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Practice bulletins > #212 Pregnancy and Heart Disease > Flashcards

#212 Pregnancy and Heart Disease Flashcards

1
Q

What is the leading cause of death in pregnant women and women in the postpartum period? What % of maternal deaths does this account for?

A

Cardiovascular disease. 26.5% of US pregnancy-related deaths

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2
Q

How many pregnancies are there per year in the US?

A

Nearly 4 million

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3
Q

Cardiovascular disease affects what % of US pregnancies?

A

1-4%

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4
Q

What is the maternal morbidity and mortality secondary to congenital heart disease in the US?

A

morbidity - 11%

mortality - 0.5%

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5
Q

What are the most common presentations of maternal acquired heart disease during pregnancy and the postpartum periods (dx not symptoms)?

A

Heart failure, myocardial infarction, arrhythmia, or aortic dissection

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6
Q

What are the 4 key risk factors linked to cardiovascular disease-related maternal mortality.

A
  1. Race/ethnicity: non-hispanic black
  2. Age: >40yo
  3. HTN
  4. Obesity
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7
Q

What is the risk of non-hispanic black women mortality from cardiovascular disease-related pregnancy complications compared with non-hispanic white?

A

3.4 times higher risk of dying

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8
Q

What pregnancy complications/outcomes are non-Hispanic black women are more risk for compared to non-Hispanic white women?

A

Gestational DM, PEC, preterm delivery, low-birth weight infant

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9
Q

How does cardiac output change throughout pregnancy and postpartum?

A 
1st tri= increase 5-10%
2nd and 3rd tri = increase 35-45%
Stage 1 labor = increase 30%
Stage 2 labor = increase 50%
Early pp = increase 60-80%
3-6mo pp = return to prepregnancy values
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10
Q

How does heart rate change during pregnancy and postpartum?

A 
1st tri = increase 3-5%
2nd tri = increase 10-15%
3rd tri = increase 15-20%
Labor = increase 40-50% during ctx
Early pp = decrease 5-10% w/in 24hrs
3-6mo = return to pre pregnancy
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11
Q

How does blood pressure change during pregnancy and postpartum?

A

1st tri = decrease 10%
2nd tri = decrease 5%
3rd tri = increase 5%
labor = SBP increase 15-25% and DBP increase 10-15% during ctx
Early pp = SBP decrease 5-10% w/in 48hrs; may increase again days 3-6 d/t fluid shifts
3-6mo: return to prepregnancy values

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12
Q

How does plasma volume change during pregnancy and postpartum?

A 
1st tri = increase
2nd and 3rd tri = increase 40-50%
Labor = increases
Early pp = increase 500mL d/t autotransfusion
3-6mo: return to prepregnancy values
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13
Q

How many days postpartum can blood pressure increase again?

A

Days 3-6, d/t fluid shifts

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14
Q

At what time postpartum do you expect maternal hemodynamics to generally return to prepregnancy state?

A

3-6mo after delivery

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15
Q

How does left ventricular end diastolic volume change during pregnancy?

A

Increases by approximately 10%

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16
Q

How does the left and right ventricular mass change during pregnancy?

A

Increase by approximately 50% and 40% respectively

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17
Q

What % of women will have diastolic dysfunction at term and how does this present?

A

Approximately 20% of women have diastolic dysfunction at term, which may be associated with dyspnea on exertion

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18
Q

Within what time frame will structural changes of the maternal heart return to baseline?

A

Before 1 year postpartum

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19
Q

By how much does red blood cell mass increase during pregnancy?

A

Increase by 20-30%

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20
Q

Why should you check hemoglobin or hematocrit levels each trimester in women with cardiovascular disease?

A

Severe anemia may be associated with heart failure and myocardial ischemia

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21
Q

When should you evaluate a pregnant woman complaining of shortness of breath?

A

Prompt eval: SOB at rest, paroxysmal nocturnal dyspnea, orthopena, bilateral infiltrates on CXR or refractory pneumonia.
Non emergent eval: SOB w/ mod exertion, new-onset asthma, persistent cough, or moderate or severe OSA

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22
Q

When should you reassure a woman complaining of SOB in pregnancy?

