Heart failure is a complication in as many as 11% of pregnancies. However, normal cardiovascular changes during pregnancy can mimic heart failure symptoms, making it easy to misdiagnose. In this video, Dr. Oliveros discusses:
Specific symptoms and characteristics you can look for to identify heart failure in pregnant patients
Why the early postpartum period can be especially challenging for patients with heart failure
How to use the Zahara Risk Score, the CARPREG II Risk Score, and the Maternal WHO Modified Risk Assessment to assess patient risk
Please also see Dr. Oliveros's other two video presentations on treating cardiovascular issues during pregnancy, including:
Multidisciplinary Group Approach to Managing Pregnant Patients with Cardiovascular Disease
Heart Failure with Preserved Ejection Fraction and Pregnancy
My name is Estefania Oliveros and I'm an Assistant Professor of Medicine at Temple University Hospital. The learning objectives for today is gonna be to summarize the evaluation and management of heart failure during pregnancy and identify the role of the multidisciplinary teams in managing this condition. So, what's your area of expertise? Are you a primary care cardiologist, Odyn or other? It really doesn't matter. Let's just dive in uh because all of us at one point, we have to deal with these very prevalent issue. One of the things uh that we're gonna start by talking is about cardiovascular physiology during pregnancy, there's initial hemodynamic changes you can see here in my Y axis. The percentage of change in here are the weeks until you meet uh 40 weeks, 42 weeks where the person is gonna be ready for delivery first, you have an increase in plasma volume that starts augmenting per trimester until you reach a peak of about uh an increase of 50% by the time you are delivering. Other things that are happening is that you have a decrease in your first trimester of your systemic uh vascular resistance that then returns to normal probably in what we call the fourth trans master or the 1st 12 weeks after delivery. In addition to that, you'll see a decrease in the mean arterial pressure, an increase in your heart rate, which is very notable and about like 10 to 15% of your baseline heart rate. And all of that comes as well with an increase in stroke, which consequently also will increase your cardiac output specifically after 7 to 8 weeks of pregnancy. What other changes that will be notable and important in patients with a heart failure are some of the hematologic changes in the Y axis. You see an increase in the intravascular volume. And here uh in the X axis, you'll see the weeks of gestation, you will experience uh an increase in blood volume for about like 40 to 50% same as with plasma volume. And overall your red cell volume will also increase in viscosity about 30%. All of this is relevant when you're considering people that are high in heart failure, symptoms with increase in volume just as a physiological condition. And you add uh the aggregate component of uh heart failure acceleration, red cell volume increase will also affect uh your uh risk for thrombosis. Other things that are happening is that you will have a natural increase in sodium and water rotation a lot and you tend to run in and estrogen which basically makes uh your blood kind of uh increase in the amount of volume and plasma that you're generating and you'll have an increase in erythropoiesis, precipitated by beta uh HC in Choon, somatotropin uh hormones. So what happens during labor? One of the most interesting things is a very dynamic process in which you will have in the first trimester as we talked about and increasing your heart and cardiac output from 5 to 10% 2nd trimester to 35 to 45% in your stage labors, uh you will have an increase up to almost like 50%. Your heart rate, blood pressure and plasma volume will also increase. And when the person is actively in labor, you will see an increase with every contraction of um blood pressure about 15 to 25%. And uh your cardiac out is also gonna be increasing as well. Other things that are important is when you're thinking about the stages in labor stage, one refers immediately when the cervix is relaxing and causing it to dilate and out. Stage two is more related to uterine contractions and increasing strength. And it is exactly when the infant is delivered. Stage three would be when the placenta is coming out in the early postpartum period. What you know is that all that cardiac output has basically increased from like 30% to almost 60 to 80% within that first hour. And if you have a strong volume, that a baseline is decreased with someone with heart failure, this can be a very challenging time. Other things that you'll see is that your heart rate uh decreases within the 1st 24 hours and you go back to your normal heart rate by six weeks. Other things that you will note is that there's a lot of auto transfusion that happens. So once the placenta is coming out with every contraction that your uterus is having, you also will get 500 CCS back. So, um that's important to take note of in patients that are going into the delivery overloaded. After 3 to 6 months, everything goes back to normal. So let's jump into a case. You have a 37 year old uh female black G four P, 2, 38 weeks pregnant. She has a blood pressure of 1 90/1 10 and a heart rate of 1 10. Uh She's tay. She has elevated GVP up to her neck, uh 18 plus an S3 and plus two lower trim. Do you think this is normal heart failure or this is just normal pregnancy finding? In this case? Uh We're talking specifically about heart failure and it's something very hard to diagnose many times. You will find a patient in clinic that uh is telling you am I pregnant or in heart failure. Basically, both of them can have symptoms of breathlessness, weakness, uh edema, but syncopy should not be part of your specific uh characteristics of a pregnant person. Tachycardia can be present of both splitting of the first heart sound can be uh present in a normal pregnant person. You can hear a breast uh that can be confused by a systolic murmur. And you can have displacement of the apex upwards to the left. When you have the abdomen, that is uh moving up your diaphragm and your intrathoracic uh organs. Sometimes you think it's failure. And when you think it's failure is when you see some of these characteristics, you see progressive dynia orthopnea, nocturnal cough, syncopy, chest pain or heis. Other things that are more in line with heart failure rather than, than than pregnancy are diagnosis, clopping of the fingers, persistent neck pain, distension, systolic murmurs. But when you're talking about uh grade three out of six diastolic murmur, cardiom arrhythmias, uh or a split second sound or even signs of pulmonary hypertension. Interestingly, um about 25% of women initially get misdiagnosed at the time of pregnancy when they're having heart failure symptoms. And in a survey done uh in 2016, what they felt was they were actually dismissed and usually led to a delay in the actual diagnosis of heart failure and acute and prompt intervention. So, how frequent is this problem? You have CDC data uh showing that cardiomyopathies and cardiovascular disease uh accounts for 26.7% of pregnancy related deaths. You have seen uh an increase a rise in mortality uh by 24% and the prevalence of pregnant people with cardiac disease is going up. Heart failure will complicate about 11% of the pregnancies and high risk pregnancies have actually increased from 2007 to 2015. From 0.7 to 10.9%. They use us. Uh United States maternal mortality rates uh begin uh between 2018 and 2021 have actually shown an increase uh every year here we have in the X axis uh from 2018 to 2021. All the rates from 17.4 to 32.9. And it's notable that black women have the highest uh number 69.9 maternal deaths per 100,000 births in the US. When you compare what's happening in the US compared to other industrialized nations, the problem becomes a little bit more evident even uh US occupies the first position here uh for 23.8 deaths per 100,000 births. This is data from 2020 you see other countries like uh Canada and France that are ranging between 8.6 to 8.7. And other countries like New Zealand, which is only about 1.7 potential causes of heart failure during pregnancy are related to theologies. You have hypertrophic cardiomyopathy, which you should consider family history and echocardiograms, prepartum cardiomyopathy related to uh people uh from black race, prelay and obesity, left ventricular non compaction chemotherapy, induced dilated fami cardiomyopathy, stress cardiomyopathy can happen uh after and or delivery with regional emotional abnormalities that are really not matching uh vascular distribution or congenital uh diseases, Babul heart disease, and ischemic heart disease. So when you address this problem, you have to know what is the risk. So there's three calculators that we go over in a second in which we can estimate. What's the chances that the pregnant person will have cardiovascular risk in this uh patient that we were discussing recently. Uh what is her risk score? You do an echocardiogram and you demonstrate that her LVF is 35%. When you have the Sahara risk score, you're basically using different predictors such as arrhythmias, nyh, a class left heart obstruction, cardio medication before pregnancy, systemic A V valve regurgitation, pulmonary A V valve regurgitation. And you educate uh a point and that tells you what's the risk. For example, in the patient that we presented, she has nyh a class two symptoms. So her risk score uh is about 0.5. So it would be 7.5%. If you use the car to rescore, then you include other things such as mechanical valve, uh ventricular dysfunction, pulmonary hypertension, ordinary artery disease, high risk Carthy prior uh cardiac interventions or late pregnancy assessments. And in this case, you adjudicate other uh scores. This was published in 2018. For this patient. It would be uh more than four. We put in her a risk uh for having 41% of cardiac events at the time of pregnancy. One of the other ways uh to assess people with cardiovascular problems during pregnancy are using the maternal um who modified um risk assessment in which you classify them as 12341 would be someone with hypertension diabetes, obesity, repaired simple lesions, uncomplicated mouth, my disease or pulmonary stenosis or simple palpitations. And those people should be referred to tertiary care center. When you have a class two is when you're talking about unoperated A SDS or B SDS repair to travel. Fellow quotation of the order arrhythmias. LVF, more than 45 functional class two, rheumatic heart disease, mechanical valve. And um there's not an urgent referral, but it's something that needs to be considered. You add into that layer. A multidisciplinary cardio rics team that should be equipped to manage all the issues including MFM cardiology, pulmonary hypertension or other uh congenital specialists that are required when you have who uh group three or four is when you're having people uh with mechanical valve disease. Um with symptoms, complex congenital and cyanotic heart disease, pulmonary hypertension. Your LVF is less than 45%. Your function class is more than two. You have severe mitotic disease, erotic dilation by cos aortic valve or morphin. And that require and will imply an urgent referral. The mortality for each group is very different. It can range from 9.9 to 28.9% during pregnancy, which are all very, um, alarming numbers. When you are class four, you can also reach up to 50%. Ideally, what you wanna do is you wanna do an echocardiograph every 4 to 8 weeks and have zero bnps for all these people to constantly raise GSS. Going back to the patient that we were discussing, she had a risk of 0.75 which is 7.5 car break of two, which is 41%. And because she was under, uh, the who group three and four, her mortality was ranging between 29 and 50%.
