///SOAP 2019 Maternal Cardiac Disease Delivery Planning Algorithm/Framework
SOAP 2019 Maternal Cardiac Disease Delivery Planning Algorithm/Framework2019-04-18T14:22:44-06:00

SOAP 2019 Maternal Cardiac Disease Delivery Planning Algorithm/Framework

Marie-Louise Meng, MD, Richard Smiley MD, PhD, Katherine Arendt, MDs

1.      WHO:

a.      PATIENT:

                                                              i.      Risk Stratify: Identify maternal cardiac lesion and severity of disease

1.      Modified WHO scale (mWHO II-III, III, IV consider transfer to referral hospital)1

2.      CARPREG II Risk score (CARPREG >1 consider transfer to referral hospital)2

                                                             ii.      Early Assessment and Management

1.      Evaluate maternal function and pregnancy-related changes NYHA classes I-IV, symptoms: ask about climbing stairs and for examples of usual physical activity.

a.      Identify baseline function: Pre-pregnancy function

b.      Identify changes in function: Function in each trimester (particularly at 26-30 weeks)

c.       Assess current symptoms

2.      Gather additional (baseline) data at antepartum visit

a.      BNP, ECG, TTE

b.      Elevated BNP levels are associated with cardiac events, NT- proBNP >128 pg/mL at 20 weeks pregnancy is predictive of cardiac events later in the pregnancy.1

c.       Exercise test

d.      ECG:

                                                                                                                                      i.      Leftward heart rotation 15–20° with leftward axis deviation.

                                                                                                                                     ii.      Transient ST/T wave changes

                                                                                                                                   iii.      Lead III: Q wave and inverted T waves

                                                                                                                                   iv.      aVF: attenuated Q wave

                                                                                                                                     v.      V1-3: inverted T wave

                                                                                                                                   vi.      LV hypertrophy pattern may be seen

                                                                                                                                 vii.      Holter monitoring for patients with paroxysmal or persistent arrhythmias such as ventricular tachycardia, atrial fibrillation or atrial flutter or in patients who experience palpitations.

e.      TTE: some changes in size and function parameters may be normal but all changes from baseline should be assessed with a cardiologist

f.        If aortic pathology exists consider complete aortic imaging by computed tomography (CT) scanning or magnetic resonance imaging (MRI)

3.       Optimize early anticoagulation for:

a.      Mechanical valves

b.      Low ejection fraction

c.       Pulmonary hypertension

d.      Arrhythmias  

4.      Optimize cardiac function medically or surgically depending on specific lesions, consult cardiologists1,3,4

5.      Assess and address non-cardiac medical issues

a.      Medical history

b.      Surgical history

c.       Obstetric history (fetal concerns)

d.      Current medications

e.      Allergies

f.        Social history/support (services needed to help patient to follow regimen)

 

b.      TEAM: (severity of lesion will determine need for additional team members – italicized specialties are optional)

                                                              i.      Obstetrician/Maternal Fetal Medicine

                                                             ii.      Anesthesiologist (Obstetric and Cardiothoracic)

                                                           iii.      Cardiologist

                                                           iv.      Neonatologist

                                                             v.      Hematologist

                                                           vi.      Cardiothoracic surgeon

                                                         vii.      ECMO surgeon

                                                       viii.      Perfusionist

                                                           ix.      Intensivist

                                                             x.      Critical Care Obstetric Nurse

                                                           xi.      Critical Care Nurse

 

2.      WHAT:

a.      Route of delivery per obstetrician:

                                                              i.      Vaginal delivery: preferred mode of delivery for majority of women with heart disease unless maternal or fetal instability is present or highly likely

1.    Active phase of the second stage may be delayed for 1-2h to allow maximal descent of the fetal head, as to shorten the active phase of the second stage: While a prolonged second state followed by instrumented delivery can increase bleeding risk, some obstetricians may choose to prolong the passive second stage to promote a shortened active stage during which the patient does bare down, but only a few effective pushes are required to deliver the fetus: .1

2.    Assisted delivery: forceps or a vacuum may be performed further reduce maternal effort, as indicated by the underlying cardiac lesion.1

                                                             ii.      Potential cesarean delivery indications:1

1.      Maternal or fetal instability:

a.      Acute decompensated heart failure (severe right heart failure or LVEF<25%, failing Fontan, oxygen saturation <85%, severe peripartum cardiomyopathy)

b.      Pulmonary hypertensive crisis (controversial in severe pulmonary hypertension or Eisenmenger’s in absence of “crisis”) 

c.       Severe, symptomatic aortic stenosis

d.      Maternal intolerance to labor

e.      Fetal intolerance to labor

2.      Current anticoagulation precluding neuraxial anesthesia or vaginal delivery (fetal coagulopathy, maternal warfarin,  and risk of intracerebral hemorrhage)

3.      Aortopathy1: significant aortic dilation (should not perform repeated valsalva maneuver)

a.      Marfan’s Syndrome: >40mm

b.      Bicuspid aortic valve: >45mm

c.       Turner: Aortic size index >20mm/m2

                                                           iii.      Elective termination (considered in women with mWHO Class IV disease)

b.      Contraception plan:

                                                              i.      Tubal ligation

                                                             ii.      Intrauterine device

                                                           iii.      Oral

                                                           iv.      Partner sterilization

 

  1. WHEN: The goal is to deliver the fetus as close to term as possible but pre-term deliveries may be indicated for fetal or maternal instability or for obstetric indications.

