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Publicaciones > Revista > 12V41N2
 

Prognostic value of echocardiographic studies in the diagnosis and follow-up of cardiac pathology duringpregnancy

 

Ana G. Múnera*, Rubén D. Manrique**, Juana C. Orrego***,
Clara  Mesa****,  Carlos Betancur+,  Martín Gómez++.

 

Calle 7 B n. 27-30 Apartamento 1004. Medellín, Colombia.
Correo electrónico

The authors declare not having conflicts of interest


Print version Imprimir sólo la columna central

 

 

SUMMARY

Objetives: to assess the prognostic utility of echocardiography in pregnant woment with suspected cardiovascular disease referred to a tertiary care center.
Materials and Methods: In this retrospective review, 153 consecutive women who underwent clinical and echocardiographic evaluation at baseline were followed until delivery for major and minor maternal cardiovascular events and for fetal complications.
Results: Echocardiographic studies were determined as normal for the gestational period in 74 (48%) and abnormal in 79 (52%) patients. Congenital diseases were the most common cardiac anomalies. There was a statistically higher incidence of major and minor maternal cardiovascular complications and a alower APGAR score in the abnormal echocardiographic group. Patients with functional class III-IV at the time of presentation and with pulmonary arterial systolic pressure > 30 mmHg had a higher number of events. All pregnant women with a left ventricular ejection fraction < 40% experirnced at least one major or minor cardiovascular event (p=0.022). A left atrial volume > 34 ml/m2 was also asociated with a higher frequency of events (p=0.018).
Conclusions: The presence of structural heart disease is associated with increased risk for maternal cardiovascular and fetal complications. Echocardiography is a valuable tool for risk assessment of pregnant women with suspected cardiac disease.

Key words:Pregnancy. Cardiovascular disease. Echocardiography.
 
Rev Fed Arg Cardiol. 2012; 41(2): 114-120
 

 

INTRODUCTION
Cardiac disease presents in 0.5-1.0% of all pregnant women [1]. In western developed countries 0.2-4% of all pregnancies are complicated by cardiovascular diseases [2,3]. Pregnancy and the peripartum period are associated to significant circulatory changes that may lead to clinical impairment in women with structural heart disease as base disease [1].

Physiological changes in pregnancy
Blood volume increases during pregnancy, starting from the sixth week of gestation, and reaches 40% above the baseline in the 24th week of gestation; later the increase continues but at a lower velocity. During pregnancy, a 30-50% increase of cardiac output occurs; in the initial part of the pregnancy cardiac output is increased by the growing stroke volume, and in the late part of the gestation by the increase in heart rate. The heart rate starts to increase after the first 20 weeks and increases until the 32nd week, and it remains high 2-5 days after the delivery. Systemic pressure usually decreases in the initial part of the pregnancy and diastolic pressure usually drops 10 mmHg below the baseline in the second three-month period. During labor, oxygen consumption increases three times and systolic and diastolic blood pressure increases during contractions. The cardiac output increases by 15% in the early labor, 25% in the first stage, and 50% during the stage of expulsion, presenting an 80% increase in the early postpartum due to autotransfusion by uterine involution and absorption of leg edema. These changes occur in spite of the blood loss during the delivery and they may cause an increase in the left ventricular filling pressure, stroke volume and cardiac output [3,4].

Cardiovascular evaluation during pregnancy
Due to the physiological changes in pregnancy, symptoms and signs may arise that may resemble heart disease. It is usual during gestation to find a decrease in the capacity for exercise, fatigue, dyspnea, orthopnea, palpitations, dizziness [5].

Murmurs during gestation are typically mild (degree I or II), located in the pulmonary region and never accompanied by diastolic murmurs or signs of heart failure. Normal continuous murmurs may be auscultated, such as the cervical venous hum and mammary murmur that could be continuous or systolic, and may disappear by compressing the diaphragm of the stethoscope over the breast [6].

