Cardio-obstetrics: What the

obstetrician needs to know

Fernando Aguirre-Amezquita, MD
3rd year MFM Fellow
Disclosures
None
DEEP DIVE INTO THE COLD WATERS
OF CARDIO-OBSTETRICS
Objectives
● Review maternal mortality and morbidity related to cardiovascular disease and
current efforts to reduce its impact.
● Overview of risk assessment and stratification of cardiac disease in pregnancy.

● Discuss the key points of antepartum, intrapartum and postpartum management

of pregnancy in patients with cardiovascular disease.
 Maternal Mortality and Morbidity
In the U.S. maternal mortality is increasing and is higher that other developed countries
(17.4/ 100,000 live births 2018).

- 658 women die each year due to pregnancy complications.

Cardiovascular disease is the leading cause of maternal deaths in the U.S.

Significant racial and ethnic disparities exist affecting mainly mothers of non-hispanic
black race and of Native American background.

-Rates are 2-4 times higher than whites or Asian

National Vital Statistics. National Center for Health Statistics 1999-2017

Cardiovascular disease in pregnancy
26.5% of maternal deaths are related to cardiovascular disease.

-15.5 % pre-existing cardiovascular conditions

-11 % cardiomyopathy

Hypertensive disorders of pregnancy are linked to 7.4% of pregnancy related death.

Advances in medicine have improved the lifespan of patients allowing women to reach
reproductive age.
What have we learned
from MMRCs?
Maternal Mortality Review Committees (MMRC) have been established to review
maternal mortality cases.

Conclusion of these committees include:

● 3 out of 5 maternal deaths are preventable.

● Delays in recognition of symptoms by providers.

● Late presentation for evaluation due to lack of access to care.

The California Success Story

California has achieved the lowest maternal mortality rate in the U.S. of about 7.3
/100,000 live births.

California Maternal Quality Care Collaborative (CMQCC) has developed safety bundles
and Tool kits.

A review of the Cardiovascular disease Toolkit Algorithms show these could detect up to
88% of high risk patients requiring cardiac evaluation.
www.CMQCC.org
Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. California
Department of Public Health, 2017 https://www.cmqcc.org/resources-toolkits/toolkits/improving-
health-care-response-cardiovascular-diseasepregnancy.
Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. California Department of Public Health, 2017
https://www.cmqcc.org/resources-toolkits/toolkits/improving-health-care-response-cardiovascular-diseasepregnancy.
What considerations are important in the care of
cardiovascular disease in pregnancy?

Preconception counseling, risk assessment, multidisciplinary management with

delivery at an experience center are crucial to optimize outcomes.
The Pregnancy Heart Team.
Specialized, multidisciplinary team determined by
the severity of maternal condition and anticipated
risk:
● Cardiologist
● Maternal fetal medicine
● Obstetric care provider
● Cardiothoracic surgery
● Cardiac Anesthesiology
● Obstetric Anesthesiology
● Hematologist
● Genetic Counseling services
● Labor and Delivery RNs and Staff
Where should patients with cardiac disease be delivered?

To determine the best location for delivery.
● Risk assessment and anticipated needs. (ei
need for ICU, ECMO)
● Logistical nuances. (ei. Location of L&D
from other services)
● Staffing (ei specialized RNs, Cardiac
anesthesiologist 24/7).
Patient with high-risk cardiac conditions (mWHO
III-IV) should deliver at an institution with Level 4
Capabilities :
● Cardiology and Cardiothoracic Surgery
● Cardiac ICU with ECMO availability.
● Cardiac monitoring and capabilities for labor
and delivery.

● Special Cardiac L&D suite.

What considerations are important during prenatal care?

Maternal assessments Fetal assessments:

● Close prenatal care and assessment of ● Serial fetal growth

cardiac symptoms ● +/- Fetal echocardiography (ei.left sided
● Echocardiography or other cardiac lesions)
● Antenatal surveillance.
testing
● Labor and Delivery planning and
Anesthesia consultation.
 Important factors when
estimating risks:

Can we predict maternal ● Primary cardiac defect

● Genetic conditions
risk in patients with ● History of surgical intervention
known cardiac disease ? ●
●
Medications
Comorbidities
● Residual sequelae from lesions
● Social factors (ie, Access to care,
geographical distance, compliance)
Risk Prediction Models in Pregnancy
Goal beign to decrease subjectivity and
improve reproducibility and
communication.
These models are not perfect and have
limitations (ie. Population studied).
Cardiac event prediction models have raised
the concern for risk-overestimation.
Current Risk Predictions Models :
● NYHA Classification (functional
status/symptoms)
● CARPREG I (4 indicators, no lesions
specific)
● ZAHARA (studied in CHD patients)
● Modified WHO (included all lesions)
● CARPREG II (included, physical exam
social factors)
Which is best risk prediction models?
The modified WHO classification has
been validated and had a more accurate risk
prediction than other models. (Balci et al.
2014)

It is simple and widely used.

