Despite significant improvements in survival and quality of life of patients with congenital heart defects and other heart disease is not recommended for women with certain risk diseases pregnancy; this includes:
Heart diseases account for approximately 10% of obstetric maternal deaths. in the United States since the incidence of rheumatic heart disease has declined significantly, most heart problems occur during pregnancy due to congenital heart defects. But in Southeast Asia, Africa, India, the Middle East and parts of Australia and New Zealand rheumatic heart disease still occur frequently. Despite significant improvements in survival and quality of life of patients with congenital heart defects and other heart disease is not recommended for women with certain risk diseases pregnancy; This information can include: Pulmonary hypertension Eisenmenger syndrome coarctation, which was not treated or is associated with an aneurysm Marfan syndrome with a diameter of the aortic root of> 4.5 cm Severe symptomatic aortic stenosis, a single ventricle and impaired systolic function (treated or not treated according to the Fontan procedure) Preceding postpartum cardiomyopathy pathophysiology pregnancy stresses the heart and circulatory system and often worsens a known heart disease; a slight heart disease may be evident during pregnancy. Diminished by the decreased hemoglobin (Hb) and the increase in blood volume, stroke volume, and finally the pulse rate affect. Cardiac output increases from 30 to 50%. These changes are greatest between the 28th and 34th week of pregnancy. During childbirth, the cardiac output increases with each contraction by 20%; other charges are the strong pressing during the second stage of labor and the increase in venous blood, which is contracting uterus returns from the heart. Only a few weeks after delivery, the cardiovascular-loads not reach the pregnancy rates. Symptoms and complaints During normal pregnancy or as a result of heart disease typically occur clinical signs similar to those of heart failure (eg. As slight dyspnea, systolic murmur, Jugularvenenstauung, tachycardia, edema in the dependent parts, slight cardiomegaly in the chest x-ray -Aufnahme- heart failure). Diastolic or presystolic noises are specific for a heart defect. Heart failure sometimes causes premature labor and arrhythmias. The risk of maternal or fetal death correlated with the function-related classification of New York Heart Association (NYHA) that occur the amount of physical activity in the symptoms of heart failure, is the foundation. The risk is not increased when the symptoms not under load (Class I) occur only at higher load (Class II) the risk is increased if the symptoms occur under light load (Class III) under minimal exertion or even at rest ( NYHA class IV) occur (class IV) diagnosis Clinical evaluation Usually echocardiography The diagnosis is made clinically and by echocardiography. Since a genetic predisposition to heart disease is women should genetic counseling and fetal echocardiography are offered with congenital heart defects. Treatment avoidance of warfarin, ACE inhibitors, aldosterone antagonists, thiazide diuretics and certain antiarrhythmics (eg. As amiodarone) In NYHA class III or IV avoiding heavy load and possibly bed rest after the 20th week Most other treatments for heart failure and arrhythmias Common pregnancy tests, adequate rest, avoid heavy weight gain and general pollution and the treatment of anemia are absolutely necessary. An anesthesiologist who is familiar with heart disease in pregnancy should be present at birth and are ideally already consulted prenatally. During childbirth pain and anxiety must be effectively treated to minimize the occurrence of tachycardia. Immediately after birth, the women are closely monitored, and the monitoring will continue for several weeks after birth by a cardiologist. Before a woman with a disease in NYHA Class III or IV becomes pregnant, the disease should be medically treated optimally and, if necessary, by a surgical procedure (eg. As in causal cardiac valve disorders) therapy. Pregnant women with heart failure class IV need to be advised to leave early to perform a therapeutic abortion. Some women with heart failure and poor heart function may need from 20 weeks digoxin 0.25 mg p.o. 1 time / day plus bed rest. Although, cardiac glycosides (eg. digoxin, digitoxin) cross the placenta newborns (and children) but are relatively resistant to their toxicity. ACE inhibitors are contraindicated, since they can cause damage to the fetal kidneys. Aldosterone antagonist (spironolactone, eplerenone) should be avoided as they can cause feminization of a male fetus. Other regimens of heart failure (eg. As non-thiazide diuretics, nitrates, positive inotropic agents) may, depending on the severity of the disease and risk to the fetus during pregnancy will continue as it has been set by the cardiologist and perinatologist. Arrhythmias Atrial fibrillation can accompany a cardiomyopathy or valve disorders. Similar to non-pregnant patients, the frequency control is carried out with ?