Women with heart disease should receive preconception counseling, including information about the risks for the mother and the fetus during pregnancy and morbidity and mortality for the mother in the long run. The functional classification of NYHA is used as a prognostic predictor: patients with functional class III and IV have a mortality close to 7% and morbidity greater than 30%. In a study of 252 pregnancies in women with heart disease [7], five predictors of complications for the mother were found:

  1. Previous cardiac events (heart failure, transient ischemic event, cerebrovascular disease previous to the pregnancy).
  2. Prior arrhythmia (sustained symptomatic tachyarrhythmia or bradyarrhythmia that requires treatment).
  3. NYHA III or IV or cyanosis.
  4. Valve or outflow tract obstruction (aortic valve area <1.5 cm2, mitral valve area < 2 cm2, peak gradient in the left ventricular outflow tract >30 mmHg).
  5. Myocardial dysfunction (ejection fraction lower than 40%, hypertrophic or restrictive cardiomyopathy).

Patients with no other risk factor, one or more risk factors have a frequency of cardiac events during gestation of 3, 30 and 66% respectively. Another multicenter prospective study of maternal prognosis in women with cardiac disease (562 patients) where these same predictors of maternal cardiac events were used, had similar findings with risk of events during pregnancy of 5, 27 and 75% according to the presence of none, one and more than one risk factor respectively [8].

The different cardiac injuries present during gestation, whether congenital or acquired can be classified as of low, intermediary or high risk. The European Consensus on Management of Cardiovascular Diseases during Pregnancy from 2011 advises that maternal risk should be evaluated according to the modified classification of risk of the World Health Organization (WHO) [3,9,10]. This classification of risk integrates the known cardiovascular risk factors, including heart disease and other comorbidities, and it includes contraindications for the gestation that are not included in other studies [8,11].

The counseling and management of women in the productive age with suspicion of heart disease begins before gestation occurs. The key to optimize the good results in patients with heart disease is an accurate diagnosis of the etiology, risk classification, proper follow-up and management by a multidisciplinary team. The patients in high risk should be referred to specialized centers [3].

The main goal of cardiologists in the management of women with heart disease is to prevent the death of the mother. Many women with heart disease may have a successful pregnancy. The management of these patients should be multidisciplinary, with a team that includes specialists in the areas of obstetrics, cardiology, neonatology and anesthesiology among others [9].

The main objective of this study was to determine the diagnostic and prognostic usefulness of echocardiography in a group of pregnant women with suspicion of heart disease, referred between May 2006 and June 2009 to the Noninvasive Cardiology Service in a Reference Center of Cardiology and Obstetrics. The echocardiographic studies, structural cardiac alterations, primary, secondary maternal and fetal cardiac events were evaluated.

 

MATERIAL AND METHODS
A study of the cohort type was carried out with the group of pregnant patients that were admitted consecutively into the Service of Noninvasive Cardiology of the General Hospital of Medellín for their evaluation due to suspicion of structural heart disease in the term comprised between May 2006 and June 2009. The sample was constituted by 153 patients who had a follow-up during pregnancy, delivery and postpartum period.

All the patients underwent a full echocardiographic study according to the recommendations for the quantification of cardiac cavities by the American and European Societies of Echocardiography [12].

During follow-up the presence of primary maternal cardiac events was evaluated (pulmonary edema, sustained symptomatic arrhythmia that required therapy, stroke, heart arrest, death of the mother) and secondary maternal cardiac events (worsening of NYHA functional class in more than 2 degrees, need for emergency invasive intervention during pregnancy or six months after the delivery and symptomatic nonsustained arrhythmia that required treatment).

Results were evaluated in terms of the pregnancy outcome: abortion (death of the fetus <20 weeks), fetal death (death of the fetus ≥20 weeks), neonatal death (death of the infant within the first month after being born), premature birth (babies born with <37 of pregnancy), small size for the gestational age (babies born with a weight <10th percentile of the weight for the gestational age), intracranial bleeding, respiratory distress, APGAR at the first minute and the fifth minute.

