Maternal valvular heart disease in pregnancy

Maternal mortality due to valvular heart disease: a population-based study in Turkey

BACKGROUND/AIM

To assess the clinical and demographic features of maternal mortality cases among patients with cardiac valvular diseases between 2012 and 2019.

METHODS

Maternal mortality due to valvular heart disease between January 2012 and December 2019 in Turkey was retrospectively analyzed. The cases were classified according to New York Heart Association (NYHA) classification based on the severity of the heart disease. NYHA classification groups were divided into two; as class I-II (n = 34) and class III-IV (n = 31). Two groups were compared in terms of demographic and clinical characteristics.

RESULTS

Valvular heart disease was diagnosed in 41 (63.1%) of the cases before pregnancy. It was found that 100% (n = 21) of the warfarin users had switched to low molecular weight heparin treatment due to concerns about warfarin embryopathy after the diagnosis of pregnancy, and only 14.2% (n = 3) of them had been monitorized with Antifactor Xa activity to evaluate the effectiveness of the medication. Two NYHA groups had similar clinical characteristics. Intensive care unit admission rate, frequency of prosthetic valve, rate of thromboprophylaxis, type of valvular disease and reasons of maternal death were similar between the NYHA groups (p < 0.05).

CONCLUSION

Maternal mortality may be observed in cases with NYHA class I-II in almost similar rates with NYHA class III-IV. Therefore, it is crucial to adequately assess the mortality risk of pregnant women with cardiac valvular pathologies and to achieve early diagnosis and appropriate treatment in order to reduce maternal mortality.

The Pattern of Valvular Heart Diseases in India During Pregnancy and Its Outcomes

INTRODUCTION

The incidence of rheumatic heart disease is very high in India. The data on the pattern of valvular heart diseases during pregnancy and its outcomes is very scarce. Again, the data in the Indian scenario, the differences in outcomes between different grades of valvular heart diseases and its impact on pregnancy outcomes is very less. We planned to study the different patterns of valvular heart diseases during pregnancy and their outcomes with respect to cardiac complication and perinatal outcomes.

MATERIALS AND METHODS

It was a hospital-based prospective observational study. We recruited 71 patients after taking written informed consent. All patients were with term gestation and valvular heart diseases. We did 2D echocardiography to analyze the valve lesion and assess the valve lesion with its maternal and perinatal outcomes.

RESULTS

The mean age of participants in the study was 27 + 5.2 years. A total of 54 patients (76.1%) were less than 30 years and 17 (23.9%) were more than 30 years of age. Six patients (8.5%) presented with New York Heart Association (NYHA) class I, 39 patients (54.9%) presented with NYHA class II, 25 patients (35.2%) presented with NYHA class III and one patient (1.4%) presented with NYHA class IV. The most common etiology of valvular heart diseases was found to be rheumatic in 62 patients (87.3%). The most common valve involved was the mitral valve (69%). New-onset atrial fibrillation (AF) was reported in 26.8% patients and pulmonary edema developed in 15.5% patients. Live birth was observed in 66 patients (93%) compared to stillbirth reported in five patients (7%).

CONCLUSION

No significant difference in maternal and perinatal outcomes between moderate and severe grades of different valvular heart diseases.

The Use of Echocardiography and Advanced Cardiac Ultrasonography During Pregnancy

PURPOSE OF REVIEW

Pregnancy is a time of significant cardiovascular change. Echocardiography is the primary imaging modality used to assess cardiovascular anatomy and physiology during pregnancy. Both two-dimensional (2D) echocardiography and advanced cardiac ultrasound modalities play pivotal roles in identifying and monitoring these changes, especially in women with preexisting or new cardiac disease. This paper reviews the role of echocardiography and advanced cardiac ultrasound during normal pregnancy and pregnancy complicated by hypertensive disorders, valvular disorders, and cardiomyopathy. It also examines the role of echocardiography in guiding decisions about delivery.

RECENT FINDINGS

The data establishing normal echo parameters during pregnancy are inconsistent. In addition, there is limited research exploring the role of advanced cardiac ultrasound modalities, such as tissue Doppler imaging or speckle tracking echocardiography, in assessing cardiac function during pregnancy. What data there are suggest that these advanced modalities can be used to identify subclinical changes before traditional echocardiography can, and thus have clear utility in identifying early abnormal cardiac responses to pregnancy. Echocardiography is the modality of choice for imaging the heart in pregnant women. Advanced ultrasound modalities increasingly play a role in identifying abnormal adaptations to pregnancy and detecting subclinical changes. This, in turn, can help promote a healthy pregnancy for both mother and fetus.

No longer rare diseases and obstetric anesthesia

PURPOSE OF REVIEW

With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist.

RECENT FINDINGS

With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances.

SUMMARY

Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.

