Cardiac disease in pregnancy and hypertrophic cardiomyopathy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Anjan K. Chakrabarti, M.D. [2]
Overview
Patients with pre-existing cardiomyopathies prior to pregnancy often have significant difficulty dealing with the physiologic and hemodynamic changes that occur during pregnancy, labor, and delivery. In addition to these patients, there is a subset of patients who will develop peripartum cardiomyopathy.
Pre-Existing Cardiomyopathies
Dilated Cardiomyopaty
This section will primarily focus on dilated cardiomyopathy (DCM) in pregnancy. For a more detailed discussion of dilated cardiomyopathy, click here.
Currently, DCM is responsible for "approximately 10,000 deaths and 46,000 hospital stays each year in the United States and is the most common indication for cardiac transplantation."[1] The cause often remains unknown, in up to 50% of cases.[2]
In general, women with dilated cardiomyopathy are advised to avoid pregnancy for the following reasons:
- Dilated cardiomyopathy has been associated with A-type lamin gene defects, which are associated with a high rate of heart failure and life-threatening arrhythmias, as predicted by NYHA functional class[3]
- The increase in intravascular volume and cardiac output during pregnancy leads to a greater risk for complications in women with dilated cardiomyopathy, especially in the 3rd trimester
- A history of cardiac events including previous episodes of heart failure, atrial fibrillation or atrial flutter, transient ischemic attack, or a history of cardiac events before pregnancy is predictive of negative pregnancy-related cardiac outcomes[4]
The following should be considered when managing heart failure during pregnancy:[5]
- Goals are similar to non-pregnant patients, including continuation of chronic therapies (with a few exceptions, including ACE Inhibitors, Angiotensin Receptor Blockers, and Aldosterone antagonists)
- Beta-blockers can and should be continued through pregnancy
- Vasodilator therapy can be achieved with Amlodipine and Hydralazine safely
- Sodium restriction and digoxin can both be used during pregnancy
- In the setting of acute decompansation, intravenous diuretics, vasodilators, and monitoring with right heart cathterization are all acceptable
Finally, the following should be considered during labor and delivery:
References
- ↑ Manolio TA, Baughman KL, Rodeheffer R, Pearson TA, Bristow JD, Michels VV; et al. (1992). "Prevalence and etiology of idiopathic dilated cardiomyopathy (summary of a National Heart, Lung, and Blood Institute workshop". Am J Cardiol. 69 (17): 1458–66. PMID 1590237.
- ↑ Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL; et al. (2000). "Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy". N Engl J Med. 342 (15): 1077–84. doi:10.1056/NEJM200004133421502. PMID 10760308.
- ↑ Pasotti M, Klersy C, Pilotto A, Marziliano N, Rapezzi C, Serio A; et al. (2008). "Long-term outcome and risk stratification in dilated cardiolaminopathies". J Am Coll Cardiol. 52 (15): 1250–60. doi:10.1016/j.jacc.2008.06.044. PMID 18926329.
- ↑ Siu SC, Colman JM, Sorensen S, Smallhorn JF, Farine D, Amankwah KS; et al. (2002). "Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease". Circulation. 105 (18): 2179–84. PMID 11994252.
- ↑ Stergiopoulos K, Shiang E, Bench T (2011). "Pregnancy in patients with pre-existing cardiomyopathies". J Am Coll Cardiol. 58 (4): 337–50. doi:10.1016/j.jacc.2011.04.014. PMID 21757110.