2018 esc guidelines for the management of cardiovascular ... disea… · pre-pregnancy risk...

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC).

Endorsed by: the International Society of Gender medicine (IGM), the German Institute of Gender in Medicine (DGesGM), the European Society of Anaesthesiology (ESA), and the European Society of Gynecology (ESG). Authors/Task Force Members: Vera Regitz-Zagrosek (Chairperson) (Germany), Jolien W. Roos-Hesselink (Co-Chairperson) (The Netherlands), Johann Bauersachs (Germany), Carina Blomström-Lundqvist (Sweden), Renata Cífková (Czech Republic), Michele De Bonis (Italy), Bernard Iung (France), Mark R. Johnson (UK), Ulrich Kintscher (Germany), Peter Kranke (Germany), Irene Marthe Lang (Austria), Joao Morais (Portugal), Petronella G. Pieper (The Netherlands), Patrizia Presbitero (Italy), Susanna Price (UK), Giuseppe M. C. Rosano (UK/Italy), Ute Seeland (Germany), Tommaso Simoncini (Italy), Lorna Swan (UK), Carole Warnes (USA).

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340

www.escardio.org/guidelines

http://www.escardio.org/guidelines

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www.escardio.org/gui delines 2018 ESC Guidelines for the managem European Heart Journal

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Pregnant women with heart disease:

INCREASED RISK of complications

Hypercoagulative state Increase plasma volume / CO 40-50%

Decrease SVR / PVR

Human albumin



Pregnant women with heart disease:

INCREASED RISK of complications

Recommendations Class Level

Pre-pregnancy risk assessment and counselling is indicated in all women with known or suspected congenital or acquired cardiovascular and aortic disease.

I C

Risk assessment and counselling:

- informed decision-making

- timely changes in medication

- planning of care during pregnancy (place, time) www.escardio.org/guidelines



Risk assessment:

When

Who mother, baby

Type and magnitude of risk

mother: cardiovascular complications

obstetric complications

risk of fertility treatment

baby: genetic, early birth, growth,

drugs, death

Heart failure Arrhythmias

TE complications

What is new?



Risk assessment:

When

What is new?




Risk assessment:

When wish to become pregnant: full risk assessment




Pre-pregnancy

Indications for intervention (surgical or catheter) do not differ in women who consider pregnancy compared with other patients. There are a few exceptions, such as severe aortic dilatation and severe asymptomatic mitral stenosis.

Recommendations Class Level

9 2018 ESC Guidelines for the management of cardiovascular

diseases during pregnancy European Heart Journal (2018)

00, 1–83- doi:10.1093/eurheartj/ehy 340


Pre-pregnancy risk assessment and counselling is indicated in all women with known or suspected congenital or acquired cardiovascular and aortic disease.

I C

It is recommended to perform risk assessment in all women with cardiac diseases of childbearing age and after conception, using the mWHO classification of maternal risk.

I C

It is recommended that high-risk patients are treated in specialized centres by a multidisciplinary pregnancy heart team.

I C

It is recommended that the valve prosthesis for a woman contemplating pregnancy is chosen in consultation with a pregnancy heart team.

I C


Pre-pregnancy counseling





Maternal risk of complications during pregnancy

Possible irreversible effects of pregnancy on the maternal cardiac condition

Fetal risk (miscarriage, birth weight, small for gestational age)

Medication use

Genetic aspects

Longterm prognosis of the mother


Pregnancy heart team





Minimum

Cardiologist

Obstetrician / gynaecologist

Anesthetist

When necessary

Cardiothoracic surgeon

Hematologist

Internal medicine

……


Risk assessment:

What is the mWHO classification or maternal cardiovascular risk

- expert system that integrates disease-specifi

information and other predictors of risk

- adapted from WHO classification

for the use of contraceptives Thorne et al, Heart 2016



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2018 ESC Guidelines for the management of cardiovascular European Heart Journal (2018) 00, 1–83- doi:

diseases during pregnancy 10.1093/eurheartj/ehy 340

rg/guidelines www.escardio.o

Risk assessment: Why mWHO classification?

