A 29-year-old pregnant woman with a history of anthracycline-induced clinical heart failure

doi:10.4236/health.2011.31007

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Vol.3, No.1, 37-38 (2011) Health

doi:10.4236/health.2011.31007

A 29-year-old pregnant woman with a history of

anthracycline-induced clinical heart failure

Valentina Scheggi*, Fabio Mori

Department of Cardiology, Azienda Ospedaliero-Unive rsit a ria Careggi, Firenze, Italy;

*Corresponding Author: v[email protected]

Received 11 November 2010; revised 2 November 2010; accepted 8 November 2011

ABSTRACT

The number of women with heart disease who

reach childbearing age in a good functional

state increases continuously as advances in

diagnosis and treatment improve overall health

and prognosis. The cardiologist’s role is to give

the woman an estimate of both maternal and

fetal risk to allow her to make an informed deci-

sion about embarking on a pregnancy, and to

provide appropriate antenatal care. There are

only a few data about the natural history of

anthracycline-induced cardiomyopathy during

preg- nancy; we report our experience of a

29-year- old pregnant woman with a history of

anthracycline-induced clinical heart f ai l ure.

Keywords: Anthracyclines; Heart Failure;

Pregnancy; Cardiomyopathy

1. INTRODUCTION

Heart disease is present in 0.5-1% of all pregnancies

and accounts for about 10-15% of all maternal death.

Management of these patients requires teamwork of ob-

stetricians, neonato logists, cardiologists, anesthetists and

sometimes cardiac surgeons but there are only a few data

in the literature to guide clinicians in maternal and fetal

care. We report the case of a pregnant woman with anth-

racycline-induced cardiomyopathy and a review of the

literature.

2. METHODS

We evaluated a 29-year-old woman in the 5th week of

pregnancy. During childhood she had osteosarcoma

treated with anthracyclines and at the age of 2 5 years she

presented anthracycline-induced NYHA class IV heart

failure with markedly reduced systolic left ventricular

function (EF 24%) and severe mitral regurgitation. She

was treated with ACE-inhibitors, beta-blockers and di-

uretics with good clinical result and improving systolic

left ventricular function with EF until 47% and trivial

mitral regurgitation.

At the time of evaluation the pulse was 83 bpm, blood

pressure was 90/60 mmHg, without signs of heart failure;

the electrocardiogram was normal and p-BPN was 600

pg/ml.

The ACE-inhibitor was discontinued and she was

treated with bisoprolol and LMWH.

Her clinical conditions and left systolic ventricular

function continued to be stable and she vaginally deli-

vered a healthy child at 35 weeks of pregnancy.

The follow up after delivery was uneventful with sta-

ble EF.

3. DISCUSSION

Mortality among minimally symptomatic pregnant

women with cardiac disease is about 1%, as among the

healthy general population. In contrast, severely symp-

tomatic women have been reported to experience a mor-

tality risk up to 5-15%.

Just a small number of parameters allow dichotomic

classification into high-risk and low -risk patients.

In a prospective multicentre study enrolling 562

women, Siu et al. [1] identified poor functional NYHA

class or cyanosis, left ventricular systolic dysfunction

(EF < 50%), and left heart obstruction as major deter-

minants for mater nal cardiac complications.

Neonatal complications (20% of pregnancies) were

associated with poor functional class or cyanosis, left

heart obstruction, anticoagulation, smoking, and multiple

gestations.

Vere na Stangl et al. [2] found that women at high-risk

(as defined above) had a 6.1-fold higher maternal com-

plication rate and a 6.1 times higher fetal/neonatal event

rate; 64.7% of the high-risk women delivered prema-

turely, compared to 16.4% in the low-ris k group.

V. Scheggi et al. / Ntural Science 3 (2011) 37-38

In low-risk women, fetal complications were compa-

rable to those reported for the general population but

preterm birth rate was slightly higher.

Thorne et al. [3] showed that the risk of maternal

death is approximately 7% if the patient is in New York

Heart Association (NYHA) functional class III or IV.

Other adverse risk factors include ejection fraction <

20%, mitral regurgitation, right ventricular failure, atrial

fibrillation, and systemic hypotension.

The natural history of specific types of cardiomyopa-

thy during pregnancy is unknown and there are only a

few data about pregnant women with anthracycline-in-

duced cardiomyopathy.

Anthracycline-cardiotoxicity can become manifest as

either clinical heart failure or asymptomatic cardiac

dysfunction. Both can develop also years after the cessa-

tion of treatment, as happened in our patient.

Elvira C. van Dalen [4] evaluated the incidence of pe-

ripartum anthracycline-induced clinical heart failure in a

cohort of 53 women. This study demonstrates a low risk

in childhood cancer survivors.

It is worth noticing that 2 of the 53 women included in

this study developed heart failure shortly after the end of

anthracycline therapy and that neither of them developed

any peripartum cardiac problems.

About therapy, sodium and physical activity restric-

tions, in association with drugs like digoxin and furose-

mide, help control heart failure during pregnancy.

Hydralazine, with or w ithout nitrates, is an alternative

to angiotensin-converting enzyme inhibitors, that are

associated with side effects.

As anti-arrhythmics, amiodarone may be toxic but

beta-blockers c a n be us ed safel y.

Finally, patients with ventricular dysfunction must be

anticoagulated with heparin at prophylactic doses to

prevent thromboembolism.

4. CONCLUSION

In summary, pregnancy outcome in women who re-

ceived anthracyclines for malignancy in childhood is

generally favorable. Th ose with left ventricular dysfunc-

tion, as our patient, should be considered at increased

risk but probably the most important prognostic f actor is

the NYHA class.

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Spears, J.C., Tam, J.W., Amankwah, K.S., Smallhorn,

J.F., Farine, D. and Sorensen, S. (2001) Prospective

multicenter study of pregnancy outcomes in women with

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doi:10.1161/hc3001.093437

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