A

No interference with activities of daily living; with heavy exertion only

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23
Q

When should you reassure a pregnant woman complaining of chest pain?

A

Reflux related pain that resolves with treatment

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24
Q

When should you evaluate a pregnant woman complaining of chest pain?

A

Prompt eval: At rest or with minimal exertion

Nonemergent: atypical

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25
Q

When should you reassure a pregnant woman complaining of palpitations?

A

If only lasts a few seconds, self-limited

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26
Q

When should you evaluate a pregnant woman complaining of palpitations?

A

Prompt eval: Associated with near syncope

Nonemergent: brief, self-limited; no lightheadedness or syncope

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27
Q

When should you reassure a pregnant reporting syncope?

A

Dizziness only with prolonged standing or dehydration

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28
Q

When should you evaluate a pregnant woman complaining of syncope?

A

Prompt eval: exertional or unprovoked

Nonemergent: vasovagal

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29
Q

When should you reassure a pregnant patient reporting fatigue?

A

If mild

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30
Q

When should you evaluate a pregnant patient complaining of fatigue?

A

Prompt eval: Extreme fatigue

Nonemergent eval: mild or moderate

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31
Q

At what HR should you reassure a pregnant woman?

A

<90

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32
Q

At what HR should you evaluate a pregnant woman?

A

Prompt eval: >120

Nonemergent: 90-119

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33
Q

What is a normal respiratory rate during pregnancy?

A

12-15 per minute

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34
Q

What oxygen saturation should you reassure a pregnant woman?

A

> 97%

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35
Q

What oxygen saturation for a pregnant woman would you offer non emergent eval vs prompt eval?

A

Nonemergent: 95-97%
Prompt: <95%

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36
Q

What extra heart sounds can you hear during pregnancy that you should reassure the patient?

A

S3, barely audible soft systolic murmur

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37
Q

What does modified WHO Pregnancy Risk Class I mean regarding maternal mortality, morbidity, risk of cardiac event, and follow up?

A

No detectable increased risk of maternal mortality and no or mild increase in morbidity.
2-5% risk of maternal cardiac event rate.
Follow up: Cardiology eval once or twice during pregnancy

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38
Q

What does modified WHO Pregnancy Risk Class 2 mean regarding maternal mortality, morbidity, risk of cardiac event, and follow up?

A

Small increased risk of maternal mortality or moderate increase in morbidity.
6-10% maternal cardiac event rate.
Follow up: Cardiology, every trimester

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39
Q

What does modified WHO Pregnancy Risk Classes 2 and 3 mean regarding maternal mortality, morbidity, risk of cardiac event, and follow up?

A

Intermediate increased risk of maternal mortality or moderate to severe increase in morbidity.
11-19% maternal cardiac event rate.
Follow up: Cardiology, every trimester

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40
Q

What does modified WHO Pregnancy Risk Class 3 mean regarding maternal mortality, morbidity, risk of cardiac event, and follow up?

A

Significantly increased risk of maternal mortality or severe morbidity.
20-27% maternal cardiac event rate.
Follow up: Cardiology every 1-2 months.

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41
Q

What does modified WHO Pregnancy Risk Class 4 mean regarding maternal mortality, morbidity, risk of cardiac event, and follow up?

A

Pregnancy contraindicated.
Discuss induced abortion
Extremely high risk of maternal mortality or severe morbidity.
>27% maternal cardiac event rate.
Follow up: cardiology every month (minimum)

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42
Q

What cardiac lesions are modified WHO pregnancy risk class 1?

A

Uncomplicated, small, or mild pulmonary stenosis, patent ductus arteriosus, mitral valve prolapse. Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage). Atrial or ventricular ectopic beast, isolated.

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43
Q

What cardiac lesions are modified WHO pregnancy risk class 2?

