Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 106

Challenge: A patient with heart disease presenting for ART.

Background:

Ischemic heart disease:

 A high index of suspicion is needed to diagnose, as women may present with atypical symptoms.

 The treatment of pregnant or postpartum women with ACS is the same as for the nonpregnant patient.

Congenital heart disease:

 Maternal risk is strongly influenced by cardiac output and functional class prior to pregnancy

 During pregnancy women with CHD are at risk of arrhythmia.

 Prematurity and low birth weight are frequent complications.

Cardiomyopathy:

 Hypertrophic cardiomyopathy (HCM) is often well tolerated and should not represent a contraindication to pregnancy.

 Preterm birth occurs in a quarter of patients with HCM.

 In dilating forms of cardiomyopathy (DCM), pregnancy can result in significant deterioration of LV function.

 Women with cardiomyopathy are at risk of arrhythmia.

Valve disease:

 Stenotic valve disease is generally less well tolerated in pregnancy than regurgitant valve disease.

 For the majority of patients with prosthetic valves pregnancy is safe provided appropriate anticoagulation is continued.

 Substitution of warfarin with subcutaneous LMWH in combination with oral aspirin for the period of organogenesis and/or throughout the pregnancy, with monitoring of anti‐Xa levels is a safe option.

Management options:

 Aim for single embryo transfer (to reduce the risk of multiple pregnancy and OHSS).

 Reduce risk of OHSS (gentle COS, GnRH antagonist cycle with GnRH agonist trigger).

 Prepregnancy assessment by an obstetric physician or a maternal medicine specialist and a cardiologist is mandatory.

 A thorough discussion of maternal and fetal risks must take place.

 Adjustment of medications as appropriate and referral to a multidisciplinary team as soon as pregnancy is confirmed.

 If on LMWH, stop 24 hours before oocyte retrieval, and consider restarting on the evening of oocyte retrieval.

 For women with mechanical heart valves, antibiotic prophylaxis for endocarditis prevention is not routinely indicated at oocyte retrieval.