[Peripartum cardiomyopathy: interdisciplinary challenge]

Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.

Pregnancy in sick sinus syndrome with pacemaker - two cases

Sick sinus syndrome is a generalized abnormality of cardiac impulse formation that may be caused by extrinsic causes or by intrinsic disease of the sinus node making it unable to perform pace making function. It can be manifested for the first time in pregnancy. First case was diagnosed as sick sinus syndrome at 8 weeks of gestation having Mobitz type I heart block (Wenckebach block), and needed temporary pacemaker during caesarean section. Second case was diagnosed at 24 weeks of gestation having complete heart block and needed permanent pacemaker at 38 weeks of gestation due to exaggeration of the symptoms. Both the cases were dealt successfully by caesarean section under general anesthesia in close collaboration with cardiologists and anesthesiologists.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy of unknown aetiology associated with significant mortality and morbidity and characterized by heart failure in late pregnancy or puerperium. Recently PPCM workshop committee has recommended inclusion of echocardiographic features of LV dysfunction to redefine PPCM. Subsequent pregnancies are associated with a very high mortality in these patients and hence should be avoided. Women with PPCM continue to have significant mortality despite the use of conventional drugs for managing heart failure. Use of newer drugs such as immunoglobulin, pentoxifylline, bromocriptine, and cabergoline along with newer interventions such as plasmapheresis, immunoadsorption, ventricular assist devices and last but not the least the heart transplantation hold promise for future.

Percutaneous balloon mitral valvotomy during pregnancy

Rheumatic mitral valve stenosis continues to be the most frequently encountered clinically significant valvular abnormality in pregnant women. We retrospectively studied the fetal outcomes of patients with severe rheumatic Mitral Valve Stenosis (MS) admitted to hospital with heart failure and underwent Percutaneous Balloon Mitral Valvotomy (PBMV) during pregnancy. We identified all of the pregnant cases with rheumatic MS from February 1st 1994 till February 1st 2011 who underwent PBMV from medical records in the tertiary referral center of Madani Heart Hospital in Tabriz, Iran. Follow up was done by phone call and office visit. During this period 24 pregnant patients with mean ages of 29.45 +/- 5.05 (19-38) had undergone PBMV for severe MS. Fourteen patients could not be reached and were lost to follow-up. PBMV had been performed during second trimester of pregnancy in 20 cases (83.3%) and during third trimester in 4 patients (16.6%). The success rate of PBMV was 100%. Pulmonary artery pressure reduced from 58.88 +/- 21.97 to 38.50 +/- 8.87 (p < 0.05), peak and mean transmitral valve gradient reduced 25.20 +/- 9.71 to 11.03 +/- 3.61 (p < 0.0001), 14.18 +/- 7.60 to 5.00 +/- 1.39 (p = 0.004), respectively. We conducted follow up in 10 patients with good fetal outcome in all except in 2 infants who died during follow up with intractable heart failure. Twenty patients were in normal sinus rhythm at the time of procedure (83.3%) and 4 of them (16.7%) had arterial fibrillation. PBMV during pregnancy could be recommended as a relatively safe procedure for mother and fetus.

[Structure of cardiovascular pathology in pregnant women and efficacy of regional specialized management]

From 2000 to 2011 in prospective and retrospective studies we investigated pregnancy outcomes in all 30417 women treated within framework of the multidisciplinary management system for pregnant patients with cardiovascular diseases (hypertension, structural heart disease, aortic pathology and inflammatory autoimmune rheumatic diseases) designed and conducted in the Udmurt Republic of Russian Federation in late 1980-th. The system comprises specialized outpatient and inpatient departments, sanatorium and a maternity hospital at the regional cardiological center and provides ambulatory and hospital management and rehabilitation. Perinatal mortality decreased 65.8% from 11.1% in 2000 to 3.8% in 2011. Within 20 years no mother died.

[Ovarian vein syndrome during pregnancy--diagnostic and treatment]

PURPOSE

To access the presence of Ovarian Vein Syndrome in second trimester pregnancy and safety and effectiveness of stents insertion in symptomatic hydronephrosis during pregnancy.