A

Unoperated atrial or ventricular septal defect. Repaired tetralogy of fallot or aortic coarctation. ost arrhythmias (supraventricular arrhthmias). Turner syndrome without congenital cardiac disease.

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44
Q

What cardiac lesions are modified WHO pregnancy risk classes 2 and 3?

A

Mild left ventricular impairment (EF >45%), hypertrophic cardiomyopathy, native or bioprotehstic valve disease not considered mWHO Risk Class 1 or 4 (mild mitral stenosis, moderate aortic stenosis), Marfan or other HTAD syndrome without aortic dilation. Aorta <45mm in bicuspid aortic valve pathology. Repaired coarctation without residua (non-Turner), atrioventricular septal defect

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45
Q

What cardiac lesions are modified WHO pregnancy risk class 3?

A

Moderate LV impairment (EF 30-45%), previous peripartum cardiomyopathy without any residual left ventricular impairment, mechanical valve, systemic RV with good or mildly decrease function, uncomplicated Fontan circulation, unrepaired cyanotic heart disease, other complex heart disease, moderate mitral stenosis, severe asymptomatic aortic stenosis, moderate aortic dilation, ventricular tachycardia

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46
Q

What cardiac lesions are modified WHO pregnancy risk class 4?

A

Pulmonary arterial hypertension, severe systemic ventricular dysfunction, severe mitral stenosis, severe symptomatic aortic stenosis, systemic right ventricle with moderate to severely decreased ventricular function, severe aortic dilation, vascular Ehlers-Danlos, severe (re)coarctation, Fontan circulation with any complication

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47
Q

What should be discussed with women with cardiovascular disease that want to get pregnant?

A
  1. Pregnancy can contribute to decline in cardiac status that may not return to baseline after pregnancy
  2. Maternal morbidity or mortality is possible
  3. Fetal risk of congenital heart or genetic conditions, fetal growth restriction, preterm birth, IUFD, perinatal mortality is higher risk
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48
Q

What is risk of ACE or ARB use during pregnancy?

A

Teratogenic. Associated with fetal renal failure, growth restriction, malformations, and death

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49
Q

What is use of propanolol, atenolol, metoprolol, or carvedilol associated with in pregnancy?

A

May increase risk of growth restriction

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50
Q

What is risk of esmolol during pregnancy?

A

May cause beta blockage in fetus

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51
Q

What is risk of nitroprusside during pregnancy?

A

Potential for fetal cyanide toxicity with high doses

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52
Q

What is risk of nitroglycerin during pregnancy?

A

No adverse fetal effects, observe for risks of methemoglobinemia

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53
Q

What is risk of amiodarone during pregnancy?

A

May be associated with fetal thyroid toxicity

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54
Q

What is the risk of phenytoin use during pregnancy?

A

Teratogenic. Potential for early hemorrhagic disease of the newborn

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55
Q

What is the risk of warfarin in preganncy?

A

Teratogenic. Risk of fetal hemorrhage.

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56
Q

What is risk of furosemide in pregnancy?

A

No known adverse fetal effects

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57
Q

What is risk of digoxin in pregnancy?

A

No adverse fetal effects

58
Q

What tool is available to assess for cardiovascular disease in the antepartum and postpartum periods?

A

The California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm

59
Q

How does pregnancy affect the level of brain natriuretic peptide levels in health women?

A

Increase twofold during pregnancy, with further increase early after delivery, but values remain within normal range

60
Q

What causes a significant increase in BNP in pregnant women?

A

Heart failure from left ventricular systolic dysfunction, diastolic dysfunction, and hypertensive disorders, including preeclampsia

61
Q

Should a baseline BNP level be measured during pregnancy?

A

Yes, for women at high risk of or with known heart diseases, such as dilated cardiomyopathy and congenital heart disease

62
Q

Does a normal or low BNP level help exclude cardiac decompensation during pregnancy?

A

Yes

63
Q

How does the work up of acute coronary syndrome associated with pregnancy differ from the general adult population?

A

It does not. Comparable symptoms, EKG abnormalities, and elevations in biomarkers such as troponin.