The type of delivery was evaluated, as well as indications for C-section and type of anesthesia used.

For the statistical analysis, the data file was refined to guarantee its quality and consistency, and information biases were controlled. For qualitative variables the description was made in percentages and frequency tables. Quantitative variables were described as statistics of central tendency and dispersion.

Comparison tables to evaluate the possible relationships between variables were made after classifying continuous variables; in them the hypothesis of no relationship was evaluated using Pearson’s Chi square or tendency, when the variable was of the ordinal type, using as significance criteria a p value<0.05.

The investigation was made according to the guidelines established by the Declaration of Helsinki of the World Medical Association. The protocol of the investigation was evaluated and approved by the Committee of Investigation and Ethics of the General Hospital of Medellín.

 

RESULTS
The population was constituted by 153 patients with an average age of 24.3 (±7.2) years. In Table 1 the characteristics of the population studied were presented.

Table 1. Characteristics of mothers at the time of the echocardiographic study.
VARIABLE

AVERAGE

SD

MINIMAL

MAXIMAL

AGE (years)

24

7.2

14

44

HEART RATE (beats/minute).

82

13.8

49

121

SYSTOLIC BLOOD PRESSURE (mmHg)

112

16.2

80

170

DIASTOLIC BLOOD PRESSURE (mmHg)

68

12.3

32

98

HEIGHT (cm)

157

7.04

138

177

WEIGHT (Kilograms)

63

11.8

42

95

BMI (Kilograms/m2)

25.4

4.07

18

35

BODY SURFACE (m2)

1.59

0.16

1.23

2.05

mmHg: (millimeters of mercury) cm: (centimeter) Kgs: (Kilograms) m2 (square meter).

 

The average gestational age at the time of the echocardiographic study was 31.7 (±5.9) weeks. First-time pregnancies were 47.7% (73 patients), second-time pregnancies 21.6% (21 patients) and mothers with more than 3 pregnancies the rest of the population (30.7%).

Eight patients (5.2%) maintained the habit of smoking during pregnancy and a patient was a drug addict.

In the population being studied 6 patients had undergone surgery before the pregnancy: 4 due to valve disease (with prosthetic valves at the time of pregnancy), one patient due to ventricular septal defect closure and patent ductus arteriosus, and another patient by aorta coarctation correction.

In Table 2 the frequency of diseases associated to pregnancy is described. In the group of infections, the most frequent ones were urine and gynecological infections; two patients had infections by the human immunodeficiency virus.

Table 2. Diseases associated to pregnancy.
DISEASE

FREQUENCY

PERCENTAGE (%)

HYPERTENSION.

46

30

INFECTIONS

29

18.9

PATHOLOGICAL ANEMIA

25

16.3

DIABETES

6

3.9

SYSTEMIC LUPUS ERYTHEMATOSUS

1

0.65

IDIOPATHIC THROMBOCYTOPENIC PURPURA

1

0.65

 

Functional class before pregnancy was Class I in 91.5% of the patients, Class II in 7.8%, and Class IV in a patient (0.65%). During pregnancy 28 patients (18.3%) worsened one functional class and 10 (6.5%) worsened two or more functional classes. Patients with Functional Class III-IV were found to have a greater frequency of primary events in the mother (41.7% vs. 2.1%, p=0.0000) and secondary events (58.3% vs. 2.1%, p=0.000), with these differences being statistically significant.

The indications of the echocardiographic study were: heart murmur (57%), evaluation due to history of heart disease (22%), syncope (9%), arrhythmia (4.2%), pulmonary thromboembolism (3%), dyspnea (2.1%) and other causes (2.7%).

The treatment the patients received because of their cardiovascular disease was: calcium antagonists (13 patients), diuretics (12 patients), alpha methyldopa (10 patients), beta blockers (6 patients), heparins (4 patients), IV vasodilators (4 patients), oral anticoagulation with warfarin (3 patients), acetylsalicylic acid (2 patients).