ROPAC 0.73

Hagen EJHF 2016





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diseases during pregnancy oi:10.1093/eurheartj/ehy 340

www. escardio.org/guidelines 2018 ESC Guidelines for the management of cardiovascular European Heart Journal (2018) 00, 1–83- d

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Contraindication for pregnancy (mWHO 4)

T he following p atients shoul d be counsell n ed against preg ancy:

u

‒ Fontan op arrhythmi

‒ pulmonar ‒ severe sys ‒ severe (re ‒ systemic r

eration and a as, or valve re y arterial hype temic ventric -)coarctation ight ventricle

ditional co gurgitation) rtension lar dysfuncti

with modera e

orbidities (vent

on (EF <30% or

te or severely d

ricular dysfunctio

NYHA class III–IV)

creased ventricu

n,

lar function ‒ severe aortic dilatation or (history of) aortic dissection ‒ severe MS (even when asymptomatic) ‒ patients with severe AS who are symptomatic, or asymptomatic patients with

impaired LV function or a pathological exercise test ‒ if LVEF does not normalize in women with previous PPCM

Marfan





Bicuspid LoeysDietz Turner aortic valve

Vascular Ehlers-Danlos

become pregnant

Advise not to Ascending aorta >45 mm (or >40 mm in family history of dissection or sudden death)

aorta >50 mm

dAscending mAscending aorta >45 mm (or >40mm in family history of dissection or sudden death)

ASI >25 mm/m2 All patients


www.escardio.org/guidelines 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340

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Cardiovascular event rate in large series

Counselling

Care during pregnancy

Minimal follow up visits during pregnancy

www.escardio.org/guidelinesCare during delivery 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340







2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

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Counselling



wwwC.aesrcearddiuo.roirng/ggudideelliinveesry European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340



































What is new?




Pregnancy Heart Team

cardiologist

obstetrician anesthetist

geneticist CT surgeon

pediatric cardiologist

neonatologist

nurse specialist

hematologist

pulmonary specialist




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Counselling



wwwC.aesrcearddiuo.roirng/ggudideelliinveesry 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340




































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comprehensive but not

complete

ALLWAYS consult the disease-specific sections

for more information



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Not just disease-based



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find extra information in the

disease-specific sections

table with risk predictors


uidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340

ww.escardio.org/guidelines 2018 ESC G w

Table 4 Predictors of maternal cardiovascular events

24

Predictors of maternal cardiovascular events

Prior cardiac event (heart failure, transient ischaemic attack, stroke, arrhythmia)

Pulmonary arterial hypertension

NYHA class III/IV Cardiac medication before pregnancy

Left heart obstruction (moderate to severe) Cyanosis (O2 <90%)

Reduced systemic ventricular systolic function (ejection fraction <40%)

Natriuretic peptide levels (NT-proBNP >128 pg/mL at 20 weeks predictive of event later in pregnancy)

Reduced subpulmonary ventricular function (TAPSE <16 mm)

Smoking history

Systemic atrioventricular valve regurgitation (moderate to severe)

Mechanical valve prosthesis

Pulmonary atrioventricular valve regurgitation (moderate to severe)

Repaired or unrepaired cyanotic heart disease






predictor of neonatal events

increased risk of neonatal events on top of already increased risk due to maternal heart disease


uidelines for the management of cardiovascular diseases during pregnancy European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340

ww.escardio.org/guidelines 2018 ESC G 26

Predictors of maternal cardiovascular events Pulmonary arterial hypertension

Cardiac medication before pregnancy

Cyanosis (O2 <90%)

Natriuretic peptide levels (NT-proBNP >128 pg/mL at 20 weeks predictive of event later in pregnancy)

Smoking history



Prior cardiac event (heart failure, transient ischaemic attack, stroke, arrhythmia)

NYHA class III/IV

Left heart obstruction (moderate to severe)

