From the Guidelines
Yes, there is a risk score to predict adverse outcomes in pregnant women with dilated cardiomyopathy (DCM) and severely reduced left ventricular function. The modified World Health Organization (mWHO) classification system is commonly used, which categorizes DCM with severely reduced LVF as class III-IV, indicating a high to extremely high risk of maternal mortality or severe morbidity. Additionally, the CARPREG II score evaluates specific risk factors including prior cardiac events, NYHA functional class, left ventricular ejection fraction <40%, and other cardiac lesions to quantify risk 1. For pregnant women with DCM and severely reduced LVF, these scoring systems typically predict a 19-27% risk of adverse maternal cardiac events. Management requires multidisciplinary care involving cardiology, maternal-fetal medicine, and anesthesiology. Close monitoring of cardiac function throughout pregnancy with serial echocardiograms is essential, as pregnancy-related hemodynamic changes can significantly worsen cardiac function. Heart failure medications safe in pregnancy (beta-blockers like metoprolol, hydralazine, and sometimes carefully monitored ACE inhibitors after the first trimester) should be optimized 1. These risk assessment tools are valuable because the increased blood volume, cardiac output, and heart rate during pregnancy place additional strain on an already compromised heart, potentially leading to heart failure decompensation, arrhythmias, or even death. Some key points to consider in the management of these patients include:
- The use of the mWHO classification system to assess maternal risk and guide management decisions 1
- The importance of close monitoring of cardiac function and adjustment of heart failure medications as needed 1
- The potential benefits and risks of breastfeeding in women with DCM and severely reduced LVF, and the need for multidisciplinary consultation to make informed decisions about lactation 1. Overall, the use of risk assessment tools such as the mWHO classification system and the CARPREG II score, in combination with close monitoring and multidisciplinary care, can help to optimize outcomes for pregnant women with DCM and severely reduced LVF.
From the Research
Risk Score to Predict Adverse Outcomes
- There are several risk scores and predictors that can be used to predict adverse outcomes in pregnant women with dilated cardiomyopathy (DCM) and severely reduced left ventricular function (LVF), including the Carpreg score 2.
- The Carpreg score is a predictor of maternal complication rate, with higher scores indicating a higher risk of complications 2.
- Other predictors of adverse outcomes include:
- Left ventricular ejection fraction (LVEF) < 30% 3, 4
- New York Heart Association (NYHA) functional classification > II 3, 4
- Ventricular tachyarrhythmias, including patients with implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator 3
- Atrial fibrillation with rapid ventricular rate 3
- Severe mitral regurgitation 3
- Significant right ventricular failure 3
- Hypotension 3
- These predictors can help identify women who are at high risk of adverse outcomes and may require closer monitoring and management during pregnancy.
Management and Outcomes
- Women with DCM and severely reduced LVF should undergo preconception evaluation, risk assessment, and treatment modification, including discontinuation and replacement of contraindicated medications 3.
- A close follow-up and treatment by a multidisciplinary team is recommended at all stages: preconception, gestation, delivery, and postpartum 3.
- Pregnancy in women with DCM is associated with a high rate of complications, including cardiac events, premature delivery, and adverse neonatal outcomes 2, 5, 4.
- However, with proper management and care, many women with DCM can have a successful pregnancy and outcome 3, 5.