The result of the echocardiographic studies was normal for the pregnancy in 74 patients (48%) and abnormal in 79 patients (52%).

The pathological findings in the abnormal echocardiographic studies (n=79) were summarized in Table 3. It is worth mentioning that in some patients more than one pathology was found. In these 79 patients, 101 structural alterations were found.

Table 3. Echocardiographic findings.
PATHOLOGY

FREQUENCY

%

DIASTOLIC DYSFUNCTION

16(153)

10.46

HYPERTENSIVE HEART DISEASE

14(153)

9.15

ATRIAL SEPTAL DEFECT

9 (153)

5.88

VENTRICULAR SEPTAL DEFECT

9 (153)

5.88

NONRHEUMATIC MITRAL DISEASE

7(153)

4.58

BICUSPID AORTIC VALVE

6( 153)

3.92

AORTIC COARCTATION

5 (153)

3.27

PULMONARY STENOSIS

5 (153)

3.27

VALVE PROSTHESIS

5(153)

3.27

RHEUMATIC MITRAL DISEASE

4(153)

2.61

PATENT DUCTUS ARTERIOSUS

3 (153)

1.96

MITRAL VALVE PROLAPSE

3(153)

1.96

LVOT OBSTRUCTION UNLIKE THE VALVE ONE

3 (153)

1.96

PERIPARTUM HEART DISEASE

2(153)

1.3

RVOT OBSTRUCTION UNLIKE THE VALVE ONE

1(153)

0.65

EBSTEIN ANOMALY

1(153)

0.65

UNICUSPID AORTA

1(153)

0.65

PULMONARY THROMBOEMBOLISM

1(153)

0.65

SEVERE PULMONARY HYPERTENSION IN STUDY

1(153)

0.65

PULMONARY LEFT BRANCH STENOSIS

1(153)

0.65

TACHYCARDIOMYOPATHY

1(153)

0.65

DILATED HEART DISEASE

1(153)

0.65

HYPERTROPHIC HEART DISEASE

1(153)

0.65

AORTIC AND MITRAL RHEUMATIC DISEASE.

1(153)

0.65

 

About the presence of arrhythmias, sinus tachycardia was verified in 33 patients (22%), occasional ventricular arrhythmia in 3 patients (2%) and frequent ventricular arrhythmia in 3 patients (2%), long QT syndrome in a patient and paroxysmal supraventricular arrhythmia in one patient.

In the total population studied, the kind of delivery was vaginal in 56% of the cases (n=85), vaginal with forceps in 8.5% of the cases (n=13), and C-section in the remaining 35% (n=53). Two patients did not reach the time of the delivery, one patient died before the delivery, and another one had an abortion.

The indications of C-section were (n=53): non-cardiac causes in the mother (64%), in the fetus (34%) and cardiac in the mother 2% (1 patient). When the frequency of C-sections was compared in the group of mothers with normal echocardiographic study (n=22, 30%) vs. the group of mothers with abnormal echocardiographic study (n=31, 40%), a statistically significant difference was not found (p=0.286).

The anesthesia used was epidural in 50% of the cases (n=76), rachidian 14% (n=21), general 8% (n=12) and with no anesthesia in 28% of the cases. In two patients there was no record of the type of anesthesia, since one of them died before the delivery and another one had an abortion.

All primary cardiac events (15 events: 6 pulmonary edemas, 2 sustained arrhythmias that required treatment, 4 heart arrests, 2 deaths of the mother, and one cerebrovascular disease) presented in the group of patients with abnormal echocardiographic studies (n=8; p=0.014).

Secondary cardiac events in the mother, which were 16, were: changes in 2 or more NYHA functional classes (n=10), 5 surgeries during pregnancy or 6 months after the delivery, 1 symptomatic nonsustained arrhythmia that required treatment. All of them appeared, but for one in patients with abnormal echocardiographic study (p=0.018). Table 4.

