Management of high risk cardiac conditions in pregnancy: Anticoagulation, severe stenotic valvular disease and cardiomyopathy

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Successful pregnancy with left ventricular assist device failure in the setting of peripartum cardiomyopathy

Pregnancy is contraindicated for women with left ventricular dysfunction due to high maternal and fetal mortality. We present a case of a pregnant 31-year-old woman with a history of heart failure due to peripartum cardiomyopathy from a previous pregnancy. She had a left ventricular assist device (LVAD) and was on warfarin due to recurrent thrombosis of her device. During her course, she had multiple cardiac complications, including thrombosis of the LVAD, which required deactivation. At 32 weeks, a cesarean section was performed due to acute decompensation, and a transthoracic echocardiogram revealed a left ventricular ejection fraction of 30% to 34%, a dilated left ventricle, and moderate global hypokinesis. This case highlights the need for coordinated care from cardiologists and maternal-fetal medicine specialists to minimize symptoms to obtain ideal outcomes for mother and infant despite LVAD deactivation.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Pregnancy in the FONTAN palliation: physiology, management and new insights from bioengineering

Fontan palliation for the single ventricle results in a challenging and delicate physiological state. At rest, the body adapts to a low cardiac output and high systemic venous pressure. However, when physiological demands increase, such as in the case of exercise or pregnancy, this delicate physiology struggles to adapt due to the inability of the heart to pump blood into the lungs and the consequent lack of augmentation of the cardiac output.

Due to the advances in paediatric cardiology, surgery and intensive care, today most patients born with congenital heart disease reach adulthood. Consequently, many women with a Fontan circulation are becoming pregnant and so far data suggest that, although maternal risk is not high, the outcomes are poor for the foetus. Little is known about the reasons for this disparity and how the Fontan circulation adapts to the physiological demands of pregnancy.

Here we review current knowledge about pregnancy in Fontan patients and explore the potential role of computational modelling as a means of better understanding this complex physiology in order to potentially improve outcomes, particularly for the foetus.

Cardiac and obstetric outcomes in pregnant patients with heart disease: a retrospective cohort study

BACKGROUND

Cardiac diseases complicate 4% of pregnancies, with a mortality rate between 0 and 15%. Early referral has shown to reduce the risk of maternal major cardiac events (MACEs).

METHODS

We retrospectively analyzed a cohort of pregnant women with heart disease from two referral centers in Mexico City. We examined MACEs: maternal death, pulmonary edema, acute heart failure, endocarditis, stroke, myocardial infarction, acute aortic syndromes, arrhythmias requiring urgent treatment, and the need for an urgent intervention; preterm birth and obstetric events such as HELLP syndrome, preeclampsia, eclampsia, placental abruption, obstetric hemorrhage. We analyzed the association between each modified World Health Organization (mWHO) group and MACEs, preterm birth and obstetric outcomes between March 2014 and March 2019.

RESULTS

Using the mWHO classification, 399 deliveries were included and stratified as follows: I, 162; II, 133; II-III, 21; III, 18; and IV, 52 patients. MACEs were observed in 12.5% of the cohort and were associated with mWHO II (odds ratio [OR], 3.0; 95% confidence interval [95% CI], 1.1-8.1; p = 0.027), II-III (OR, 3.3; 95% CI, 0.9-1.0; p = 0.116), III (OR, 5.3; 95% CI, 1.2-23; p = 0.026), and IV (OR, 8.2; 95% CI, 2.7-24.5; p < 0.001) after adjusting for age, desaturation, previous functional class, and gestational age at referral. An association between mWHO and frequency of preterm birth was observed. Association between mWHO and obstetric events, even when adjusted, was not observed.

CONCLUSIONS

The prevalence of MACEs and preterm birth is similar to that seen worldwide; MACEs and preterm birth are associated with the severity of heart disease stratified by mWHO, but there is no association between the severity of heart disease and obstetric events.

The effect of yoga on uterine artery Doppler indices, maternal and fetal complications in pregnant women: A quasi-experimental study

BACKGROUND

Today, the effect of yoga has been examined on various physical and psychological dimensions of pregnant women. However, there are still sparse studies on the effect of yoga on the uterine artery indices as well as maternal and fetal complications.

OBJECTIVE

The aim was to determine the effect of yoga on uterine artery Doppler indices, maternal and fetal Complications.

MATERIALS AND METHODS

This quasi-experiential study was conducted, on 100 pregnant women. The participants were assigned to yoga and control groups. In the yoga group, the participants exercised yoga for 1 h. On the other hand, the control group received routine care.

RESULTS

The results showed that in the yoga group, the functional indices of the uterine artery (S/D, PI, RI, and DN) improved more significantly compared to the control (p = 0.01). The results also showed that in the yoga group, maternal complications (diabetes and preeclampsia), as well as fetal complications (SAG, IUGR), were significantly lower compared to the control (p = 0.01).

CONCLUSION

This study revealed the positive effects of yoga on improving fetal development indices and reducing maternal and fetal complications following pregnancy. It can be used as a Complementary therapy alongside other treatments for mothers.

Changes in ET-1, Plasma Neuropeptide Y, and CGRP in Child Patients With Congenital Heart Disease Complicated With Pulmonary Hypertension Before and After Operation

This study aims to explore the changes in endothelin-1 (ET-1), plasma neuropeptide Y, and calcitonin gene-related peptide (CGRP) in child patients before and after operation. A total of 80 child patients with congenital heart disease (CHD) complicated with pulmonary hypertension (PH) were enrolled and divided into control group (n = 40, conservative treatment for various reasons) and observation group (n = 40, active preoperative preparation and timely operative intervention) according to different treatments. There were positive correlations between systolic pulmonary arterial pressure (sPAP) and ET-1, plasma neuropeptide Y, while negative correlation between sPAP and CGRP. In conclusion, our data demonstrate that the levels of ET-1, plasma neuropeptide Y, and CGRP in PH-CHD were significantly changed after interventions, which provides new leads as alternative biomarkers to assess the efficacy of treatments against PH-CHD.

Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy

Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).