-blockers, calcium channel blockers or digoxin (antiarrhythmic). Certain antiarrhythmic drugs (eg. As amiodarone) should be avoided. In pregnant patients with new-onset atrial fibrillation or hemodynamic instability or uncontrollable drug ventricular rate to restore sinus rhythm cardioversion may be required. Since the relative hypercoagulable increases the likelihood of atrial thrombi (and subsequent systemic or pulmonary embolism) during pregnancy, anticoagulants are often required. It is used standard or low molecular weight heparin. Neither standard heparin, low molecular weight heparins cross the placenta, but low molecular weight heparins may have a lower risk of fetal thrombocytopenia. Warfarin crosses the placenta and can, especially during the first trimester, lead to fetal abnormalities (see Table: Some drugs with adverse effects during pregnancy). However, the risk is dose dependent, and the incidence is very low at a dose of ? 5 mg per day. The use of warfarin during the last months of pregnancy is associated with risks. A quick lifting of the anticoagulant effect of warfarin can be difficult, but is due to fetal or neonatal intracranial haemorrhage due to birth trauma or due to maternal hemorrhage (eg., By injury or emergency caesarean section) is required. The treatment of acute supraventricular or ventricular tachycardia is the same as for non-pregnant patients (Supraventricular reentrant tachycardias and Professional.heading on page Ventricular Tachycardia: treatment) .Endokarditis prophylaxis for pregnant patients with a structural heart disease are indications and applications of endocarditis prophylaxis in the case of non obstetric events identical to those of non-pregnant patients (Infectious endocarditis: prevention). The guidelines of the American Heart Association in 2008 recommended no endocarditis prophylaxis and no Caesarean section because the Bakteriämierate is low. In high risk patients (eg., Those having prosthetic heart materials endocarditis a history of an untreated congenital cyanotic Herzläsion or heart transplantation with valvulopathy), however, often considered a prevention into account when rupture of membranes, even if there is no evidence of a benefit. If patients with structural heart disease chorioamnionitis or other infection (eg. As pyelonephritis) requiring hospitalization, develop, antibiotics should be given active against the most common pathogens in endocarditis. Summary Pregnancy is possible (for women with certain high-risk heart disease z. B. pulmonary hypertension, Eisenmenger syndrome, untreated or with an aneurysm associated coarctation, Marfan syndrome with a diameter of the aortic root of> 4.5 cm, severe symptomatic aortic stenosis , a single ventricle with impaired systolic function, previous postpartum cardiomyopathy, heart failure NYHA class III or IV) is not advisable. Heart failure and arrhythmias as well as in non-pregnant patients treated during pregnancy, except that certain drugs (e.g., as warfarin, ACE inhibitors, aldosterone antagonists, thiazide diuretics, certain antiarrhythmic agents such as amiodarone) are avoided. Most pregnant patients with atrial fibrillation are treated with standard or low molecular weight heparin. The indications for endocarditis prophylaxis in pregnant patients with structural heart disease are the same as in other patients. Valvular insufficiency and in pregnancy stenosis and regurgitation (insufficiency) concern during pregnancy most common mitral and aortic valve. Mitral stenosis is the most common valve disease during pregnancy. Pregnancy increases the noise of a mitral and aortic stenosis, but reduces the mitral and aortic regurgitation a. During pregnancy, a slight mitral or aortic regurgitation can usually tolerate well. Stenosis is more difficult to tolerate and creates conditions for maternal