MATERIAL AND METHODS

From 01.01.2007 to 30.12.2011, 66 women were hospitalized in the Urology Clinic at the University Hospital "St. George" Plovdiv. Sixty six patients presented acute pyelonephritis and painful hydronephrosis. 61 cases were with right hydronephrosis (92%), 2 (3%) on the left side and 3 (5%) with hydronephrosis in both sides. On the Ultrasound Doppler investigation, 61 cases with right hydronephrosis were with varicose right ovarian vein anomalies, which cause unilateral ureteral obstructions. Using ultrasound guidance, 66 retrograde ureteral stents were successfully placed under local anesthesia.

RESULTS

In 66 patients with urinary infection, we observed remission of fever during the first 24-48 hours after the placement of the ureteral stents.

CONCLUSIONS

Ovarian vein syndrome is a ureteral dilatation secondary to ovarian vein dilatation. The majority of cases are diagnosed during pregnancy, with a 90% predominance on the right side. Retrograde ureteral stenting is an effective, simple and safe method in treating symptomatic hydronephrosis during pregnancy.

Cardiac disease in pregnancy

Cardiac disease is the leading cause of maternal mortality in the UK. The major causes of cardiac deaths in pregnancy include cardiomyopathy, myocardial infarction, ischaemic heart disease and dissection of the thoracic aorta. With increasing numbers of migrant women in the UK, rheumatic heart disease in pregnancy has also re-emerged. Women with uncorrected congenital heart disease and those who have undergone corrective or palliative surgery may have complicated pregnancies. Women with metal prosthetic valves face difficult decisions regarding anticoagulation in pregnancy and have an increased risk of haemorrhage. Not all women with significant heart disease are able to meet the increased physiological demands of pregnancy. The care of pregnant women with heart disease thus requires a multidisciplinary approach, involving obstetricians, cardiologists and anaesthetists. This allows appropriate surveillance of maternal and fetal wellbeing, as well as planning and documentation of the management of elective and emergency delivery. This review discusses common cardiac conditions encountered in pregnancy and their antenatal and intrapartum management.

Pulmonary embolism in pregnancy. Consensus and controversies

Venous thrombotic events (VTE) occur 1-2 per 10,000 pregnancies and remain one of the leading causes of maternal mortality in the developed world. The two largest risk factors are a personal history of VTE and heritable thrombophilias. D-dimer tests for VTE in pregnancy have a high false positive rate and at least some false negatives have been reported. Compression ultrasound should be used to evaluate pregnant women for deep venous thrombosis followed by magnetic resonance imaging of the pelvis for a negative test and strong remaining clinical suspicion. For pulmonary embolism, a chest x-ray should be used to triage the patient to either a ventilation/perfusion study after a normal X-ray or a CT pulmonary angiogram after an abnormal one. Treatment generally consists of low molecular weight heparin through a minimum of six weeks post-partum. Thombolysis might have merit in life-threatening, massive pulmonary embolism. VTE prophylaxis in at-risk populations remains a major area of uncertainty. Mechanical prophylaxis for all women undergoing cesarean, in particular, has a paucity of supportive evidence.

Hypertrophic cardiomyopathy and pregnancy

Women with pre-existing cardiomyopathies have limited cardiovascular reserve. The hemodynamic challenges of pregnancy, labor, and delivery pose unique risks to this group of patients, which can result in clinical decompensation with overt heart failure, arrhythmias, and rarely, maternal death. A multidisciplinary team approach and a controlled delivery are crucial to adequate management of patients with underlying heart disease. Preconception planning and risk assessment are essential and proper counseling should be offered to expectant mothers regarding both the risks that pregnancy poses, and the implications for future offspring. In this paper, we will review the hemodynamic stressors that pregnancy places upon women with hypertrophic cardiomyopathies, risk assessment and discuss what evidence exists regarding the management during pregnancy, labor, and delivery for hypertrophic cardiomyopathy.

