Heart Failure and Pregnancy

Podcast Transcript

Announcer:

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Karlee Hoffman, DO:

So systolic heart failure in pregnancy, two things we don't really ever want to hear together. At Cleveland Clinic we have this true multidisciplinary team that allows us to have successful deliveries with these patients. In the pregnant patient there's limited data and I'm going to present what we have for you. So we're going to set the ground rules for heart failure in pregnancy, discuss where we know the data is which is peripartum cardiomyopathy. We're going to briefly discuss obstetric considerations, postpartum management and preconception counseling. So let's go into the data that we have. Every time I present these slides it's amazing how this trend continues to go up and up and up.

So the last data that we have in 2021 when we're looking at pregnancy related mortality in the United States, it continues to increase 32.9 per 100,000 births in the United States amongst all different races. Again, increase amongst all of these groups. Specifically why we're talking about heart failure is because heart failure accounts for about 12% of these pregnancy related deaths in the United States in this timeframe. So going back to the ground rules let's talk about heart failure. When we look at risk, this is the ultimate risk, the highest risk: WHO risk class IV. So World Health Organization recognizes if you have an ejection fraction less than 30% this is an extremely high rate for maternal mortality if you proceed with your pregnancy and they actually say that if pregnancy occurs you should terminate, and this should be discussed with the patient. And why is this the case?

Why do these patients struggle during their pregnancy? So what happens during pregnancy it's an ultimate nine-month stress test. I like to think of it as a marathon followed by the sprint of labor. So if you look at this through the trimesters, so we have the first trimester, by this time they get to the second trimester their cardiac output nearly doubles. So you have a hypotensive patient that has almost twice the amount of cardiac output. If you have underlying systolic heart failure, you can see how this does not fare well. So most of our patients with preexisting heart failure, really the stress of pregnancy comes in the second trimester. If this is a new diagnosis of heart failure it usually presents in the second to third trimester. So what causes heart failure in pregnancy? A majority of these patients have what we call peripartum cardiomyopathy and we'll define this a little bit more. But we can't forget about the other causes and these are additional patients we see in our Cardio-Ob clinic.

We have a significant amount of congenital heart disease patients that are living longer, doing better and getting pregnant. We also have undifferentiated non-ischemic cardiomyopathy, hypertrophic cardiomyopathy and then our ischemic and valvular disease. So for the sake of this talk we're going to focus on peripartum cardiomyopathy, so let's define it. It's an idiopathic cardiomyopathy that presents with an ejection fraction at less than 45% and it's a diagnosis of exclusion. This is made during the first five months after delivery or the early postpartum period. A lot of times there's a delay in diagnosis because again we have young healthy females, they don't have any reason to see a doctor. They have a lot of other variables going on after delivery, fluid shifts, maybe some gestational hypertension and these symptoms of heart failure really mimic the same symptoms of pregnancy and there's a vast array of severity.

So these patients present with preeclampsia, hypertension, come in with a mildly reduced ejection fraction that can be managed as an outpatient and some of these patients come in to see us in full-blown cardiogenic shock. The good thing for all these patients is there's a high rate of recovery if this is true and true peripartum cardiomyopathy. All right, so what's the incidence? Depending on what study you look at about one in every 2,500 to 4,000 births in the United States. The thought is why is this happening? One, females are older when they're getting pregnant. They're also having multi fetal pregnancies due to IVF and overall just general recognition. Preeclampsia and gestational hypertension account for a large amount of these patients and also 40% of patients with peripartum cardiomyopathy are African Americans. So what happens? Unfortunately about 50% of these patients present with a catastrophic event and that's how they're first diagnosed with peripartum cardiomyopathy.

That includes cardiopulmonary arrest, pulmonary embolism, other thromboembolism complications, cardiogenic shock requiring mechanical support or death even and there's a high risk of LV thrombus in these patients. So we'll talk about anticoagulation and what the criteria are for that in a minute. But again, thromboembolism in these patients anywhere between 5 and 9% and it's really the perfect storm. Right? They have a low ejection fraction, they have a hypercoagulable state and they're on bedrest around the pregnancy and not really moving around as much as they typically do. So it's a setup for these adverse outcomes in these patients.

So what about the prognosis? Prognosis really depends on where the ejection fraction is at the time of diagnosis, it's really the most reliable predictor of the outcome for the patient. If the EF is less than 30%, there's definitely a lower rate of recovery and increased risk of adverse events. Like I said before, there's definitely a higher rate of recovery in this heart failure group compared to others and typically we see this in the first three to six months after diagnosis. But there can be a delayed recovery up to two years postpartum. A lot of this data came from the IPAC study that showed 72% of postpartum cardiomyopathy patients recovered at 12 months, and their ejection fraction was more than 50%. So normal.

