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2022, Number S5

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Cardiovasc Metab Sci 2022; 33 (S5)

Pregnancy and cardiovascular risk

Lía-Crosa, Verónica1; Aquieri, Analía2; Pineda, Vizmary3; Fernandez, Diana4; Volberg, Verónica5; Rubilar, Bibiana6

Language: English
References: 17
Page: s434-438
PDF size: 205.49 Kb.






INTRODUCTION

Cardiovascular diseases are among the leading causes of maternal death.1 These entities complicate between 0.2 and 4% of pregnancies, and this prevalence is increasing. On the one hand, girls with congenital heart disease reach childbearing age thanks to partial or total surgical correction of the heart disease; on the other hand, assisted fertilization techniques have extended maternal age with older mothers with more significant comorbidities. Finally, the increase in the prevalence of cardiovascular risk factors (CVRFs) in women of any age also operates as an additional factor.2,3 Latin America also adds another scourge, the Chagas-Mazza disease. According to data from the World Health Organization (WHO), 60 million people are at risk of suffering from it,4 and 20-30% of them will develop heart disease. The impact on women is related to heart disease and the additional risk of vertical transmission.



EVALUATION OF THE GLOBAL RISK OF PREGNANT WOMEN WITH HEART DISEASE

The risk of possible complications during pregnancy is related to multiple factors, such as:

  • 1. The type of underlying heart disease
  • 2. Ventricular and valvular function
  • 3. Pre-gestational functional class
  • 4. The presence of cyanosis
  • 5. The presence of CVRFs
  • 6. Obstetric history
  • 7. Maternal age

The risk calculation must be personalized, integrating all the variables.5 The hemodynamic changes of pregnancy, i.e., increased cardiac output and heart rate and decreased vascular resistance, will influence heart disease and may aggravate it.6,7 Sometimes, the diagnosis of maternal heart disease is established during pregnancy because these changes decompensate the underlying disease.

Therefore, the pre-pregnancy consultation is of great value since it allows the estimation of the individual risk, requesting complementary studies, planning the surgical correction, and establishing a multidisciplinary follow-up team.



1. TYPE OF MATERNAL HEART DISEASE

The most widely used current tool to estimate maternal and fetal risk is the modified World Health Organization (WHO) Risk Scale published in 2018 by the WHO8-10 (Table 1). It considers 5 categories, each of which gives a range of risk.



2. EVALUATION OF THE FUNCTIONAL CLASS

Functional class (FC) is an independent risk factor for maternal-fetal mortality. Women in FC I have a mortality of less than 1%, while those in FC IV reach up to 15%. For its part, the fetal risk is 20 to 30% in FC IV, in addition to increased morbidity due to prematurity, low birth weight, spontaneous abortion, and congenital heart disease.

FC can be evaluated with a stress test or the measurement of natriuretic peptides (BNP or NT-proBNP). An NT-proBNP concentration > 128 pg/mL at 20 weeks of gestation predicts late events during pregnancy.11,12



3. CARDIOVASCULAR RISK FACTORS

Pregestational CVRFs increase maternal-fetal risk during pregnancy and for the rest of a woman's life. Furthermore, increasing maternal age is associated with a higher prevalence of CVRFs. The cumulative burden of CVRFs is associated with a higher risk of maternal cardiovascular complications, premature birth, and fetal death. Therefore, in the postpartum period, it is relevant to evaluate all women in the risk category in the puerperium and at 6 to 12 months postpartum. Instructions must be given about lifestyle changes, and implementing treatment of CVRFs has to be done, informing about the implications for a future pregnancy and the increase in CVD risk.13-16



4. THE OBSTETRIC HISTORY

The history of adverse evolution in previous pregnancies confers a higher risk of new events or complications, such as abortion or stillbirth, preeclampsia, gestational diabetes, placental abruption, or peripartum cardiomyopathy. At the other extreme, the absence of complications in previous pregnancies could indicate good tolerance to the stress of pregnancy.