Coronary angiography and percutaneous interventions in pregnancy

Pregnancy and the need for cardiac catheterization poises a unique challenge that requires the balance of risk and benefit both to the mother and the fetus. Fortunately, the need for radiological invasive procedures for cardiac diagnosis has been markedly reduced with the widespread growth in imaging technology using non-ionizing energies such as ultrasound for diagnosis of underlying cardiac pathology. As the age of active childbearing has increased in many countries, an increasing overlap has developed with the childbearing overlapping the early years of acute coronary artery disease. Both acute coronary syndromes and classic congenital valve disorders are increasingly being treated successfully with invasive cath lab technologies that require some degree of risk to the pregnancy. We review the pathophysiology of both valvular and coronary pathologies that may become symptomatic or acutely decompensated and require consideration for invasive cardiac therapy. Potential risks both from radiation, acute medication use and potential need for longer term oral medications resulting from the invasive cardiac procedures are reviewed. Final specific measures to reduce the risks most pertinent to pregnancy are discussed. While risks are present during pregnancy that are unique, emergently indicated invasive cardiac procedures should not be denied or delayed solely on the pregnant state as many of these procedures have highly time responsive benefits that can be lost by irrational delays.

[2011 European Society of Cardiology guidelines for the management of cardiovascular diseases during pregnancy. Part 1]

In this article, we describe the 2011 European guidelines on the management of cardiovascular diseases during pregnancy, with particular attention to the management of valvular heart disease and anticoagulation.We will also describe cardiologic conditions in which pregnancy is contraindicated and the preferred way of delivery.

[Chronic hypertension and pregnancy]

Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal mortality and morbidity. The management of patients with chronic hypertension requires a multidisciplinary approach prior to conception, during pregnancy and post-partum. In the preconception period, fetotoxic agents should be discontinued. It is also essential to undertake a full cardiovascular examination which may, in some cases, question the possibility of pregnancy. During pregnancy, blood pressure should be monitored and controlled, but not necessarily returned to a normal value. Low blood pressure levels could indeed lead to placental hypoperfusion and fetal growth restriction. Close clinical, biological and ultrasound monitoring is recommended, even postpartum, since those patients are at higher risk for preeclampsia.

Congenital endocardial cushion defect detected during uncomplicated pregnancy: a case report

BACKGROUND

The first symptoms of previously undiagnosed congenital heart disease may become apparent during pregnancy. It is important to recognize structural heart lesions since they require additional monitoring during the prenatal, peripartum, and postpartum periods and are associated with increased maternal and fetal morbidity and mortality.

CASE

We report a case of a new diagnosis of an endocardial cushion defect in an otherwise healthy woman in her third trimester whose presenting complaint was dyspnea in the left lateral decubitus position.

CONCLUSION

We located only one other case report of a congenital heart lesion first diagnosed during pregnancy. While rare, since the signs and symptoms of congenital heart disease may also occur in normal pregnant women, it is important for the clinician to be aware that structural heart lesions are part of the differential diagnosis.

[Heart disease and pregnancy]

Pregnancy is associated with important haemodynamic changes that increase during delivery and may decompensate an underlying heart disease. Some situations (fortunately rare) are at very high risk and can contra-indicate pregnancy (Eisenmenger syndrome, severe stenotic left heart valve, severely dilated aorta and severe left ventricular dysfunction). Women with less severe disease can have a pregnancy with specific follow-up (shunt lesions, operated tetralogy of Fallot, mecanical valve). Peri-partum cardiomyopathy is an entity specific to pregnancy because of timing of its diagnosis. The presence of heart disease during pregnancy raises a number of different problems. This underlines the need for a multidisciplinary approach at each phase: before and during pregnancy as well as during the post-partum period. Modalities of delivery should be discussed and planned taking into account the type of heart disease and its tolerance towards the end of pregnancy.

Could it have been better? A patient with peripartum cardiomyopathy treated with conventional therapy

INTRODUCTION

Peripartum cardiomyopathy is a life threatening condition of unknown cause that occurs in previously healthy women. It is characterized by symptoms of heart failure due to left ventricular dysfunction that occurs in the last month of pregnancy or the first five months after delivery.