64
Q

True or false, an elevated troponin in immediate postpartum period is always abnormal?

A

False

65
Q

True or false, preeclampsia with severe features can cause increase in troponin levels?

A

True

66
Q

True or false, chronic renal disease can cause an increase in troponin level?

A

True

67
Q

What are frequent normal echocardiogram findings during late gestation?

A

Cardiac chamber enlargement, concentric cardiac remodeling, diastolic dysfunction, valvular annular dilatation with regurgitation, and small asymptomatic pericardial effusion

68
Q

How does iodinated contrast material affect developing fetus?

A

Not teratogenic or carcinogenic, but crosses the placenta and can produce transient depressive effects on the developing fetal thyroid gland

69
Q

Is administration of iodinated contrast a contraindication to breastfeeding?

A

No

70
Q

Should breastfeeding be interrupted after gadolinium contrast is administered?

A

No

71
Q

Is gadolinium contrast contraindicated in pregnancy?

A

Should only be used if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome

72
Q

When is a Holter monitor useful during pregnancy?

A

Helpful for assessing symptoms of palpitations, lightheadedness, and syncope during pregnancy

73
Q

Is d-dimer recommended as part of routine evaluation of cardiac disease in pregnancy or postpartum?

A

No

74
Q

What is the definition of pulmonary arterial hypertension?

A

Mean pulmonary arterial pressure more than 25mmHg at rest

75
Q

What is the risk of maternal mortality with pulmonary arterial hypertension?

A

Range from 9-28%

76
Q

Should all women with congenital heart diseases get a fetal echocardiogram during pregnancy?

A

Yes

77
Q

True or false, women with mechanical heart valves require therapeutic anticoagulation during pregnancy?

A

True

78
Q

What should all pregnant women with mechanical or bioprosthetic valves be on?

A

Daily low-dose (81mg) aspirin

79
Q

What prepregnancy assessment should be done in a woman with preexisting dilated cardiomyopathy?

A

Baseline BNP level, transthoracic echocardiogram to assess ejection fraction, and hemodynamics, as well as an exercise stress test to assess functional capacity

80
Q

What is the risk of major adverse CV events during pregnancy in women with preexisting dilated cardiomyopathy?

A

25-40%, mainly heart failure

81
Q

What is the most common genetic cardiac disease? What is the prevalence?

A

Hypertrophic cardiomyopathy. Prevalence of 2%.

82
Q

Where do most aortic dissections occur in young patients?

A

Ascending aorta

83
Q

What is the recommendation for women with vascular Ehlers-Danlos syndrome considering pregnancy?

A

Avoid it

84
Q

What aortic dimension guarantees a safe pregnancy in a patient with aortopathy?

A

None

85
Q

True or false, women with Marfan syndrome with a normal-sized aorta do not need aorta surveillance during pregnancy?

A

False, need surveillance each semester

86
Q

True or false, all patients with Marfans syndrome can deliver vaginally (if otherwise not contraindicated)?

A

False. Cesarean section recommended if ascending aorta is 40mm or greater.

87
Q

True or false, all patients with a bicuspid aortic valve can deliver vaginally (if otherwise not contraindicated)?

A

False. Cesarean section recommended for women with ascending aorta 45mm or greater

88
Q

What are the most common arrhythmias during pregnancy?

A

Premature atrial beats and paroxysmal supraventricular tachycardia (usually AV nodal reentrant tachycardia that can be successfully treated with meds)

89
Q

What is the most common type of ventricular tachycardia that occurs in the absence of a structural heart disease?

A

Right ventricular outflow tract ventricular tachycardia

90
Q

Are ventricular arrhythmias commonly encountered in pregnancy?

A

Rarely

91
Q

What is right ventricular outflow tract ventricular tachycardia sensitive to? How do you treat it?

A

Catecholamine sensitive. Treat with beta-blockers and verapamil

92
Q

How are women with long QT syndrome treated throughout pregnancy?

