• Home
  • Aim of this blog

Dr.S.Venkatesan MD

Expressions in cardiology

Feeds:
Posts
Comments
« This RCA is trying to teach some basic lessons in ACS
How did all those calcium entered my father’s coronary artery doctor ? »

Pregnancy in Hypertrophic cardiomyopathy : LSCS or vaginal delivery ?

August 27, 2021 by dr s venkatesan

Background

Yesterday, my fellow informed me about a frantic call for cardiac fitness for an emergency cesarian section in 24-year-old woman with hypertrophic cardiomyopathy, who is asymptomatic and has a 20mmhg gradient across LVOT.

“Was she in labor”?

“No, she is 36 weeks term.

“Why LSCS? Why emergency”?

“I don’t know sir. Let me discuss and come again”.

 HCM in pregnancy: An approach

Hypertrophic cardiomyopathy is a specific genetic disorder of myocyte (myosin and others) within the sarcomere. Though uncommon in pregnancy it raises considerable anxiety to the patient, family, and the obstetrician. 

Hemodynamics

Though we tend to worry more about dynamic LVOT obstruction, it is actually the restrictive physiology of LV myocardium that might cause more concern. Three key variables operate in this entity namely preload, afterload, and contractility that determine the cardiac hemodynamics and possibly the symptoms. We know the classical consequence of pregnancy is a fall in systemic vascular resistance( SVR) ie afterload.

In pregnancy, there is a complex interaction between these three parameters along with heart rate. Fortunately, the net effect ends up favorable for LV performance. This is made possible because a major compensation occurs by a 50% increase in blood volume that effectively counters the deleterious effect of fall in SVR on LVOT gradient. (If mitral regurgitation is significant, the fall in SVR actually may help reduce regurgitant fraction especially if its intrinsic defect )

Maternal outcome 

Is good (if not excellent). Maternal mortality reported in the literature, is gradually coming down (0 to .5% in various series)  However, about 15 % of HCM patients with gross LVH or obstruction, may develop pulmonary congestion in the third trimester. In some patients, VPDs, nonsustained VT, even AF can lead to some tense cardiac consultations but are usually innocuous. I am not sure about the sudden death in pregnancy. I guess it should be negligible, unlike the non-pregnant HCM. 

A mystery learning point

It is surprising  both fetal and maternal outcome is little related to the severity of LVOT gradient (Ref 2) 

Indication  for cesarian 

  • Most mothers can deliver per vaginalis without much hemodynamic challenge. 
  • Vey rarely cardiac indication for LSCS need to happen. (However, in the real world many land up in LSCS , since true indication can be blurred due to  cardio-obstetrical anxiety)
  • Spinal anesthesia to be avoided as hypotension is poorly tolerated 
  • Beta-blockers to be continued during pregnancy labor.(Need not start however if already not taking)

Fetal outcome

Premature birth, stillbirths, low weight are little more common than normal pregnancies. Fetal bradycardia due to beta-blockers has been noted but not troublesome.

What is the role of cardiologist?

The precise answer is “minuscule role”. I can vouch for this from a personal level. ( Consults are meant only for bringing some comfort to the obstetrical team). Active cardiac interventions are rarely required or rather desired. (Of course, patients who have significant symptoms, operated for HC, on OAC for AF, the rare ones with ICD needs expert care)

Final message 

  • Women with  HCM can safely become pregnant and deliver.
  • Best outcome is likely for both mother, and baby if basic precautions are taken.
  • LSCS is rarely required*.
  • Counseling about the condition needs to be gentle and just adequate. Dwelling deep into the pathology, hemodynamics, and statistics in totally asymptotic patients invites trouble to all stakeholders. 

*It is worthwhile to note other forms of severe  LVOT obstruction like valvular, supra valvular stenosis, and Aortic pathologies like Marfan, coarctation aorta are serious entities that deserve prompt cesarian sections.

Reference

1.Thaman R, Varnava A, Hamid MS, Firoozi S, Sachdev B, Condon M, Gimeno JR, Murphy R, Elliott PM, McKenna WJ. Pregnancy related complications in women with hypertrophic cardiomyopathy. Heart. 2003 Jul;89(7):752-6. doi: 10.1136/heart.89.7.752. PMID: 12807849; PMCID: PMC1767741.

2.

https://academic.oup.com/eurheartj/article/38/35/2683/3811991

 

3. ESC 2018 pregnancy heart disease guidelines 

Rate this:

Share this:

  • LinkedIn
  • WhatsApp
  • Twitter
  • Facebook
  • Email

Like this:

Like Loading...