and fetal complications. Mitral stenosis is particularly dangerous; Tachycardia, increased blood volume and increased cardiac output cause with this disease a rapid rise in pulmonary capillary pressure and ultimately pulmonary edema. Often Atrial fibrillation occurs. Treating mitral stenosis, prevention of tachycardia, treatment of pulmonary edema and atrial fibrillation, and sometimes valvulotomy In aortic stenosis, surgical correction before pregnancy if possible, ideally be diagnosed before becoming pregnant and medically treated cardiac valve disorders; in case of serious diseases surgical correction is often necessary. In some situations, prophylactic antibiotics are required (heart disease in pregnancy: endocarditis prophylaxis) .Mitralstenose The patients must be carefully monitored during pregnancy, as mitral stenosis can develop rapidly into a threatening disease. If necessary, a valvulotomy in pregnancy can be carried out safely, but increases one open-heart surgery, the risk to the fetus. Tachycardia should be prevented so that the diastolic flow can be maximized through the stenotic mitral valve. If there is a pulmonary edema, loop diuretics can be used. Anticoagulation for atrial fibrillation and monitoring of heart rate (heart disease during pregnancy: arrhythmia) is required. During childbirth is mostly a nerve block (eg. As slow epidural infusion) bevorzugt.Aortenstenose A aortic stenosis should be treated if possible before pregnancy, because surgical repair during pregnancy has more risks and a Kathetervalvuloplastie is not very effective. During the birth of a local anesthetic is given preference if necessary but is also performed under general anesthesia. A block anesthesia should be avoided as it causes a decreased filling pressure (preload), which is already reduced by the aortic anyway. The pressing during the second stage of labor, which can reduce the filling pressures suddenly and affect cardiac output should be prevented; it is preferred surgical vaginal delivery. A caesarean section is carried out at obstetric indication (Caesarean section). Other heart disease in pregnancy mitral valve prolapse This disease is more common in young women and often run in families on. The mitral valve prolapse is normally an independent anomaly, but cause mitral regurgitation to some extent, or can occur when accompanied by a Marfan syndrome or an atrial septal defect. Women with mitral valve prolapse tolerate pregnancy generally good. The relative increase in ventricular size in a normal pregnancy reduces the difference between the disproportionately large mitral valve and the ventricle. ?-blockers are indicated for recurrent arrhythmias. Rarely thrombus and systemic emboli develop and demand an anticoagulant Therapie.Kongenitale heart disease for most asymptomatic patients, the risk does not increase during pregnancy. However, patients are with Eisenmenger syndrome (rare these days), primary pulmonary hypertension or possibly sole pulmonary unknown reasons prone to sudden cardiac death during childbirth, during the postpartum period (6 weeks after delivery) or after a miscarriage> 20th SSW. Therefore be advised to avoid pregnancy. but when these patients become pregnant, they are taking birth closely monitored with a pulmonary artery catheter and an arterial line. In patients with intracardiac shunts the goal, a right-left shunt by maintaining the peripheral and minimizing the pulmonary vascular resistance must be prevented. In patients with Marfan syndrome is an increased risk during pregnancy suffering aortic dissection or rupture of an aortic aneurysm. Bed rest, ?-blockers, avoid Valsalva-Press printing tests and echocardiographic determination of the aortic diameter are erforderlich.Peripartale Cardiomyopathy Congestive heart failure with no apparent cause (z. B. MI, heart valve changes) can in patients without previous heart disease in the time between the last few months develop pregnancy and 5 months post partum. Risk factors include multiparity age ? 30 years multiple pregnancy preeclampsia The 5-year mortality rate is 50%. The risk of recurrence for subsequent pregnancies is high, especially for patients with residual cardiac dysfunction. therefore it is not recommended further pregnancies. The treatment corresponds to that of heart failure (treatment). ACE inhibitors and aldosterone are relatively contraindicated, but can be used if the expected benefits outweigh the potential risks significantly.