Mitral Valve Prolapse in Pregnancy

Mitral valve prolapse is a benign condition. Mitral regurgitation is only complicated in patients with severe mitral valve prolapse. Women with mitral valve prolapse in the absence of other cardiovascular disorders tolerate pregnancy well and do not develop remarkable cardiac complications. Nevertheless, serious complications of mitral valve prolapse, including arrhythmia, infective endocarditis and cerebral ischemic events, can be present in pregnancy. Debates remain with regard to the use of prophylactic antibiotics and β-blockers in the pregnant women with mitral valve prolapse. The prognosis of the pregnant patients might be closely related to the pathological and (or) functional changes of the mitral valve. Non-myxomatous mitral valve prolapse poses no or little obstetric risks in terms of pregnancy, labor and neonatal complications; whereas myxomatous mitral valve prolapse is a major etiology of valvular heart disease in women of childbearing age. In the pregnant patients with mitral valve prolapse progressing into major complications, surgical interventions are considered. Medicinal treatment of such patients with β-blockers should be a concern for the fetal safety.

Percutaneous mitral commisurotomy during pregnancy - A report of two cases performed in a United Kingdom tertiary centre and a review of the literature

We report two cases of severe mitral stenosis where percutaneous mitral commisurotomy was performed within pregnancy. The first case involves an emergency procedure for a new diagnosis of severe mitral stenosis in a woman presenting with pulmonary oedema at 27 weeks' gestation. The second case is of a woman known to have mitral stenosis who underwent a semi-elective procedure for deterioration in symptoms. This procedure is not commonly performed in the United Kingdom because of low incidence of rheumatic heart disease. In addition, percutaneous mitral commisurotomy during pregnancy is rarely performed in the United Kingdom because of the improved healthcare system where majority of the women with moderate to severe mitral stenosis (even asymptomatic) will undergo planned interventions (percutaneous mitral commisurotomy or mitral valve surgery) before contemplating pregnancy. These cases highlight both the acute and chronic presentations of mitral stenosis and the impact pregnancy has on this condition. In addition, these cases show the importance of retaining skills in performing percutaneous mitral commisurotomy within our United Kingdom cardiologists.

Valve disease in pregnancy

Maternal cardiac disease is a major cause of non-obstetric morbidity and accounts for 10-25% of maternal mortality. Valvular heart disease may result from congenital abnormalities or acquired lesions, some of which may involve more than one valve. Maternal and fetal risks in pregnant patients with valve disease vary according to the type and severity of the valve lesion along with resulting abnormalities of functional capacity, left ventricular function, and pulmonary artery pressure. Certain high-risk conditions are considered contraindications to pregnancy, while others may be successfully managed with observation, medications, and, in refractory cases, surgical intervention. Communication between the patient׳s obstetrician, maternal-fetal medicine specialist, obstetrical anesthesiologist, and cardiologist is critical in managing a pregnancy with underlying maternal cardiac disease. The management of the various types of valve diseases in pregnancy will be reviewed here, along with a discussion of related complications including mechanical prosthetic valves and infective endocarditis.

Multidisciplinary management of pregnancy in complex congenital heart disease: a model for coordination of care

With advancements in medical care, many women with complex congenital heart disease (CHD) are now living into adulthood and childbearing years. The strains of pregnancy and parturition can be dangerous in such patients, and careful interdisciplinary plans must be made to optimize maternal and fetal health through this process. Several large studies have been published regarding risk prediction and medical management of pregnancy in complex CHD, though few case studies detailing clinical care plans have been published. The objective of this report is to describe the process of developing a detailed pregnancy and delivery care plan for three women with complex CHD, including perspectives from the multidisciplinary specialists involved in the process. This article demonstrates that collaboration between specialists in the fields of cardiology, anesthesiology, high-risk obstetrics, maternal fetal medicine, and neonatology results in clinically successful individualized treatment plans for the management of pregnancy in complex CHD. Multidisciplinary collaboration is a crucial element in the management of pregnancy in complex CHD. We provide a template used in three cases which can serve as a model for the design of future care plans.

Pregnancy outcomes in women with mitral valve prolapse and mitral valve regurgitation

PURPOSE

To examine pregnancy and perinatal outcomes in patients with mitral valve disorders [mitral valve prolapse and/or mitral regurgitation; mitral valve disorders (MVD)].

METHODS

A retrospective comparative study was conducted comparing all singleton deliveries, during the years 1988-2010, of women with and without known MVD. Women lacking prenatal care were excluded. Stratified analysis using logistic regression was performed to control for confounds.

RESULTS

Out of 233,194 singleton deliveries that occurred during the study period, 390 deliveries occurred in women with MVD. Using a multivariate analysis, advanced maternal age (OR = 1.06; 95 % CI 1.05-1.08; P < 0.001), recurrent abortions (OR = 1.62; 95 % CI 1.15-2.28; P = 0.005), hypertensive disorders (OR = 1.62; 95 % CI 1.17-2.26; P = 0.004) and Jewish ethnicity (OR = 2.21; 95 % CI 1.76-2.79; P < 0.001) were found to be significantly associated with MVD. Since cesarean sections (CS) were significantly higher in deliveries of patients with MVD (17.9 vs. 14 %; P = 0.025), another multivariate analysis was constructed, with CS as the outcome variable. MVD was not found to be an independent risk factor for CS (OR = 1.05; 95 % CI 0.79-1.37; P = 0.74).

CONCLUSIONS

MVD associated with advanced maternal age, recurrent abortions, Jewish ethnicity and hypertensive disorders were not found to be an independent risk factor for CS.