5. MATERNAL AGE

Maternal age is not considered in the scales that assess the risk of cardiovascular complications in patients with heart disease. However, evidence shows that pregnancies in women over 35 are associated with more significant direct obstetric complications. In mothers over 40 years of age, the risk of cardiovascular complications increases markedly by preeclampsia, stroke, and coronary artery dissection.



PRE-PREGNANCY CONSULTATION



PRE-PREGNANCY EVALUATION IN PATIENTS WITH HEART DISEASE ALLOWS:

  • 1. To assess the maternal-fetal risk linked to heart disease.
  • 2. To optimize the pre-gestational conditions of the risk factors.
  • 3. To detect heart disease plausible for surgical correction.
  • 4. To establish the interdisciplinary cardio-obstetrics team.
  • 5. To define the level of complexity of the care center for the mother and the newborn.
  • 6. To perform maternal treatment for Chagas disease.

Contact with the health system in these conditions is an ideal time to recommend lifestyle changes that will impact the mother and the offspring.

Likewise, it allows modifying contraindicated medication during pregnancy, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor antagonists (ARBs), opting for drugs of proven innocuousness.



CHAGAS DISEASE AND PREGNANCY

Given the high prevalence of this entity in Latin America and its growing detection in North America and Europe due to migratory currents, research is imperative to reduce vertical transmission and congenital Chagas4,17 (Table 2).

Most women of childbearing age with positive serology are asymptomatic. In those with heart disease, the entity does not differ from other populations with rhythm disturbances or conduction disorders, dilated cardiomyopathy, ventricular dysfunction, and apical aneurysm with a thromboembolic risk. Neonatal congenital Chagas is usually asymptomatic, and early detection allows a cure rate close to 100%.

The indicated screening will be:

  • 1. In the mother: 2 quantitative reagent tests IIF, ELISA, HAI, or particle agglutination.
  • 2. In children: identify the parasite with micro hematocrit in the newborn and search for antibodies with serological tests from 10 months of life.



FOLLOW-UP DURING PREGNANCY OF THE PATIENT WITH HEART DISEASE

The design of the follow-up and treatment plan will be marked by the type of maternal heart disease and the obstetric and fetal-neonatal conditions, for which the integration of a multidisciplinary team is valuable (Table 3). On the other hand, the level of complexity of the health center where the mother and child are cared for will be assessed, considering adequate neonatology for extremely premature infants.8



TIMING AND MODE OF TERMINATION OF PREGNANCY IN PATIENTS WITH HEART DISEASE

The delivery time will depend on the maternal-fetal conditions trying to reach fetal maturity without putting the mother's life at risk by prolonging the pregnancy. Vaginal delivery is always preferred, resulting in less blood loss and a lower risk of infection and venous thromboembolism. Elective cesarean section is of no benefit to the mother and should be considered when:

  • 1. There is an obstetric indication for fetal distress.
  • 2. In women taking oral anticoagulants.
  • 3. In the presence of heart failure or hemodynamic decompensation.
  • 4. Severe symptomatic aortic or mitral stenosis.
  • 5. Severe forms of pulmonary hypertension.
  • 6. Bicuspid aortic valve with an aortic root greater than 45 mm in diameter.
  • 7. Marfan syndrome with an aortic root greater than 40 mm in diameter.



CONCLUSIONS

Pregnancy in women with heart disease challenges the treating team. It requires an individualized evaluation and interdisciplinary follow-up that, in the ideal scenario, should begin in the pre-gestational stage. In addition, pregnancy provides a valuable opportunity to indicate lifestyle modifications that will impact maternal and offspring cardiovascular health (Figure 1).


REFERENCES

  1. Slomski A. Why do hundreds of US women die annually in childbirth? JAMA 2019; 321 (13): 1239-1241.

  2. Donati S, Maraschini A, Dell'Oro S, Lega I, D'Aloja P. The way to move beyond the numbers: the lesson learnt from the Italian obstetric surveillance system. Ann Ist Super Sanita. 2019; 55 (4): 363-370.

  3. Lima FV, Yang J, Xu J, Stergiopoulos K. National trends and in-hospital outcomes in pregnant women with heart disease in the United States. Am J Cardiol. 2017; 119 (10): 1694-1700.

  4. World Health Organization. Available in: https://www.who.int/es/news-room/fact-sheets/detail/chagas-disease-(american-trypanosomiasis 27/4/2019.

  5. Kampman MA, Valente MA, van Melle JP, Balci A, Roos-Hesselink JW, Mulder BJ et al. Cardiac adaption during pregnancy in women with congenital heart disease and healthy women. Heart. 2016; 102: 1302-1308.

  6. Cornette J, Ruys TP, Rossi A, Rizopoulos D, Takkenberg JJ, Karamermer Y et al. Hemodynamic adaptation to pregnancy in women with structural heart disease. Int J Cardiol. 2013; 168: 825-831.

  7. Roos-Hesselink JW, Budts W, Walker F, De Backer JFA, Swan L, Stones W et al. Organisation of care for pregnancy in patients with congenital heart disease. Heart. 2017; 103: 1854-1859.

  8. Damman K, Valente MA, Voors AA, O´Connor CM, Van Veldhuisen DJ, Hillege HL. Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis. Eur Heart J. 2014; 35 (7): 455-469.

  9. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367: 1066-1074.

  10. Pijuan-Domènech A, Galian L, Goya M, Casellas M, Merced C, Ferreira-Gonzalez I et al. Cardiac complications during pregnancy are better predicted with the modified who risk score. Int J Cardiol. 2015; 195: 149-154.

  11. Tanous D, Siu SC, Mason J, Greutmann M, Wald RM, Parker JD et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol. 2010; 56: 1247-1253.

  12. Kampman MA, Balci A, van Veldhuisen DJ, van Dijk AP, Roos-Hesselink JW, Sollie-Szarynska KM et al. N-terminal pro-b-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease. Eur Heart J. 2014; 35: 708-715.

  13. Del Sueldo MA, Mendonca RMA, Sánchez-Zambrano MB, Zilberman J, Múnera-Echeverri AG, Paniagua M et al. Guía de práctica clínica de la Sociedad Interamericana de Cardiología sobre prevención primaria de enfermedad cardiovascular en la mujer. Arch Cardiol Méx. 2022; 92 (Supl. 2): 1-68.

  14. Wang MC, Freaney PM, Perak AM, Allen NB, Greenland P, Grobman WA et al. Association of pre-pregnancy cardiovascular risk factor burden with adverse maternal and offspring outcomes. Eur J Prev Cardiol. 2022; 29: e156-e158.

  15. Liu H, Huang TT, Lin JH. Risk factors and risk index of cardiac events in pregnant women with heart disease. Chin Med J (Engl). 2012; 125: 3410-3415.

  16. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstrom-Lundqvist C, Cífková R, De Bonis M et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018; 39 (34): 3165-3241.

  17. Benassi MD, Avayú DH, Tomasella MP, Valera ED, Pesce R, Lynch S, et al. Consenso enfermedad de Chagas 2019. Rev Argent Cardiol. 2020; 88 (Supl. 8): 1-74.



AFFILIATIONS

1 Director. Cardio Obstetrics Course, Sociedad Argentina de Cardiología (SAC), Heart and Woman Area Member.

2 Director. Consensus on cardiovascular disease in pregnant women SAC, Heart and Woman Area Member.

3 Internist and cardiologist of the Obstetrics and Gynecology Center, Sociedad Dominicana de Cardiología.

4 Dekegate, SOBOCAR del Consejo Mujer, SIAC 2021-2022.

5 Advisor Heart and Woman Area SAC, Delegate, Women Council, SIAC 2019-2022.

6 Director. Heart and Woman Area, SAC 2020-2022.



CORRESPONDENCE

Verónica Lía Crosa. E-mail: veritocrosa@gmail.com


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