CASE REPORT

We presented woman who underwent caesarean section due to preeclampsia. Two weeks after delivery first signs of heart failure appeared and only after six weeks following the onset of symptoms peripartal cardiomyopathy was recognized. A conventional treatment with diuretics, ACE inhibitor and beta blocker along with anticoagulant therapy was applied, which resulted in a complete recovery of the left ventricular function four months after.

CONCLUSION

Timely detection and initiation of treatment are an important precondition for the complete or partial recovery.

[Cardiopulmonary emergencies during pregnancy and the postpartum period]

The number of patients who develop cardiac problems during pregnancy are increasing and represent to date the major cause of maternal death in western countries. Pregnancy induces several changes which together increase the hemodynamic burden on the cardiovascular system and can also cause a prothrombotic state. Hence, latent or apparent cardiac disease can acutely decompensate during pregnancy. From a cardiovascular perspective, pregnancies are most often complicated by acute coronary syndromes, peripartum cardiomyopathy, arrhythmias, or pulmonary embolism. Due to potential fetal harm conventional diagnostic and therapeutic approaches are limited by the restricted use of radiogenic cardiac imaging and applicable medications. Therefore, knowledge about available therapeutic options is of greatest importance, since guideline recommendations have clearly been demonstrated to reduce morbidity and mortality in acute cardiac emergencies during pregnancy.

[Acute myocardial infarction in pregnant woman]

The article presents a case of 30-year-old patient at her 30th week of pregnancy who was admitted to our clinic with non-ST elevation myocardial infarction resulting from coronary artery embolism. A successful recanalisation of the occluded artery by balloon angioplasty was performed.

Successful maternal-foetal outcome using nitric oxide and sildenafil in pulmonary hypertension with atrial septal defect and HIV infection

Pulmonary hypertension associated with pregnancy carries a poor prognosis. We describe successful maternal-foetal outcome for a 30-year-old woman who was found to have severe pulmonary hypertension, human immunodeficiency virus (HIV) and an atrial septal defect. Prior to delivery, she was managed with subcutaneous enoxaparine, sildenafil, nitric oxide, careful maintenance of a euvolemic status and antiretroviral therapy. She was planned for an elective Caesarean section to reduce the risk of maternal-foetal HIV transmission, but went into labour in the coronary care unit. During delivery, antibiotic prophylaxis was given, although there was insufficient time for intravenous zidovudine. Peripartum, the patient was continued on nitric oxide and subcutaneous enoxaparine. She was eventually weaned off the nitric oxide and recovered well.

[Cardiac angiosarcoma in a pregnant women]

We present a case of cardiac angiosarcoma in a pregnant women. Clinical manifestations of angiosarcoma were unspecific and progressed rapidly as hemopericardium, cardiac tamponade, heart failure, fever, chest pain. Pregnancy was interrupted at 22-nd week. The patient died in 6 months after appearance of first symptoms.

[Periportal cardiomyopathy. Some peculiarities of clinical picture and course of the disease]

Results of the study of special characteristics of the course of chronic heart failure (CHF) in women with periportal cardiomyopathy (PCMP) are presented. We have found that prevalence of PCMP in the structure of dilated cardiomyopathy is 9.5%. PCMP compared with idiopathic cardiomyopathy is characterized by less pronounced dilation of left cardiac chambers, relative preservation of left ventricular contractile function, more favorable course of CHF with lower frequency of destabilizations of clinical state. PCMP has developed mainly during postportal period and in women with preexisting anemia and chronic viral diseases.