Categories:

● I (low risk)
● II, II-III (intermediate risk)
● III (high risk)
● IV (extremely high risk)
Practice Bulletine No 212 Pregnancy and Heart Disease. ACOG.
Jan 2020.
CARPREG II
CARPREG II model was published in 2018.
(Silversides et al. 2018 )

This model includes patient history, physical

exam, medications and access to care and quality
of care.

Compared with CARPREG, ZAHARA-I, and

mWHO, the CARPREG II risk score not only had
the highest discriminative accuracy. It was the
only risk classification system that had good
calibrative accuracy.
When is pregnancy contraindicated?
Pregnancy is contraindicated in patients with
extremely high-risk cardiac conditions
(mWHO IV or >4 points CARPREG II)

>27% risk of a cardiac event and extremely

high risk of maternal M&M.

● Severe cardiac dysfunction

● Severe left heart obstruction
● Pulmonary Hypertension
● Severe aortopathy with high risk for
dissection.
 ● Use the most comprehensive
risk prediction model that best
integrates your patient’s risk
factors and historical and clinical
information.
In conclusion... ● Compare risk assessment
between prediction models
● Use clinical judgement
● Involve cardiology or other
disciplines in the decision making.
Labor and
Delivery
How does labor and delivery affect heart disease?

Practice Bulletin No 212 Pregnancy and Heart Disease. ACOG. Jan

2020.
 Preload: How much
blood fills the ventricles.
Affected by VR,
compliance, atrial
contraction, HR.
Right sided lesions:
Are generally well
tolerated. Careful with
preload, risk of Right HF.
Aortic stenosis: Preload
dependent with fixed-CO. Avoid
hypotension related tachycardia.
Mitral valve stenosis:
↑↑↑ risk for pulmonary
edema and atrial
arrhythmias
Avoid tachycardia and
fluid overload.
Afterload: Resistance
or workload, usually
SVR
What preparations are needed for labor and delivery?

● Coordinated multidisciplinary care meeting including L&D, +/- Cardiac ICU team
(RNs, staff, OR) where:
● Delivery plan with location specifics.
● Obstetric Anesthesia plan in place.
● Cardiac monitoring specifications during labor, delivery and postpartum.
● Management of Anticoagulation
● Check lists
Labor and delivery considerations
● Delivery location: Cardiac ICU or in a
cardiac L&D unit, with immediate access
to ECMO or cardiothoracic surgery
procedural areas.
● Five-lead ECG telemetry (history of
tachyarrhythmias, ischemic heart disease,
aortic stenosis, hypertrophic
cardiomyopathy)

● Pulse-oximeter with visible waveform and

audible alarms.

● Strict monitoring of I & O

Labor and delivery considerations
● Arterial line: consider in patients at
risk of rapid decompensation with
hypotension. (ei. Severe aortic stenosis,
severe left ventricular dysfunction or
pulmonary HTN.
● Code cart :Team should ACLS trained
and be familiar with Defibrillator
settings.
● Emergency cesarean section tray in
case of the need for perimortem cesarean
section.
● Antibiotic prophylaxis ( Patient with a
particular increase risk for Infective
endocarditis with vaginal delivery)
Obstetric Anesthesia in Cardiac Disease
Labor pain triggers a catecholamine response
that causes cardiac stress.

Neuroaxial analgesia is the preferred method

in the cardiac patient.

● Epidural, Spinal and CSE are generally

safe but use should be individualized.

General anesthesia is rarely indicated

(pulmonary hypertension with right HF, severe
Left sided lesions, obstetric emergencies or
recently anticoagulated)
 Neuroaxial Blockade
Neuroaxial anesthesia causes
sympathectomy.
Autonomic Innervation
Use of vasopressors, volume and patient ↓Sympathetic
positioning can improve these changes. ↑ Parasympathetic

Sympathectomy occurs faster with spinal Vasodilation

anesthesia.