TARGET DELIVERY DATE (gestational weeks/days):_________

 

  1. WHERE:
    1. Type of medical center:

                                                              i.      Local

                                                             ii.      Referral hospital (maternal or fetal indication (neonatal ICU))

    1. Location within medical center: consider severity of maternal illness, need and availability of monitoring, need for cardiothoracic surgeon/surgery and/or ECMO

                                                              i.      Labor and delivery suite labor room (may need ICU nursing support or training)

                                                             ii.      Labor and delivery suite operating room (elective CS)

                                                           iii.      Cardiothoracic operating room

                                                           iv.      Intensive care unit (may need OB nursing and OB anesthesia support)

    1. Transfer plan:

                                                              i.      Identify accepting center and physicians

                                                             ii.      Identify transport team

                                                           iii.      Communicate current patient status to transport team and accepting medical center

                                                           iv.      Seek and provide follow up and debriefing

 

  1. HOW: Peripartum plan
    1. Hemodynamic goals: Identify the lesion-specific hemodynamic goals and create a plan for maintaining hemodynamic stability

                                                              i.      Potential medications needed: phenylephrine, norepinephrine, vasopressin, dobutamine, dopamine, milrinone, epinephrine, anti-pulmonary hypertensives, oxygen

    1. Peripartum risks: Identify the peripartum risks associated with this patient’s disease(s) and create a plan for mitigating risks, and (if possible) how (and who)  to respond if the “risk event” occurs.
    2. Delivery plan:

                                                              i.      Anesthesia:

1.      Neuraxial anesthesia:

a.      relative contraindications: current anticoagulation, respiratory failure

2.      General anesthesia

                                                             ii.      Monitoring:

1.      Blood pressure: non-invasive or arterial line

2.      Telemetry in labor: Yes/No

3.      Central venous pressure: Yes/No

4.      Pulmonary artery catheter: Yes/No

5.      Transthoracic echocardiogram: Yes/No

6.      Transesophageal echocardiogram (requires sedation or general anesthesia): Yes/No

                                                           iii.      Access:

1.      Venous: peripheral or central (consider central venous access if central venous pressure monitoring is desired, or use of inotropes or vasopressors is anticipated)

2.      ECMO: back-up, place wires, place sheaths, place cannulas

a.      Veno-venous ECMO: respiratory failure

b.      Veno-arterial ECMO: cardiac failure with or without respiratory failure

                                                           iv.      Antibiotic prophylaxis

                                                             v.      Management of anticoagulation/thromboprophylaxis:

1.      When to stop

2.      When to re-start

                                                           vi.      Emergency plan: Who is on the care team if an urgent (unscheduled) delivery is necessary?

    1. Hemorrhage prevention/management:

                                                              i.      Uterotonics:

1.      Oxytocin: intravenous infusion 15-30 units/hour preferred over bolus, treat accompanying vasodilation with vasopressor, coronary vasospasm is rare

2.      Methergine: relative contraindication in hypertensive disorders

3.      Hemabate: relative contraindication in pulmonary disease

4.      Misoprostol: no contraindications

                                                             ii.      Procedures:

1.      B-lynch suture

2.      Bakri balloon

3.      Uterine artery embolization

4.      Hysterectomy

                                                           iii.      Blood products:

1.      pRBC

2.      Fresh frozen plasma

3.      Cryoprecipitate

4.      Platelets (caution in pulmonary hypertensive crisis)

    1. Post care:

                                                              i.      Recovery location:

1.      Intensive care unit

2.      High risk maternal unit

3.      Post-partum unit

                                                             ii.      Monitoring and plan for continuation, removal or addition

1.      Blood pressure: non-invasive or arterial line

2.      Telemetry: Yes/No

3.      Central venous pressure: Yes/No

4.      Pulmonary artery catheter: Yes/No

5.      Transthoracic echocardiogram: Yes/No

6.      Transesophageal echocardiogram: Yes/No

                                                           iii.      Treatment goals: most common post-partum issues are arrhythmia and heart failure

1.      Diuresis

2.      Venous thromboembolism prophylaxis

3.      Stool softening for prevention of Valsalva

4.      Diet: Sodium restriction as needed

                                                           iv.      Subspecialty follow up

 

 

 

References:

 

1.           Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165-3241.

2.           Silversides CK, Grewal J, Mason J, et al. Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. J Am Coll Cardiol. 2018;71(21):2419-2430.

3.           Elkayam U, Goland S, Pieper PG, Silverside CK. High-Risk Cardiac Disease in Pregnancy: Part I. J Am Coll Cardiol. 2016;68(4):396-410.

4.           Elkayam U, Goland S, Pieper PG, Silversides CK. High-Risk Cardiac Disease in Pregnancy: Part II. J Am Coll Cardiol. 2016;68(5):502-516.

 

   

NYHA Class

Severity

Symptoms

I

Mild

No limitation of physical activity.

II

Mild

Slight limitation of physical activity. Patient is comfortable at rest. Ordinary physical activity results in fatigue, palpitation (rapid or pounding heartbeat, dyspnea, (shortness of breath) or anginal pain (chest pain).

III

Moderate

Marked limitation of physical activity. Patient is comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

IV

Severe

Patient is unable to do any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.