Peripartum cardiomyopathy: a review

Peripartum cardiomyopathy is idiopathic heart failure occurring in the absence of any determinable heart disease during the last month of pregnancy or the first 5 months postpartum. The incidence varies worldwide but is high in developing nations; the cause of the disease might be a combination of environmental and genetic factors. Diagnostic echocardiographic criteria include left ventricular ejection fraction <0.45 or M-mode fractional shortening <30% (or both) and end-diastolic dimension >2.7 cm/m(2). Electrocardiography, magnetic resonance imaging, endomyocardial biopsy, and cardiac catheterization aid in the diagnosis and management of peripartum cardiomyopathy. Cardiac protein assays can also be useful, as suggested by reports of high levels of NT-proBNP, cardiac troponin, tumor necrosis factor-α, interleukin-6, interferon-γ, and C-reactive protein in peripartum cardiomyopathy. The prevalence of mutations associated with familial dilated-cardiomyopathy genes in patients with peripartum cardiomyopathy suggests an overlap in the clinical spectrum of these 2 diseases.Treatment for peripartum cardiomyopathy includes conventional pharmacologic heart-failure therapies-principally diuretics, angiotensin-converting enzyme inhibitors, vasodilators, digoxin, β-blockers, anticoagulants, and peripartum cardiomyopathy-targeted therapies. Therapeutic decisions are influenced by drug-safety profiles during pregnancy and lactation. Mechanical support and transplantation might be necessary in severe cases. Targeted therapies (such as intravenous immunoglobulin, pentoxifylline, and bromocriptine) have shown promise in small trials but require further evaluation. Fortunately, despite a mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, many patients with peripartum cardiomyopathy recover within 3 to 6 months of disease onset.

Hypoplastic right-heart syndrome presenting as multiple miscarriages

Reversible causes of miscarriage are many, but they affect only 1% of women who are trying to conceive. Herein, we describe the case of a 23-year-old woman who presented for evaluation of repeated miscarriages and was found to have hypoxemia and erythrocytosis. Further evaluation revealed hypoplastic right-heart syndrome with an intracardiac shunt. She underwent hybrid repair with pulmonary valve balloon valvuloplasty, followed by surgery to perform atrial septal defect closure and a Glenn anastomosis. The erythrocytosis and hypoxemia resolved, and she was able to conceive and deliver a healthy baby at term 2 years later. This is a unique case of a rare congenital heart defect that went unnoticed until adulthood, when attempts at pregnancy failed because of the associated hypoxemia. Timely and appropriate treatment led to a successful pregnancy after repeated miscarriages. This case exemplifies the need for a comprehensive medical evaluation of every woman with a history of multiple miscarriages to determine whether a reversible cause exists.

[Myocardial infarct during pregnancy]

Acute myocardial infarction during pregnancy is a rare but potentially fatal complication. We describe a 43-year-old patient with non-ST-segment elevation myocardial infarction during late pregnancy. She underwent coronary angiography but was treated conservatively after an occlusion of mid-size left oblique marginal branch was observed. During pregnancy many medications normally used in the setting of acute coronary syndrome are contraindicated and use of radiation should be minimized. Thus treatment of acute coronary syndrome must be carefully tailored in this patient group.

[Peculiarities of pregnancy management after multiple stenting of coronary arteries]

This paper describes the strategy for pregnancy and labour management in women with the history of myocardial infarction after multiple stenting of coronary arteries using stents with cytostatic coating. The authors discuss a broad range of diseases underlying coronary lesions in young pregnant women receiving antiaggregation therapy. Neither multiple stenting nor intake of aspirin and ticlopid provoked teratogenic effect.

Uncorrected tetralogy of Fallot and pregnancy: a case report

We report a case of pregnancy in a 34-year-old woman with uncorrected tetralogy of Fallot (TOF). There are more risks in patients without surgical correction. In our case, haemoglobin and haematocrit were higher, oxygen saturation was lower, and right ventricular enlargement was observed. Pregnancy was resolved successfully by caesarean section. Improvement of fetomaternal outcome may be related to corrective procedures before conception to achieve better functional heart capacity. Delicate multidisciplinary medical management is essential for these limited cases to achieve optimal prognosis.