A

beta-blocker therapy

93
Q

At what point through antepartum, intrapartum, and postpost partum is a women with long QT syndrome most at risk of ventricular tachycardia?

A

Postpartum period

94
Q

In pregnant women with structural heart disease and ventricular tachycardia, what are the treatment options?

A

Antiarrhythmic drug therapy, an implantable cardioverter-defibrillator, and ablation

95
Q

What is the rate of peripartum cardiomyopathy (per 100,000 live births) in US?

A

25-100 per 100,000 live births in the US

96
Q

How is peripartum cardiomyopathy characterized?

A

Nonischemic cardiomyopathy presenting late in pregnancy or the first few months postpartum with a decreased left ventricular ejection fraction to <45% and no previous hx of cardiac disease

97
Q

What is the etiology of peripartum cardiomyopathy?

A

Unknown. Postulated to be an autoimmune pathogenesis, recent work has focused on vascular and genetic etiologies.

98
Q

What is the overall rate of death or cardiac transplantation for women presenting with peripartum cardiomyopathy by 1 year postpartum?

A

5-10% by 1 year postpartum

99
Q

Which racial subgroup is most affected by peripartum cardiomyopathy?

A

Non-hispanic black women. Increased incidence and lower rate of complete myocardial recovery.

100
Q

What are risk factors for peripartum cardiomyopathy?

A

Non-hispanic black, increased age, multifetal pregnancies, gHTN, PEC. Hx peripartum cardiomyopathy.

101
Q

In women with a hx of peripartum cardiomyopathy, what is the risk in subsequent pregnancies?

A

As high as 20%

102
Q

What is the most important diagnostic test for suspected peripartum cardiomyopathy?

A

Echocardiogram

103
Q

True or false, medical management of peripartum cardiomyopathy follows the same general principles as management of HFrEF?

A

True

104
Q

Should breastfeeding be discouraged in women with peripartum cardiomyopathy?

A

No

105
Q

What mode of delivery should be considered for a woman with peripartum cardiomyopathy?

A

Vaginal delivery is reasonable because it results in less maternal morbidity and improved neonatal outcomes

106
Q

What % of women with peripartum cardiomyopathy with initial ejection fraction >30% had a complete myocardial recovery?

A

Nearly 90%

107
Q

Ischemic heart disease complicated how many (out of 100,000) hospitalizations for pregnancy and postpartum care?

A

8 per 100,000

108
Q

Maternal death occurs in what % of women with ischemic heart disease? When is the highest risk?

A

Maternal death occurs in 5-11% of affected patients with the highest risk in the peripartum period.

109
Q

What are risk factors for acute coronary syndrome during pregnany?

A 
Age >30yo
Non-hispanic black
High BMI
DM
Tobacco use
HLD
FHx of CVD
PIH
Hx CAD
Blood transfusion
Peripartum infection
110
Q

What is the most common cause of pregnancy-associated acute coronary syndrome? When is it most likely to happen?

A

Coronary artery dissection. Early postpartum period.

111
Q

What are atypical symptoms of acute coronary artery syndrome?

A

Vomiting, reflux, diaphoresis

112
Q

What initial medical management should be given to pregnant patient with acute coronary syndrome?

A

Oxygen supplementation, nitrates, aspirin, IV unfractionated heparin, and beta-blocker therapy. Place in left lateral tilt (30-90 degrees)

113
Q

What is the next step if a pregnant patient has acute coronary syndrome and symptoms persist after initial medical treatment?

A

Coronary angiography is the preferred test and should be performed without delay

114
Q

What are possible complications of maternal acute coronary syndrome?

A

Heart failure, cardiogenic shock, ventricular arrhythmias, recurrent myocardial infarction, death

115
Q

What is the alphabetical categorization for the Ddx of maternal cardiac arrest?

A 
A (anesthetic complications, accidents)
B (bleeding)
C (CV disorders)
D (Drugs, eg mag)
E (embolism, VTE, AFE)
F (Fever, incl sepsis)
G (general including metabolic and electrolyte)
H (HTN disoders, CVA)
116
Q

What are the two most common etiologies for maternal cardiac arrest in patients admitted for delivery?