Patients with Pulmonary HTN, severe Left

outflow tract obstruction (Aortic
Venous
Coarctation, stenosis) will not tolerate Arterial
sympathectomy, need close monitoring.
↓ Venous Return ↓ SVR
↓Preload ↑↑ Reflex
↓Cardiac Output Tachycardia
Summary of Obstetric Anesthesia Considerations

● Individualize the anesthetic approach, not routine

● Consider early epidural placement to block pain response.
● Be judicious of pre-epidural fluid bolus ( avoid in pts at risk of pulmonary edema)
● Avoid post-epidural hypotension (slow rate infusion and prompt use of vasopressors)
● Avoid suboptimal pain control.
● Consider dense neuraxial block in the second stage of labor.
● General anesthesia is usually reserve for cases of emergency or if neuroaxial
anesthesia is contraindicated (ei. recent anticoagulation, certain cardiac lesions).
General management of anticoagulation
Discontinue prophylactic LMWH 12 hours before
procedure.

Discontinue adjusted dose LMWH 24 hours

before procedure.

For women on trimester adjusted UFH

prophylactic dosing (7500-10,000 BID)
discontinue at least 12 hours before procedure.

**Consider aPTT and anti Factor Xa level on

admission.
Anticoagulation in patients at high risk of thrombotic
events

Patients with mechanical valve prosthesis, atrial fibrillation, recurrent VTE are at
significant risk of thrombotic in pregnancy and need consistent anticoagulation.

Patients with mechanical valves are anticoagulated with warfarin during pregnancy.

Discontinue Warfarin 5 days prior to procedure and transitioned to LMWH 3 days

before, a Heparin Drip can be considered for induction of labor.
Cesarean Section or Vaginal Delivery?

● The current rate of cesarean section is high, and 33% is for cardiac indications.
● There are no RCTs and most of the data come from retrospective and prospective
cohort studies.
○ Large international multicenter registries have shown no clear benefit of planned cesarean section
vs vaginal delivery.
○ A single center US prospective cohort study (Easter et al,2020) including women with a variety of
cardiovascular disease found similar cardiac adverse outcomes and decreased rates of obstetrical
morbidity with vaginal delivery.
● These data should be use with caution but considered in cases where a clear
indication for cesarean does not exist.
What about passive second stage?

A passive second stage is accomplished by

operative vaginal delivery in order to
minimize valsalva effort.

Usually recommended in cases of severe or

symptomatic valvular disease or those with
intermediate risk aortopathy.
Understanding Valsalva

Phase I : ↑intrathoracic
pressure = ↑↑Ao pressure Phase II ↓↓Ao pressure
↓↓ HR ↑↑HR

Phase III/IV : Release of

intrathoracic pressure. ↓Ao
pressure ↑HR
Then normalization.

↓↓Venous return
↓ Preload
What are the risk and benefits of passive second stage?

Benefits: Remains unclear who can tolerate a trial of valsalva and who needs assisted vaginal delivery.

● Among planned vaginal deliveries 86% were successful with a 9.5% requiring operative delivery of
these, 4/5 patients tolerated Valsalva 15-75 mins ( Eastern et al. 2020).

Risks: Remain unclear and poorly studied in this population.

● Higher rates of Postpartum hemorrhage and 3rd and 4th degree lacerations. (Ouyang et al. 2010)

Often delayed pushing is necessary to allow appropriate station for operative delivery.

○ Cahill et al. showed an increase risk of chorioamnionitis and higher postpartum hemorrhage rates
with delayed pushing ( healthy, nulliparous).
In summary…
Mode of delivery should be individualized and determined with the input of the Pregnancy Heart
team.

Most women with stable cardiac disease can undergo planned vaginal delivery with a Trial of
valsalva and few benefit from a passive 2 nd stage.

A planned cesarean section should be considered in patients with very high-risk cardiac conditions
that may not tolerate the fluctuations of cardiac output or valsalva efforts. ( ei. Marfan Syndrome
with Ao dilation >4cm)

Consider other factors that can increase the risk of an adverse outcome (ei anticoagulation, prior
obstetric history, macrosomia, nulliparity)
Managing postpartum hemorrhage
Drug Cardiopulmonary effects Notes

Oxytocin ↓ MAP Most effective uterotonic

Slight ↑PAP Administer cautiously and slowly not bolus
Consider IU or IM admin in patient with volume overload.

Methergine Can cause severe HTN and Avoid in cardiac patients

coronary vasospasm and ↑ PVR

Carboprost ↑↑↑PAP, can cause Avoid in PHTN or Right heart-lesions or failure.

(Hemabate) bronchospasm.

Misoprostol Rare cardiac events Weak uterotonic. Can use prophylactically.

Tranexamic Acid Decreases fibrinolysis Unknown risks of thrombosis. Use with caution.
Postpartum period: The 4th Trimester
Women with cardiac disease are at high risk of immediate complications during the early
postpartum period and up to the first 12 months.

● Cardiac disease is particularly linked to late maternal death as long as 1 year

postpartum.
● Peripartum cardiomyopathy is the leading (23%)of late postpartum death.
● Acute coronary syndromes and Aortic Dissection occur during the early
postpartum.

Patients with cardiac disease or cardiovascular risk must be followed closely in the
postpartum period (ei 1 week, 2 weeks and 4 weeks).
References
● Practice Bulletin No 212. Pregnancy and Heart Disease. ACOG 2019
● A. Hameed, D. Wolfe. Cardio-obstetrics: A practical guide to care for pregnant patients. First edition. 2020 Taylor and
Francis Group.
● C.Gorman, C.Errando. Neuroaxial anaesthesia in obstetrical patients with Cardiac Disease. Current opinion in
Anaesthesiology 2005 18:507-512.
● Ouyang David et al.. Obstetric outcomes in pregnant women with congenital heart disease. International Journal of
Cardiology 144 (2010) 195-199.
● Afshan B. Hameed, Christine H. Morton, and Allana Moore. Improving Health Care Response to Cardiovascular
Disease in Pregnancy and Postpartum. California Department of Public Health, Maternal, Child and Adolescent Health
Division. 2017. Available https://www.cmqcc.org/resources-toolkits.
● Easter Sarah R et al. Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease.
Am J Obstet Gynecol. 2020 January ; 222(1): 77.e1–77.e11
● Oktay Tutarel Mode of delivery for pregnant women with heart disease. Heart. , 2015, Vol.101(7), p.504-505
● Titia P E Ruys et al. Is a planned caesarean section in women with cardiac disease beneficial?. Heart. , 2015,
Vol.101(7), p.530-536
Thank you!
QUESTIONS ?

Managing the
Heparin Drip
During labor and delivery
transitioning to a UFH Drip is often
needed to minimize the time
without anticoagulation coverage
● Consult Hematology and
Notify Anesthesia
● Obtain CBC, PT/INR and
●
aPTT
Follow institutional Heparin
Drip protocol
● UFH Drip should be stopped
4-6 hours prior to placement
of neuroaxial anesthesia. A
normal PTT should be verified
● UFH should can be re-started
as soon as 1 hour after
epidural catheter placement.
● FFP, Vitamin K and
Protamine sulfate can fully
reverse heparin effects.
Noncongenital Valvular Disease
Rheumatologic valvular disease, mitral valve prolapse, valve disease related to
endocarditis.

In general the risk is highest with left sided stenotic lesions and lowest with right sided
regurgitant lesions.

Ideally symptomatic valve disease should be treated before pregnancy

Labor and delivery: Close monitoring of fluid volume status and prompt management of
neuroaxial anesthesia related sympathectomy is key.

-Aortic stenosis is preload dependent run them wet, Mitral stenosis is increases risk of
pulmonary edema run them dry.
Pulmonary artery hypertension
Defined as an mean Pulmonary arterial pressure of more than 25 mmHg

Echocardiogram can overestimate PAP and Right heart catheterization is the gold standard
for diagnosis

Risk of Maternal Mortality 9-28%. Severe PA HTN is a contraindicated in pregnancy

Managed with prostacyclin infusions

Labor and delivery: Abrupt hypotension can cause decompensation and a slow infusion of
epidural is recommended.

Avoid Carboprost H
What is the utility of BNP and NT-proBNP
Brain natriuretic peptide and N-Terminal probrain natriuretic peptide levels

BNP levels increase two-fold during pregnancy with a further increase early after delivery,
but values remain within normal range.

BNP level >100pg/ml, NT pro BNP >450 pg/ml

Levels are elevated with:

-Heart failure from left ventricular systolic and diastolic dysfunction

-Hypertensive including preeclampsia

What tests are appropriate to evaluate heart disease

Echocardiogram

EKG

Chest X-Ray

Holter Monitoring

Exercise stress test

CT Angiogram: Iodinated contrast Overall safe in pregnancy and lactation,

Cardiac MRI and MRI: Gadolium is generally contraindicated and should only used in cases where it
may improve diagnostic performance.