[Polish guidelines for the prevention and treatment of venous thromboembolism. 2012 update]

The overall objective of the Polish guidelines for the prevention and treatment of venous thromboembolism is to increase patient benefit and safety by appropriate prevention and treatment of deep vein thrombosis and pulmonary embolism as well as proper management of the complications associated with antithrombotic and thrombolytic therapy. These guidelines apply to adult trauma, cancer, surgical, and medical patients as well as those at increased risk of venous thromboembolism. Specific recommendations have been formulated for pregnant women, patients requiring surgery while receiving long-term oral anticoagulant treatment, and patients undergoing regional anesthesia and/or analgesia. We chose to update the existing Polish guidelines with the use of the most recent high-quality international guidelines that we identified and adjusted the final product to Polish cultural and organizational setting. We based our recommendations primarily on the 9th edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on Antithrombotic Therapy and Prevention of Thrombosis, the European Society of Cardiology Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism, the 3rd edition of the American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines on Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy, the ACOG practice bulletin on thromboembolism in pregnancy (Number 123), and Guidance from the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis on the Duration of Anticoagulant Therapy after a First Episode of Unprovoked Pulmonary Embolus or Deep Vein Thrombosis, as well as two other Polish practice guidelines on the prophylaxis and treatment of venous thromboembolism and the management of patients treated with oral direct inhibitors of factor X or factor II. To make recommendations regarding specific management issues that had not been addressed in other guidelines, or whenever the panel members felt they needed additional information to reach the decision, we also consulted the authors of guidelines developed by other professional societies and organizations as well as additional sources of evidence. For each adapted recommendation, we explicitly assessed its relevance and applicability in the context of the healthcare system in Poland. When necessary, we explicitly stated the rationale for modification of the previously published recommendations and judgements about the values and preferences we assumed. The information regarding reimbursement of drugs mentioned in the recommendations was added in chapters 6-9 and 13 and approved by the National Health Fund. The final version of the practice guidelines was officially approved by the scientific societies and institutions listed at the beginning of the document.  

Pregnancy-related uterine arteriovenous malformations: experience from a single medical center

PURPOSE

The purpose of this article was to investigate clinical ultrasonographic findings and the outcomes of post-pregnancy patients with acquired uterine vascular abnormalities including arteriovenous malformations (AVMs).

MATERIALS AND METHODS

We performed a computerized database search for all patients with ultrasonographic findings of a vascular abnormality including AVM in our referral center between 2000-2008. An ultrasound finding of vascular abnormality was defined as an area of strong hypervascularity within the myometrium and the presence of marked turbulence. The inclusion criteria for angiography were abnormal vaginal bleeding in a hemodynamically stable patient, bhCG serum levels ≤ 30 mIU/ml, and ultrasound demonstration of large (≥ 15 mm on the larger side of the vessel) or multiple vascular lesions.

RESULTS

16 women were identified, of whom 10 (63 %) underwent uterine artery embolization. Angiography confirmed the pre-interventional ultrasound diagnosis of AVM in all cases. AVM feeding arteries were on the left side of the uterus in 80 % of the cases. Residual tissue was ultrasonographically detected in five patients: 2 underwent hysteroscopy and guided curettage following embolization and three received methotrexate. All tissue samples were benign. One small vascular abnormality resolved spontaneously.

CONCLUSION

An acquired uterine vascular abnormality including AVM should be considered in the work-up of post-pregnancy vaginal bleeding.

Effect of percutaneous mitral vavuloplasty on pregnant mother and foetus--a tertiary care hospital experience from a developing country

This study evaluated the short and long-term consequences of Percutaneous Mitral Valvuloplasty (PMV) in pregnant patients and their offspring, in a tertiary care setting, Karachi, Pakistan. The hospital database was used to retrieve all patients who underwent PMV during pregnancy in the period 1998-2007. The follow up data of the patients and the born children were obtained from the hospital records and also by contacting the patients via phone. Six patients underwent PMV but follow-up was available for 5 patients only. All 5 patients were admitted due to severe mitral stenosis with symptoms of dyspnea and palpitation. Mean age was 27 +/- 5.3 years with a mean gestational age at the time of procedure of 22.20 +/- 1.6 weeks. The mean valve area increased from 0.94 +/- 0.22 cm2 preoperatively to 1.62 +/- 0.50 cm2 post-operatively. The ejection fraction changed from a mean of 50 +/- 11.7% to 56 +/- 2.2%. There were no maternal deaths, abortions or stillbirths. Developmental milestones were achieved at the appropriate ages in all babies. PMV appears to be a safe and effective intervention for patients with severe MS during pregnancy.