Reduced systemic ventricular systolic function (ejection fraction <40%)

Reduced subpulmonary ventricular function (TAPSE <16 mm)

Systemic atrioventricular valve regurgitation (moderate to severe)

Pulmonary atrioventricular valve w regurgitation (moderate to severe)





Predictors of maternal and neonatal events






Predictors of neonatal events

Pulmonary atrioventricular valve regurgitation (moderate to severe) Pulmonary arterial hypertension Cardiac medication before pregnancy Cyanosis (O2 <90%) 29,49

Natriuretic peptide levels (NT-proBNP >128 pg/mL at 20 weeks predictive of event later in pregnancy) Smoking history




Maternal cardiac event during pregnancy

Maternal decline in cardiac output during pregnancy

Abnormal uteroplacental Doppler flow







All women with congenital or other possibly genetic heart disease should be offered foetal echocardiography in weeks 19-22 of pregnancy.

Echocardiography is recommended in any pregnant patient with known cardiac

disease (20 weeks) or with unexplained or new cardiovascular signs or symptoms.

A delivery plan should be made between 20-30 weeks of pregnancy detailing

induction, management of labour, delivery, and post-partum surveillance.

When anticoagulation is indicated: Low molecular weight heparin should only

be used when weekly monitoring of anti-Xa levels is available.







All women with congenital or other possibly genetic heart disease should be offered foetal echocardiography in weeks 19-22 of pregnancy.

Echocardiography is recommended in any pregnant patient with known cardiac

disease (20 weeks) or with unexplained or new cardiovascular signs or symptoms. CMR when echo does not provides good images.

A delivery plan should be made between 20-30 weeks of pregnancy detailing

induction, management of labour, delivery, and post-partum surveillance.

When anticoagulation is indicated: Low molecular weight heparin should only

be used when weekly monitoring of anti-Xa levels is available.


lla C

Management of native valvular heart disease

Mitral stenosis

In patients with symptoms or pulmonary hypertension, restricted activities and beta-1-selective blockers are recommended.

I B

Diuretics are recommended when congestive symptoms persist despite beta-blockers.

l B

Intervention is recommended before pregnancy in patients with MS and valve area <1.0 cm2.

l C

Therapeutic anticoagulation using heparins or VKA is recommended in case of atrial fibrillation, left atrial thrombosis, or prior embolism.

l C

Aortic stenosis

Intervention is recommended before pregnancy in patients with severe aortic stenosis if:

• they are symptomatic l B

• OR LV dysfunction (LVEF <50%) is present l C

• OR when they develop symptoms during exercise testing l C 34 2018 ESC Guidelines for the

management of cardiovascular diseases during pregnancy

European Heart Journal (2018) 00, 1–83-

doi:10.1093/eurheartj/ehy 340



Management of native valvular heart disease





Aortic stenosis

Intervention is recommended before pregnancy in patients with severe aortic stenosis if:

• they are symptomatic l B

• OR LV dysfunction (LVEF <50%) is present l C

• OR when they develop symptoms during exercise testing l C


Mechanical valve

ROPAC registry: valve thrombosis 4.7%, 20% mortality, UK study: 9% of pregnant women with mechanical valve died

favourable outcome only in 28% of women with mech valve

www.escardio.org/guidelineswww.escardio.org/guidelines 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy 27 European Heart Journal (2018) 00, 1–83- doi:10.1093/eurheartj/ehy 340

Van Hagen Circ 2015

Vause BJOG 2017





Flowchart on anticoagulation in mechanical valves and high-dose VKA

Woman with mechanical valve and HIGH dose VKA (wafarin >5 mg/day or phenprocoumon >3 mg/day or acenocoumarol >2 mg/day)

who contemplates pregnancy: Pre-pregnancy counselling – Continue VKA antagonist until pregnant

PREGNANT

In-hospital change to i.v. UFH (aPTT ≥2x control) (l) or in-hospital change to LMWH 2-daily or continue LMWH, close monitoring b (l)

i.v. UFH (aPTT ≥2x control) (l)

Stop UFH 4-6 hours before delivery and restart 4-6 hours after delivery if no bleeding

Continue VKA, monitor INR at least 2-weekly (llb)

Continue VKA, monitor INR at least 2-weekly (lla)

Continue LMWH 2-daily close monitoring (llb)°

In-hospital change from LMWH/UFH to VKA (lIa).

When on target INR monitor INR at least 2-weekly

1st trim.

2nd/3rd

trim.

36 weeks

36 hrs before planned delivery

Delivery

In-hospital change OR to i.v. UFH aPTT ≥2x control OR

(lla)a

In-hospital change to LMWH 2-daily, close monitoring (lla)a, b






Flowchart on anticoagulation in mechanical valves and low-dose VKA

Woman with mechanical valve and LOW dose VKA (wafarin <5 mg/day or phenprocoumon <3 mg/day or acenocoumarol <2 mg/day)

who contemplates pregnancy: Pre-pregnancy counselling – Continue VKA antagonist until pregnant

PREGNANT

In-hospital change to i.v. UFH (aPTT ≥2x control) (l) or in-hospital change to LMWH 2-daily or continue LMWH, close monitoring b (l)

i.v. UFH (aPTT ≥2x control) (l)

Stop UFH 4-6 hours before delivery and restart 4-6 hours after delivery if no bleeding

Continue VKA, monitor INR at least 2-weekly (lla)

In-hospital change to LMWH 2-daily, monitoring (llb)a,b

Continue VKA, monitor INR at least 2-weekly (l)

In-hospital change from UFH to VKA (l).


In-hospital change from LMWH to VKA (l).


1st trim.

2nd/3rd

trim.

36 weeks

36 hrs before planned delivery

Delivery

OR In-hospital change to i.v.

OR UFH (aPTT ≥2x control) (llb)b






Delivery





Induction of labour should be considered at 40 weeks of gestation in all women with cardiac disease.

Vaginal delivery is the first choice for the majority of patients.

Indications for caesarean section are:

‒pre-term labour in patients on OACs,

‒aggressive aortic pathology,

‒acute intractable HF,

‒ severe forms of PH (including Eisenmenger’s syndrome).

Endocarditis prophylaxis is not recommended

Postpartum period needs attention.


General recommendations –Delivery, Termination, reproductive therapy - Essential messages





Induction of labour should be considered at 40 weeks of gestation in all women with CVD.

Vaginal delivery is the first choice for the majority of patients.

Indications for caesarean section are:

‒ pre-term labour in patients on OACs,

‒ aggressive aortic pathology,

‒ acute intractable HF,

‒ severe forms of PH (including Eisenmenger’s syndrome).

Pregnancy termination should be discussed if there is a high-risk of maternal morbidity or mortality, and/or of foetal abnormality.

Pregnancy and fertility treatment is contraindicated in women with mWHO class IV.

All patients with known cardiac or aortic disease need investigations and counselling about the risks of pregnancy pre-pregnancy or before assisted reproductive therapy.


General recommendations – contraindications for pregnancy - Essential messages





The following patients should be counselled against pregnancy:

‒ with a Fontan operation and additional comorbidities (ventricular dysfunction, arrhythmias, or valve regurgitation),

‒ with PAH,

‒ severe systemic ventricular dysfunction (EF <30% or NYHA class III–IV),

‒ severe coarctation,

‒ systemic right ventricle with moderate or severely decreased ventricular function,

‒ with vascular Ehlers-Danlos syndrome,

‒ with severe aortic dilatation or (history of) aortic dissection,

‒ with severe MS (even when asymptomatic),

‒ patients with severe AS who are symptomatic, or asymptomatic patients with impaired LV function or a pathological exercise test,

‒ if LVEF does not normalize in women with previous PPCM.




Risk assessment: not only before pregnancy

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2018 esc guidelines for the management of cardiovascular ... disea… · pre-pregnancy risk...

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