mWHO Class I - risks and lesions
2-5 vs 3-10% risk in cardiac event rate
Pregnancy heart team not required
Uncomplicated or mild PS, PDA, MVP
Successfully repaired simple lesions - ASD, VSD, PDA, anomalous PV drainaged
Isolated atrial or ventricular ectopic beats
mWHO Class II - risks and lesions
Small increased risk mortality and moderate increased risk morbidity
6-10% cardiac even rate bow 8-22%
Recommend Cards f/u qtrimester
Unoperated ASD/VSD
Repaired TOF or Coarct
SVT
Turner without cardiac disease
mWHO Class II-III risks and lesions
Cards f/u qtrimester AND pregnancy heart team
Inc risk mortality and mod to severe risk morbidity
11-19 now 13-18% cardiac event rate
Need to deliver in correct center
Mild LV impairement (>45%)
HOCM
Native or bioprosthetic valve not WHO Clas I or IV (ex mild MS, AS)
Marfan WITHOUT dilation
Aortic dilation <45mm in bicupsid
Repaired coarc (non-turner)
AVSD
mWHO Class 3 - risks and lesions
Sifnif increased risk mortality and morbidity
Cards f/u monthly and need specialty teams and delivery in expert center
Cardiac event rate ~27% (now 21-29%)
Examples
Moderate LV impairement (30-45%)
Uncomplicated mechanical valve
Systemic RV with good or mildly decreased ventric function
Uncomplicated Fontan
Unrepaired cyanotic heart disease
Moderate MS
Severe ASYMPTOMATC AS
Marfan 40-45mm
Bicuspid 45-50m
Ventricular tachycardia
mWHO Class 4
Termination or pregnancy heart team and expert center
>27% cardiac event rate now 36-50%
PAH
Systemic RV with dysfunction
Severe ventricular dysfunction (LVEF <30 or NYHA 3-4)
Hx PPCM with residual dysfunction
Severe MS
Severe Symptomatic AS
Marfan >45
Bicupsid >50
Vascular EDS
Fontan with any complication
Warfarin embryopathy
nasal hypoplasia, chondrodysplasia punctata, cardiac malformations, microcephaly, optic atrophy, blindness, deafness, and CNS abnormalities
Rate in T1 2-30% but less with <5mg / day
Compatible with breastfeeding
Warfarin reversal
Heparin reversal
Warfarin - prothrombin complex concentrates and vitamin K
LMWH - protamin sulfate (only partial reversal)
Mechanical valve targets for warfarin and LMWH
Warfarin - INR 2.5 for AV and 3 for MV
LMWH - Trough 0.6, peak AV 0.8-1.2 and 1-1.2 MV
Recommended delivery planning for mechanical heart valve
37-38wks
Warfarin - transition to LMWH at 35 wks, monitor Xa weekly then transition to IV UFH inpatient 48 hours before delivery
LMWH - transition to IV UFH 48 hours before delivery
IVF UFH 12 hours after LMWH at 18u/kg/hr without a loading dose with goal Xa 0.7-1
Utility of BNP and PRoNT BNP
BNP >100 = HF (active)
NT proBNP ?900 = HF (inert)
BNP increase during pregnancy
NT proBNP >128 at 20 weeks independent predictor of adverse cardiac events including HF need for procedure, or arrhythmia
Baseline levels important in women with cardiac disease
For cardiac patients, when would vaginal delivery NOT be default?
Marfan >4-4.5
Eisenmenger
Severe AS
Severe cardiogenic pulmonary edema
*If cant tolerate repeated chances in CO then can offer assisted second stage
All patients may have neuraxial with exceptions:
-Cant tolerate decreased SVR
-Eisengmenger
Severe AS
Swansea criteria for AFLP
6 or more without other explanation
coagulopathy
LFTs
Elevated Bili
Leukocytosis
Abdominal pain
Polydipsia/polyuria
Encephalopathy
Elevated ammonia >47
Hypoglycemia
Elevated urea
Ascites or bright liver
Renal impairment
Microvescular steatosis on biopsy
Definition of HELLP syndrome
LDA>600
Elevated LFTs
Low platelets
15% dont have HTN or proteinuria
90% with RUQ pain or malaise
Reasons for aspirin
At least 1 high risk factor:
- hx PEC
- Twins
- CHTN
- DM
- Rneal or autoimmune disease
- Multiple moderate risks
At least 2 moderate risk factors
- Nullip
- BMI >30
- Relative with PEC
- Black or low income
- AMA
- IVF
- Prior SGA
- >10 yr pregnancy interval
- Prior adverse outcome
Hgih risk factor 8% chance of PEC and decreases risk by 50% and risk of FGR
CHAP trial
Treamtent of mild HTN reduced PEC by 20%, medically indicated preterm birth <35 weeeks by 25% and severe HTN by 20% with NO difference in SGA
Delivery timing for previa
36-37 wks
delivery timing prior classical and risk of rupture
36-37 weeks
Rupture risk is 2%
Counseling on UAE for PPH
Patient needs to be HD stable
Success rates are high >80%
15% require subsequent hyst
<5% chance serious complications such as uterine necrosis, VTE or peripheran lneuropathy