KEYWORDS

Mitral stenosis, Percutaneous Mitral

[Maternal heart disease and pregnancy: a multidisciplinary approach]

In developed countries, cardiovascular diseases are becoming one of the first causes of maternal death. Myocardial infarction, dissection of the thoracic aorta and cardiomyopathies are the leading causes. However, preexisting maternal cardiac diseases, such as congenital heart diseases, are more commonly encountered and may be associated with significant maternal and perinatal morbidity. This article reviews hemodynamic changes occurring during pregnancy, proposes a risk stratification according to pre-existing cardiac diseases, and discusses the monitoring and overall management of these patients. Finally, two pregnancy-triggered cardiac diseases are discussed: coronary artery disease and peripartum cardiomyopathy.

Heart failure in pregnancy: an overview

The treatment of heart failure in pregnant women is more difficult than in non-pregnant women, and should always involve a multidisciplinary team approach. Knowledge required includes hemodynamic changes in pregnancy and the resultant effect on women with pre-existing or pregnancy-related cardiovascular disease, cardiovascular drugs in pregnancy, ethical issues and challenges regarding saving mother and baby. In addition, women having high risk cardiac lesions should be counselled strongly against pregnancy and followed up regularly. Pregnancy with heart failure is an important issue, demanding more comprehensive studies.

Moyamoya disease in pregnancy: a case series and review of management options

BACKGROUND

Pregnancy has a potentially deleterious affect on moyamoya disease (MMD), a cerebrovascular condition characterized by spontaneous occlusion of the distal internal carotid arteries resulting in the neoangiogenesis of fragile collateral blood vessels. The disease renders patients susceptible to both hemorrhagic and ischemic stroke.

METHODS

A 16-year (1995-2010) chart review was performed at the Kapi'olani Medical Center for Women and Children and the Queen's Medical Center, the two largest birthing centers in Hawai'i.

RESULTS

The authors report on three women with MMD who had the revascularization surgery prior to their first pregnancy and experienced successful pregnancy outcomes without the MMD symptoms. Two of these were managed with antiplatelet agents, one with calcium channel blockers, and two with magnesium sulphate in the perioperative period.

CONCLUSION

The authors' cases demonstrate different medical therapies, which may be of benefit for MMD with and without revascularization surgery during pregnancy.

[Primary pulmonary hypertension in pregnancy--a case report]

Primary pulmonary arterial hypertension, so called idiopathic pulmonary arterial hypertension (IPAH), is a rare and progressive disease with poor prognosis. Pregnancy in patients with this condition is hazardous and makes the prognosis significantly worse. According to WHO, IPAH is a contraindication to pregnancy because of high risk of maternal death and WHO advises to discuss termination in the event of pregnancy Below we describe a case of a young woman at 16 weeks pregnancy with severe decompensated primary pulmonary hypertension. The patient was admitted to our department because of increasing dyspnoea and swollen legs occurring from 14th week of pregnancy. In the past the patient had been diagnosed with pulmonary hypertension, which had been defined during differential diagnostics as primary pulmonary hypertension. Echocardiographic examination over the last 4 years revealed stable mean pulmonary artery pressure (PAP) of about 50 mmHg. The patient was treated efficiently with sildenafil for the last 2 years, but the therapy was discontinued after finding pregnancy. On admission it was established that pregnancy should be terminated. Other reasons of circulatory decompensation, such as pulmonary embolism, cardiac tamponade or pulmonary diseases, were excluded.

A retrospective survey of adverse maternal and neonatal outcomes for parturients with congenital heart disease

BACKGROUND

Parturients with congenital heart disease are at increased risk of maternal cardiac and neonatal complications. There is a paucity of literature regarding the relationship of complications with the type of anesthesia or mode of delivery.