Posted in Pregnancy and heart, pregnancy and heart disease, Uncategorized | Tagged esc ropac zahara pregnancy, heart disease complicating pregnancy, indication for lscs in hcm hocm, lscs or normal delivery in hocm hcm, pregnancy in hocm, pregnancy in hypertrophic cardiomyoapthy, spinal anesthesis vs ga in pregnancy |

  • Categories

  • Archives

    • May 2023 (5)
    • April 2023 (4)
    • March 2023 (5)
    • February 2023 (2)
    • January 2023 (7)
    • December 2022 (3)
    • November 2022 (5)
    • October 2022 (5)
    • September 2022 (4)
    • August 2022 (3)
    • July 2022 (9)
    • June 2022 (2)
    • May 2022 (1)
    • April 2022 (2)
    • March 2022 (1)
    • February 2022 (3)
    • January 2022 (7)
    • December 2021 (3)
    • November 2021 (5)
    • October 2021 (8)
    • September 2021 (4)
    • August 2021 (6)
    • July 2021 (6)
    • June 2021 (7)
    • May 2021 (5)
    • April 2021 (4)
    • March 2021 (3)
    • February 2021 (6)
    • January 2021 (8)
    • December 2020 (4)
    • November 2020 (5)
    • October 2020 (7)
    • September 2020 (7)
    • August 2020 (10)
    • July 2020 (6)
    • June 2020 (9)
    • May 2020 (9)
    • April 2020 (5)
    • March 2020 (7)
    • February 2020 (3)
    • January 2020 (4)
    • December 2019 (4)
    • November 2019 (6)
    • October 2019 (3)
    • September 2019 (6)
    • August 2019 (3)
    • July 2019 (1)
    • June 2019 (3)
    • May 2019 (2)
    • April 2019 (2)
    • March 2019 (2)
    • February 2019 (4)
    • January 2019 (2)
    • December 2018 (2)
    • November 2018 (2)
    • October 2018 (2)
    • September 2018 (1)
    • August 2018 (2)
    • July 2018 (3)
    • June 2018 (1)
    • May 2018 (3)
    • April 2018 (1)
    • March 2018 (3)
    • February 2018 (3)
    • January 2018 (1)
    • December 2017 (3)
    • November 2017 (3)
    • October 2017 (3)
    • September 2017 (2)
    • August 2017 (2)
    • July 2017 (2)
    • June 2017 (2)
    • May 2017 (4)
    • April 2017 (3)
    • March 2017 (3)
    • February 2017 (5)
    • January 2017 (3)
    • December 2016 (2)
    • November 2016 (5)
    • October 2016 (4)
    • September 2016 (3)
    • August 2016 (5)
    • July 2016 (3)
    • June 2016 (4)
    • May 2016 (3)
    • April 2016 (6)
    • March 2016 (4)
    • February 2016 (3)
    • January 2016 (5)
    • December 2015 (6)
    • November 2015 (5)
    • October 2015 (8)
    • September 2015 (2)
    • August 2015 (5)
    • July 2015 (7)
    • June 2015 (4)
    • May 2015 (6)
    • April 2015 (5)
    • March 2015 (7)
    • February 2015 (15)
    • January 2015 (8)
    • December 2014 (5)
    • November 2014 (9)
    • October 2014 (7)
    • September 2014 (9)
    • August 2014 (5)
    • July 2014 (11)
    • June 2014 (5)
    • May 2014 (4)
    • April 2014 (5)
    • March 2014 (8)
    • February 2014 (8)
    • January 2014 (5)
    • December 2013 (7)
    • November 2013 (7)
    • October 2013 (14)
    • September 2013 (12)
    • August 2013 (15)
    • July 2013 (15)
    • June 2013 (15)
    • May 2013 (15)
    • April 2013 (15)
    • March 2013 (15)
    • February 2013 (15)
    • January 2013 (15)
    • December 2012 (15)
    • November 2012 (15)
    • October 2012 (15)
    • September 2012 (15)
    • August 2012 (15)
    • July 2012 (15)
    • June 2012 (15)
    • May 2012 (15)
    • April 2012 (15)
    • March 2012 (15)
    • February 2012 (15)
    • January 2012 (15)
    • December 2011 (15)
    • November 2011 (17)
    • October 2011 (17)
    • September 2011 (17)
    • August 2011 (21)
    • July 2011 (20)
    • June 2011 (17)
    • May 2011 (15)
    • April 2011 (17)
    • March 2011 (25)
    • February 2011 (20)
    • January 2011 (20)
    • December 2010 (18)
    • November 2010 (21)
    • October 2010 (21)
    • September 2010 (25)
    • August 2010 (20)
    • July 2010 (10)
    • June 2010 (11)
    • May 2010 (19)
    • April 2010 (16)
    • March 2010 (14)
    • February 2010 (22)
    • January 2010 (18)
    • December 2009 (20)
    • November 2009 (20)
    • October 2009 (3)
    • September 2009 (21)
    • August 2009 (19)
    • July 2009 (12)
    • June 2009 (12)
    • May 2009 (11)
    • April 2009 (15)
    • March 2009 (21)
    • February 2009 (4)
    • January 2009 (12)
    • December 2008 (13)
    • November 2008 (9)
    • October 2008 (22)
    • September 2008 (20)
    • August 2008 (16)
    • July 2008 (14)
    • June 2008 (7)
  • Blog Stats

    • 6,073,164 hits
  • Please give your feed back .

  • Click below to see who is watching this website live !

  • This site will never aim for profit. Still ,this donation link is added at the request of few visitors who wanted to contribute and of-course that will help make it sustainable . Donate Button with Credit Cards
  • Please Note

    The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
  • Live 3D global traffic map Stats

WPThemes.


  • Follow Following
    • Dr.S.Venkatesan MD
    • Join 833 other followers
    • Already have a WordPress.com account? Log in now.
    • Dr.S.Venkatesan MD
    • Customize
    • Follow Following
    • Sign up
    • Log in
    • Copy shortlink
    • Report this content
    • View post in Reader
    • Manage subscriptions
    • Collapse this bar
 

Loading Comments...
 

    %d bloggers like this: