abortion in women with cardiac disease fiapac 2016 oskari · what kind of heart disease do pregnant...
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AbortioninwomenwithcardiacdiseaseOskariHeikinheimoDept Ob&GynUniversityofHelsinki
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OHeikinheimo conflictsofinterest
• Employedby– HospitaldistrictofHelsinkiand
Uusimaa– UniversityofHelsinki– FinnishmedicalsocietyDuodecim
• Lectures,Ad-boardmembershipsat– BayerAG– Exelgyn– Gedeon Richter– MSD
• Boardmemberat– Suomen Lääketieteen säätiö– Oheikinheimo consulting– Femeda clinic
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Contents• Background– Cardiacdiseaseinfertileagedwomen– Contraception inwomenwithcardiacdisease
• EuropeanSocietyofCardiologyguidelines– Whenthepregnancyiscontraindicated?
• Whataretherisks?• Awomanwithcardiacdiseaseseekingabortion– Whattoremember?– Proposedmanagementscheme
• Summary
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Background
• Thenumberoffertileagedwomenlivingwithcardiacdiseaseisincreasing– 0.2-0.4%ofallpregnanciescomplicatedbycardiovasculardiseaseinWesternworld (Arif &Thorne,Medicine2014)• Improvedcorrectionofcongenitalheartdisease,bettertreatment, increasingmaternalage,immigration
• Meanageoffirstintercourseamongwomenwithcardiacdiseasesimilartothatofhealthwomen(Vigl etal.,AmJCardiol 2010)
– Arethecontraceptive needcovered?
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ContraceptioninwomenwithcardiacdiseaseVigl etal.,AmJCardiol,2010
• Asurveyof536women(medianage29y)withcongenitalheartdiseasefromGermany– Highrateofunplannedpregnancies(1/10)– 20%ofthewomenusedcontraceptivemethodcontraindicated intheircondition
– 28%ofwomenwenotusingcontraceptiondespitebeingsexuallyactive
– Nocounseling• In43%concerningcontraception• In48%concerningpregnancy-relatedrisks
– Timelyandcompetentcounselingoncontraceptionneededforwomenlivingwithcardiacdisease
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ContraceptioninwomenwithcardiacdiseaseRoos-Hesselink etal.,Contraceptionandcardiovasculardisease
Eur JHeart2015
• Cardiovasculardiseasemightincreasetherisk– Thrombosis– Endocarditis
• Contraceptivecounseling– Thepossiblerisksofpregnancytomotherandchild– Risksofcontraception– Failurerates– Non-contraceptivebenefits– Availability– Individualpreferences– Protectionagainstinfection– Costs
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Whatkindofheartdiseasedopregnantwomenhave?Hink &Bolte,PregnancyHypertension2015
• Allpregnantwomenwithheartdiseasefollowed-up in2000-2011atUniversityMedicalCenterAmsterdam– 122womenwith160pregnancies– Typeofheartdisease
• Congenitalheartdisease in 53%• Arrhythmiain 16%
– NYHA-classification• NYHAI-II 93%• NYHAIII-IV 7%
– Heartfailurein• NYHAI-II 7%• NYHAIII-IV 38%• Maternaldeath 2%
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https://www.escardio.org/static_file/Escardio/Guidelines/publications/PREGN%20Guidelines-Pregnancy-FT.pdf
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ModifiedWHOclassificationofcardiovascular risks- principles
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ModifiedWHOclassificationofcardiovascular risks– WHOI
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ModifiedWHOclassificationofcardiovascular risks– WHOII-III
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ModifiedWHOclassificationofcardiovascular risks– WHOIII
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Managementofthehigh-risk(i.e.WHOIV)cardiacconditions
• Ifpregnancyoccurs,terminationshouldbeofferedinatertiarycenterwithexperiencedunit!
• Alsoterminationcarriesarisk!
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Whataretheriskstothewoman?
Condition Maternal risks
Pulmonaryhypertension High maternalmortality• 30-50%inolderseries,17-33%innewer• DuringIIItrimester/post-partumperiod• Cardiovascularcollapsefollowingevenminor
hemodynamic/volumechangesINPATIENTSWITHNOORLITTLEDISABILITYBEFORE
History ofperipartumcardiomyopathy
Mortality rateupto15%• Deteriorationupto50%despiteoptimaltherapyRecurrenceriskinsubsequent pregnancy30-50%especially ifEFnotnormalized
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Whichcardiacpatientsshouldbereferredtohospital foranabortion?
Soc Fam Plan,Contraception2012• Congenital
– Cyanoticdisease,right/leftventriculardilatation,uncontrolledtachyarytmia
• Coronarydisease– HistoryofAMI,treatmentangina
• Cardiomyopathy– Dilated,hypertrophic,historyofperipartum CMP
• Valvular disease– Significantaortic/mitralstenosis– Aortic/mitralregurgitationwithLVdilatation
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Abortioninwomenwithsignificantcardiacdisease
• Identifythewomenwithcardiovasculardisease• Consultacardiologist– Notallcardiacdiseasesarealike
• EuropeanSocietyofCardiologyguidelines
• Consultananesthesiologistexperiencedincardiacanesthesia– Followselectedpatients(pulmonaryhypertension!)longenough(atleastovernight)!
• Medicalvs.surgicalabortion– Individualdecision
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Medicalvs. surgicalabortioninwomenwithsignificantcardiacdisease
• Nopublishedliterature!• Medicalabortion– CAVEinwomenwithanticoagulation• MIFEand/orMISO
– Noknowneffectsonhemostasis– Nointeractionswithcommonlyusedanticoagulants
• Useinhospitalsetting• Surgicalabortion–Mightbehemodynamically morecontrollableinsomesituations
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Additionalantibiotics?
• Routineprophylacticantibioticsrecommended beforesurgicalabortionbyseveralguidelinesinallcases– UK,WHO,Finnish
• Morevariablerecommendationsconcerningconcerningmedicalabortion…
• Cardiologicindicationsforprophylacticantibiotics– Ifartifical materialinheart– giveantibiotics
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Womanwithuncertainhistoryofcardiacdiseaseseekingabortion
• Cardiologistsadvice– Absenceofseriousdiagnosis,nosymptoms,normalperformance• Noneedforinvestigations!
– Patientwithregularcardiacfollow-up-consultacardiologists• Referselectedcasestounitexperiencedintreatingpregnantwomenwithcardiacdisease
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Summary - abortioninwomenwithcardiacdisease
• Recognizethewomenwithahistoryof/currentcardiacdisease– Iscardiologyconsultationneeded?– Isreferral toaspecialunitneeded?
• Makenecessarypreparations,suchas– Anticoagulantmedication,antibioticprophylaxisetc.
• Chooseabortionmethodconsideringamong(amongmanythings)themedicalfactorsabove
• Starteffectiveandsuitablecontraceptionaftertheabortion
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Thankyou!Specialthanksto• HeidiEriksson• Jouni Ahonen• Janne Rapola