So what about management? I'm not going to go into this too much, but the main line is you need to know what medications are safe for the fetus during pregnancy and delivery and also which ones are safe afterwards. A very quick blanket statement, beta blockers are safe they just monitor them closely with ultrasound throughout. Obviously we have the ACEs, the ARBs, the MRAs, ivabradine all are not safe for the fetus and we avoid these during pregnancy and we have to switch to pregnancy safe medications such as hydralazine, Isordil, digoxin.

So what about anticoagulation? I want to point this out because I think we often forget about this. If you look at the guidelines (AHA), if the ejection fraction is less than 30% they need to be on a anticoagulation for at least six to eight weeks postpartum. In the European society guidelines say if their ejection fraction is less than 35% they should also be on anticoagulation. We can use warfarin, it does cross the placenta we don't use this during pregnancy but afterwards completely safe. And then our drug of choice for anticoagulation is low molecular weight heparin because it does not cross the placenta during pregnancy. So bromocriptine, quickly, it's a dopamine agonist that suppresses prolactin and there have been studies that show that it's associated with an improvement in LV function. So in Europe, they're readily using bromocriptine. Here in the United States we do not have any data.

So what about advanced therapies? A lot of these patients present in cardiogenic shock and the bottom line is that you support them like you support any other patient. You support them with inotropes, you support them with the balloon pump, you support them with ECMO and if you can save the mom and perfuse the mom, you're perfusing the baby. After delivery we can think about a durable LVAD and there are studies that show that women have received LVAD successfully, and some of them have recovered and most of them have gone on for a cardiac transplant. And again, if you need to be on temporary mechanical support and this is a transplant candidate you can proceed with transplant in these patients. Of note though, you need to know there's higher rates of graft failure and rejection. This is due to higher allograft sensitization and overall much sicker going into transplant than other patients.

So labor and delivery and I will touch on this just briefly. Again, this is a situation that requires an immense amount of team and immense amount of planning to prepare for the unpredictable. So obstetric considerations, as long as the mom is not in shock and is stable they deliver vaginally, and this again is not so easy whenever our delivery hospitals are in the community and might not be at the main centers that have the most cardiac support. But if the patient is not in cardiogenic shock and they're hemodynamically stable they should deliver vaginally. Because we know C-sections have a higher risk of infection, a higher risk of blood transfusions, surgical complications and again the prothrombotic risk. We need to think about timing also. So stabilizing the mom to get her to viability is very reasonable because we know that complications due to prematurity in these babies are very high. However, if the mom is unstable that needs to be a reason to promptly deliver.

Let's just talk about what none of us really want to talk about but need to talk about. So the key here is avoiding this, right? Avoiding heart failure and pregnancy and it really needs to be an open discussion. It needs to be a shared decision, it needs to be a conversation and they need to know the risks if they do proceed with pregnancy. 1. They need to be off of their medications that can cause fetal risk and 2. they need to know the risk of proceeding with delivering, what that looks like. And I'll be the first one to say this is a team approach and ultimately this is best in a shared group decision.

So what about contraception? This is a question I get asked very frequently and the bottom line is IUDs are highly effective and least potential for all drug interactions. So for instance our transplant patients, an IUD is the safest and preferred method for their effectiveness and this goes for every heart failure patient. The combined typical hormonal contraceptives? We want to avoid them when they have a low EF, transplant or an LVAD because of the increased thrombotic risk. Also, the increased risk of hypertension in the progestin-only pills. Many pills are great but just not quite as effective. Also, another topic I think that's important in the preconception counseling portion is that if a female has cardiomyopathy and this is a genetic underlying condition this can easily be passed on to the baby. We need to get them in with the genetic counselors, and we need to talk about what testing do we need to do for the offspring if it is a successful pregnancy and the key thing here too is peripartum cardiomyopathy. About 15% of these patients actually have an underlying genetic condition.

So what about a subsequent pregnancy? Again, this goes into the preconception counseling. So LVF is the strongest predictor of how the patient's going to do. If their EF is greater than 50% they're going to have a lower risk proceeding with a subsequent pregnancy. If their EF is low, less than 50% they have a high risk of having complications during pregnancy and how do we monitor these patients? So how I follow these patients one, again preconception counseling and then I follow them every trimester as long as they're stable and doing well. And then typically we see them about one month prior to delivery to have a whole multidisciplinary delivery plan for them. And I see them close after delivery within two to four weeks afterwards, and about one month after that for a repeat echo and repeat lab work. So with that, I appreciate your attention and we'll wrap this up.

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