Table 4. Frequency of primary and secondary maternal cardiac events according to the result of the Echocardiographic Study.

 

PARAMETER

NORMAL ECHOCARDIOGRAPHIC STUDY (74 patients)
FREQUENCY (%)

ABNORMAL ECHOCARDIOGRAPHIC STUDY (79 patients)
FREQUENCY %

 

P

PRIMARY MATERNAL CARDIAC EVENTS

0

8 (10.13%)

0.014

SECONDARY MATERNAL CARDIAC EVENTS

1 (1.4%)

9 (11.4%)

0.018

 

In the total population, the frequency of abortions was 0.65%, fetal deaths 2.6%, neonatal deaths 1.3%, prematurity 32%, and fetus of a small size for the gestational age 25.5%. The frequency of respiratory distress of newborn babies was 5% and intraventricular bleeding 3.3%. The APGAR at the first minute after birth was ≥8 in 70% of the cases, and at the fifth minute ≥8 in 91.5% of cases.

All neonatal and fetal deaths (6 cases) occurred in the group of patients with abnormal echocardiographic studies. However, a statistically significant difference (p=0.256) was not found in the frequency of neonatal events (neonatal death, fetal death, prematurity, low weight at birth, respiratory distress, intraventricular bleeding) between the group of children from patients with normal echocardiographic study vs. abnormal echocardiographic study. A statistically significant difference was found in the APGAR at the first minute and the fifth minute between the two groups (Table 5).

Table 5. Neonatal results according to the conclusion of the echocardiographic study.

 

PARAMETER

NORMAL ECHOCARDIOGRAPHIC
STUDY (n=74)

FREQUENCY (%)

ABNORMAL ECHOCARDIOGRAPHIC
STUDY (n=79)

FREQUENCY %

P

ABORTION

0

1  (1.27%)

0.97

FETAL DEATH

0

4 (5%)

0.146

NEONATAL DEATH

0

2 (2.5%)

0.50

PREMATURITY

22 (30%)

27 (34%)

0.675

SMALL FOR GESTATIONAL AGE

14 (19%)

25 (32%)

0.105

RESPIRATORY DISTRESS

1 (1.35%)

7 (9%)

0.085

INTRAVENTRICULAR BLEEDING

1 (1.35%)

4 (5%)

0.40

APGAR > 8 AT THE 1st MINUTE

61 (82.6%)

47(60%)

0.012

APGAR > 8 AT THE 5th MINUTE

72 (98%)

68(86%)

0.047

 

When evaluating pulmonary systolic pressure, patients were found to have pulmonary systolic pressure >30 mmHg, had a greater frequency of primary maternal events (14.3% vs. 2.5%, p=0.016) and secondary ones (14.3% vs. 4.2%, p=0.05). This statistically significant difference was more important when the presence of primary maternal events (33.3% vs. 3.5%, p=0.007) and secondary ones (33.3% vs. 4.9%, p=0.014) was evaluated in patients with levels of pulmonary systolic pressure ≥50 mmHg.

When evaluating the patients with ≤40% and >40% ejection fraction, it was found that 50% of the patients with <40% ejection fraction had at least one secondary maternal event (p=0.022).

When evaluating the volume of the left atrium, it was found that patients with atrial volume >34 cm/m2 had a higher frequency of neonatal events (61.9% vs. 39.6%, p=0.018) than those with lower atrial volume, a statistically significant difference.

 

DISCUSSION
The presence of heart murmurs is a normal finding during pregnancy, usually of mild intensity (degree I-II) located in the pulmonary region and never accompanied by diastolic murmurs, signs of heart failure or other manifestations such as angina, dyspnea at rest, paroxysmal nocturnal dyspnea or sustained arrhythmia. When these manifestations are present an echocardiographic study should be conducted [6].

During pregnancy, due to hemodynamic and body changes related to pregnancy, changes appear in the capacity for exercise and in literature the normal presence of fatigue with decrease of functional capacity is described [6]. In the population studied a worsening of the NYHA functional class was found in 18% of the patients and impairment in two functional classes in 6.5% of patients. The presence of changes in one or more of two functional classes should be considered a sign of alarm, since the presence of Functional Classes III-IV has been identified as a risk factor for maternal complications [7,13,14,15].

In the present study it was found that the patients with Functional Class III-IV presented primary and secondary cardiac events in the mothers in 41.7% and 58% of the cases.

Between the structural heart alterations, congenital heart diseases represented the largest group (39.6%), then hypertensive heart disease (30%), noncongenital valve disease (19.8%), cardiomyopathies (4.96%) and others 5.9%. These findings are in contrast to prior reports, with a greater prevalence of rheumatic heart disease in non-Western and developing countries [8,16,17,18,19].

In most patients with heart disease, spontaneous delivery with epidural anesthesia is indicated. Delivery by C-section should be considered in patients that receive oral anticoagulation in preterm birth, in patients with Marfan syndrome and aortic diameter >45 mm, in patients with acute aortic dissection, heart failure that cannot be treated, severe aortic stenosis and Eisenmenger syndrome [3,20,21,22].

In the present study most patients had a vaginal delivery with epidural anesthesia. The frequency of C-section had no statistical differences when compared to the group of patients with normal vs. abnormal echocardiographic study. The indication of C-section was due to obstetric causes in 98% of the cases and cardiac in 2%, similar to what was previously reported by Siu et al, with 96% of C-sections by obstetric causes and 4% by maternal cardiac causes [8].

The frequency of primary maternal cardiac events was 5.2% in the total population and 10% in the population with abnormal echocardiographic studies. This finding is similar to what was reported by Siu et al, with 13% of pregnant women with heart disease [8]. All the primary cardiac events occurred in the group of patients with structural heart disease. Maternal deaths (n=2, 1.3% of the population) occurred in a patient with Functional Class IV severe mitral stenosis refractory to medical treatment, with indication of emergency mitral valve replacement during pregnancy (not candidate for percutaneous balloon valvuloplasty), and in another patient with severe thrombocytopenic purpura and pulmonary thromboembolism. In literature a frequency of cerebrovascular disease and maternal death has been reported in 1% [8].

There were no statistically significant differences in the frequency of neonatal events (neonatal or fetal death, prematurity, low weight at birth, respiratory distress, intraventricular bleeding) between the group of children from patients with normal vs. abnormal echocardiographic study. Fetal and neonatal mortality in the group of patients with structural heart alteration, was 7.6% compared to the 2% reported [8]. The frequency of prematurity in children from mothers with heart disease (34%) was greater to the one reported previously (20%) in patients with heart disease and the obstetric population in general (4%) [8,23]. Likewise, low weight at birth presented in a higher percentage to the one reported (31% vs. 4%) [8]. It is important to highlight the finding of a higher APGAR in the children from mothers without heart disease. This variable was no cause of comparison in other studies.

The echocardiographic findings found a greater frequency of neonatal events in children from mothers with atrial volumes >34 cm/m2, a statistically significant difference (p=0.018). There are no reports about this finding in literature either.

Pulmonary hypertension of any etiology produces an increase in the risk of maternal death, equal to the impairment of ejection fraction ≤40% [4,6,7,24].

In this study a higher number of primary and secondary maternal events was found with figures of pulmonary artery pressure >30 mmHg, and the difference was even more significant when the figures of pulmonary pressure were ≥50 mmHg. Half of the patients with ejection fraction <40% had at least one secondary maternal event.

 

CONCLUSIONS
The presence of structural heart disease is associated to an increase in the incidence of primary and secondary maternal cardiac events. Echocardiography is a useful tool in the evaluation and stratification of risk in pregnant patients. This echocardiographic evaluation is necessary for preconception education, risk stratification and multidisciplinary management, to optimize results in the mother and the fetus.

 

REFERENCES

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Publication: June 2012

 
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