A

Hemorrhage (38.1%)

Amniotic fluid embolism (13.3%)

117
Q

How long after maternal arrest should you start perimortem delivery? What if arrest is unwitnessed?

A

If no resuscitation after 4 minutes. If unwitnessed, do not need to postpone delivery 4-5 mintues

118
Q

At what gestational age should you make sure to deviate the uterus during resuscitation efforts for maternal cardiac arrest?

A

20 weeks

119
Q

During maternal cardiac arrest, how do you administer epinephrine?

A

IV or IO above the diaphragm

120
Q

In women with congenital heart disease, what is the risk of congenital heart disease in the fetus?

A

4-10%

121
Q

When should aspirin be initiated for women at high risk of preeclampsia?

A

12-28wks, and continued until delivery

122
Q

How can you differentiate if pulmonary edema in preeclampsia is due to cardiogenic or noncardiogenic causes?

A

Echocardiography can help differentiate

123
Q

When should you deliver women with stable cardiac disease and via which mode of delivery?

A

Vaginal delivery at 39 weeks, with CS reserved for obstetric indications

124
Q

Apart from pain relief, what other benefit does regional anesthesia during labor provide for women with cardiac disease?

A

Pain relief -> minimize catecholamine release -> decrease cardiac output fluctuations, may render vaginal delivery feasible

125
Q

How does mode of anesthesia at time of delivery affect risk of CV events in women with CV disease?

A

Cardiovascular events (usually arrhythmias) are significantly decreased with epidural use

126
Q

What cardiovascular side effects can corticosteroids (BMZ or dexamethasone) have?

A

Fluid retention, electrolyte disturbance, HTN

127
Q

With which cardiac conditions would you think twice about giving corticosteroids for fetal lung maturity?

A 
HTN (can worsen)
heart failure (fluid retention)
128
Q

What cardiovascular side effects can hydroxyprogesterone have?

A

Fluid retention, electrolyte disturbance, HTN

129
Q

What cardiovascular side effects can misoprostol have?

A

Rare side effects

130
Q

What cardiovascular side effects can prostaglandin (PGE2) have?

A

None reported

131
Q

What cardiovascular side effects can oxytocin have?

A

Arrhythmias, hypotension

132
Q

What cardiovascular side effects can magnesium sulfate have?

A

Hypotension, vasodilation, syncope

133
Q

What cardiovascular side effects can terbutaline have?

A

Tachycardia, hypotension, arrhythmias, myocardial ischemia

134
Q

With which cardiac conditions is terbulatine contraindicated?

A

Hypertrophic obstructive cardiomyopathy. Patients at risk of arrhythmias or ischemia. Stenotic valvular lesions especially mitral stenosis

135
Q

What cardiovascular side effects can methylergonovine have?

A

Coronary artery vasospasm, HTN, arrhythmias

136
Q

With which cardiac conditions is methylergonovine contraindicated?

A

Coronary artery disease or risk for ischemia. Aortopathies

137
Q

What cardiovascular side effects can carboprost have?

A

HTN

138
Q

With which cardiac conditions is carboprost contraindicated?

A

Pulmonary HTN

139
Q

What cardiovascular side effects can tromethamine have?

A

Palpitations, tachycardia, vasodepressor syncope, pulmonary HTN.

140
Q

With which cardiac conditions is tromethamine contraindicated?

A

Pulmonary HTN. Cyanotic congenital heart disease. Pulmonary edema.

141
Q

If a woman has a cumulative lifetime duration of breastfeeding of 6-12 months, how does this affect her risk of developing CVD?

A

10% less likely to develop CVD

142
Q

What longterm outcomes are women with HTN disorders during pregnancy at higher risk for compared to normotensive pregnancies?

A

Future cardiovascular disease, cHTN, heart failure, stroke, ESRD, atrial arrhythmias, coronary heart disease, and mortality

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