• Fetal ECHO
• fetal surveillance
Prenatal • Increasing age of pregnant women leads to • Thrombi and dissections occur more frequently in
•Avoid strenuous exercise , surveillance for failure and increase pregnancy related ACS peripartum period than before delivery
arrythmia , management is as for non pregnant • Mortality after ACS – 5-10 % , highest in
•Percutaneous coronary artery intervention can be • ACS is rare during pregnancy , estimated 1.7-6.2 / peripartum period
used 100000 deliveries ( O ‘ Connor DJ ,2011 ) • Survival has improved with primary percutaneous
•Thrombolytic therapy as indicated coronary intervention
Predisposing factors : • Before delivery , ACS results in fetal mortality and
• Pre eclampsia , thrombophilia , post partum prematurity , risk related to severity of maternal
infections , severe post partum haemorrhage heart disease
Aetiology : non atherosclerotic mechanisms
• Pregnancy related spontaneous pulmonary artery
Labour , delivery , postnatal dissection ( 43%)
•Monitor ECG , supplement oxygen , epidural • Angiographically normal coronary arteries ( 18%)
beneficial • Coronary thrombosis ( 17%)
•Consider caesarean if labour occurs within 4 days of
acute myocardial infarction
•Delivery should be postponed for atleast 2 weeks post
MI to facilitate maternal management
•Postnatal : avoid fluid overload , discuss contraception
Cardiomyopathies and heart failure
Peripartum cardiomyopathy
First attributed by Gouley and colleagues in 1937
Extremes of
Malnutrition reproductive
Ethical
Diabetes age
Socio-
economic
Management of peripartum cardiomyopathy
Pre pregnancy
With normal cardiac function, pregnancy less contraindicated
Inform potential for worsening cardiac function in pregnancy
Antepartum
Echo to document ventricular size and function, mural thrombi
Non pharmaceutical therapies
Low sodium diet ( 2g/day)
Fluid restriction 2L/day
Light daily activity
Pharmacologic treatment
Beta blockers – carvedilol, extended release metoprolol ( avoid in decompensated heart
failure)
Digoxin
Thiazide diuretic (hydrochlorothiazide)
May consider loop diuretic with caution
Low molecular weight heparin if ejection fraction <35%
Vasodilators like hydralazine
Postpartum
ACE inhibitors and Angiotensin receptor blockers ( preterm neonates : cause hypotension)
Loop diuretics
Beta blocker American Journal of Critical Care2012;21: 89-98
Warfarin if ejection fraction <35%
Endomyocardial biopsy :exclude treatable causes of cardiomyopathy
Bromocriptine and peripartum
cardiomyopathy
Pre natal • Counsel about risk of deterioration • Anticoagulation with LMWH or vitamin
•Multi-displinary team care during pregnancy and postpartum K antagonists should be considered for
• If LVEF < 40 % close monitoring in those with atrial arrhythmias .
tertiary centre advised
• If LVEF < 20 % maternal mortality is
Labour , delivery , post partum very high and termination advised
•Monitor heart failure
•Avoid fluid overload
•Vigilance for arrythmias
•Adequate analgesia
•Postnatal : avoid fluid overload , discuss
contraception
Management of heart failure during pregnancy
2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy
Eur Heart J. 2018;39(34):3165-3241. doi:10.1093/eurheartj/ehy340
Management of heart failure in pregnancy
2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy
Eur Heart J. 2018;39(34):3165-3241. doi:10.1093/eurheartj/ehy340
CARDIAC ARRHYTHMIAS
• Common in pregnancy
• Most are benign: sinus bradycardia & tachycardia, atrial and ventricular premature contractions
• Pregnancy may exacerbate pre-existing arrhythmias because of increased catecholamines and
adrenergic receptor sensitivity
• Healthy, asymptomatic patients without underlying pathology: reassurance, observation, and rest
• Supraventricular tachycardia often seen in pregnancy: vagal manoeuvres or, if fails, i.v. adenosine
• AF: usually associated with underlying cardiac disease
• Any arrhythmias: cardiac decomposition can occur
• Recurrence
• Atrial arrhythmias 50%,
• Ventricular arrhythmias 25% Silversides CK. Am J Cardiol 97:1206, 2006
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