METHODS

We retrospectively reviewed all parturients with congenital heart disease undergoing delivery over a 7-year period at Tokyo Women's Medical University, Maternal and Perinatal Center to identify maternal cardiac and neonatal complications occurring during the peripartum period.

RESULTS

Of 151 pregnancies in 128 women with congenital heart disease, there were 84 vaginal and 67 cesarean deliveries. Cesarean deliveries were performed with either neuraxial (n=51) or general (n=16) anesthesia. There were no maternal deaths and two neonatal deaths (one vaginal; one cesarean delivery). The incidence of maternal cardiac events was 1 in 84 (1%) for vaginal deliveries and 10 in 67 (15%) for cesarean deliveries. Neonatal complications occurred in 11 of 84 (13%) pregnancies with vaginal delivery and 25 of 67 (37%) pregnancies with cesarean delivery. Twenty-three elective cesarean deliveries occurred for maternal cardiac problems and were associated with a significant incidence of maternal cardiac (35%) and neonatal (65%) complications. The incidence of maternal cardiac events during delivery, when stratified by severity of cardiac disease, was similar to a previously derived cardiac risk index for pregnant women with cardiac disease.

CONCLUSION

Despite a low overall incidence of maternal and neonatal mortality, pregnancy in women with congenital heart disease was associated with significant maternal cardiac and neonatal complications. Elective cesarean delivery with neuraxial anesthesia was a common approach for high-risk parturients with congenital heart disease; however, the benefit of this mode of delivery and anesthetic technique could not be ascertained.

Anaesthetic management of a parturient with moyamoya disease

Moyamoya disease is an uncommon progressive cerebral vasculopathy that is more frequently seen in the Asian population. It has been described sporadically in other parts of the world. Proper knowledge of the pathophysiology and institution of appropriate perioperative measures improves patient prognosis. We report a case of moyamoya disease for emergency Caesarean section at 37 weeks of gestation. Epidural anaesthesia was administered using 0.5 percent bupivacaine and 50 μg fentanyl. A stable haemodynamic state was maintained using left lateral uterine displacement, intravenous crystalloids and ephedrine boluses. The patient suffered no neurological deficit and was discharged with a healthy baby four days after the surgery.

Presentation and therapy of spontaneous coronary artery dissection and comparisons of postpartum versus nonpostpartum cases

Predisposing risk factors, clinical course, and prognosis of spontaneous coronary artery dissection (SCAD) remain poorly understood. We reviewed medical records and coronary angiograms of patients admitted to our institution with the diagnosis of SCAD from 1999 through 2010. A definite diagnosis of SCAD required the agreement of 2 blinded board-certified interventional cardiologists who reviewed all images separately. Baseline characteristics of patients (n = 23) included mean age 45 ± 11 years, female gender in all (100%), history of hypertension in 13 (57%), and postpartum in 7 (30%). Eleven (48%) had ST-segment elevation on initial electrocardiogram. SCAD involved the left main in 5 patients (21.7%), left anterior descending coronary artery in 16 (70%), left circumflex coronary artery in 8 (35%), and right coronary artery in 6 (26%). Four patients (17%) underwent coronary stenting and 6 (26%) required urgent bypass surgery. Comparison between postpartum and nonpostpartum patients revealed significant differences in mean peak troponin levels: 50 ± 34 ng/ml vs 21 ± 23, p = 0.04, mean left ventricular ejection fraction: 34 ± 6% vs 49 ± 9, p <0.01, proximal coronary segment distribution: 6 (86%) vs 3 (19%), p = 0.004, and left anterior descending coronary artery distribution: 7 (100%) vs 9 (56%), p = 0.04, respectively. Repeat coronary angiographies were performed in 11 patients (46%) during a mean follow-up of 39 ± 38 months and 10 (91%) were found to have healed SCAD, including those who had undergone bypass surgery. In conclusion, our patients with SCAD were characterized by female gender, absence of coronary risk factors, and a high rate of vascular healing without residual stenosis. Larger infarct was found in postpartum patients.