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Laura MRCOG Part 2 > 9) Maternal Medicine - Cardiology > Flashcards

9) Maternal Medicine - Cardiology Flashcards

1
Q

Heart disease classed as “low risk” for pregnancy (2.5-5% chance of cardiac event)

A
  • Uncomplicated/mild pulmonary stenosis, PDA, mitral valve prolapse
  • Repaired ASD, VSD, PDA, AVPD
  • Atrial/ventricular ectopic beats
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2
Q

Heart disease associated with small increase in mortality, moderate increase in morbidity for pregnancy (5-10% chance of cardiac event)

A
  • Unrepaired ASD/VSD
  • Repaired ToF
  • Most arrhythmias
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3
Q

Heart disease associated with moderate mortality/severe morbidity (10-20% chance cardiac event)

A
  • Most valvular disease
  • Mild LV dysfunction, HCM
  • Repaired coarctation
  • Marfan’s without aortic dilatation
  • Bicuspid aortic valve diameter <45mm
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4
Q

Heart disease associated with significantly increased risk of mortality (20-40% chance cardiac event)

A
  • Mechanical valves
  • Unrepaired cyanotic heart disease
  • Fontan circulation
  • Marfan’s with aorta 40-45mm
  • Aorta 45-50mm with bicuspid aortic valve
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5
Q

Extremely high risk heart diseases (>40% chance of cardiac event) - pregnancy contraindicated

A
  • Pulmonary hypertension
  • Severe LV impairment (<30%)
  • NYHA 3/4
  • Previous PPCM with any residual impairment
  • Severe mitral stenosis
  • Severe aortic coarctation
  • Symptomatic aortic stenosis
  • Marfan with aorta >45mm
  • Bicuspid aortic valve >50mm
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6
Q

Mortality rate associated with pulmonary hypertension

A

10-25%

17% Idiopathic, 33% Associated with other conditions

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7
Q

Diagnosis of pulmonary hypertension

A
  • Doppler USS

- Mean pulmonary artery pressure >25mmHg at rest

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8
Q

Mortality rate associated with termination in pulmonary hypertension

A

7%

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9
Q

Reason for mortality in PH

A
  • Right heart failure
  • Escalating pulmonary hypertension with crisis
  • Increased shunt in Eisenmengers
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10
Q

Commonest congenital heart defect in women

A

ASD

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11
Q

PDA in pregnancy

A
  • Most cases corrected and so no problems

- Uncorrected do well but risk CCF

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12
Q

ASD in pregnancy

A
  • Well tolerated
  • Risk of paradoxical embolus (low risk)
  • May deteriorate and become hypotensive if increased L->R shunt following blood loss
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13
Q

VSD in pregnancy

A
  • Well tolerated unless Eisenmengers
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14
Q

Congenital aortic stenosis - most cases associated with what?

A
  • Bicuspid aortic valve (therefore risk of dilatation of ascending aorta)
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15
Q

What is classed as significant obstruction in aortic stenosis?

A

Valve <1cm2 or gradient >50mmHg

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16
Q

Risks of aortic stenosis

A

Angina, hypertension, heart failure, sudden death.

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17
Q

Treatment for aortic stenosis in pregnancy

A

B-blockers provided LVF normal (controls symptoms and hypertension)
Balloon valvotomy.

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18
Q

Management of coarctation of aorta in pregnancy

A
  • Usually repaired pre-pregnancy
  • MRI to exclude any aneurysms/dilataiotn
  • B-blockers and strict BP control
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19
Q

Main causes of cyanotic congenital heart disease

A
  • Pulmonary atresia

- Tetralogy of fallot

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20
Q

Problems with cyanotic heart disease in pregnancy

A
  • Worsening cyanosis due to increased R–>L shunting due to falling peripheral resistance
  • Thromboembolic risk due to polycythaemia
  • Chance of live birth <20%
  • Associated pulmonary hypertension
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21
Q

Features which improve pregnancy outcomes in congenital cyanotic heart disease

A

Resting O2 sats >85%
Hb <18
Haematocrit <55%

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22
Q

Features of Tetralogy of Fallot

A
  • Pulmonary stenosis
  • Ventricular septal defect
  • Over-riding aorta (aorta lies over VSD therefore non-oxygenated blood gets into aorta)
  • Right ventricular hypertrophy
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23
Q

Main concern in operated ToF

A

Tolerate pregnancy well.

Right ventricular dysfunction.

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24
Q

When is Fontan procedure done?

A

Tricuspid atresia/transposition with pulmonary stenosis.

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25
Q

What happens in Fontan procedure?

A

Right ventricle is bypassed and left ventricle provides pump for both circulations.

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26
Q

Risk of congenital cardiac disease in fetus of woman affected by congenital cardiac disease

A

2-5% (double general population risk)
ASD: 5-10%
Aortic stenosis: 18-20%

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27
Q

Risks in unoperated ToF

A
  • Paradoxical embolism through R–>L shunt

- Effects of cyanosis on fetus (growth restriction, miscarriage, prematurity)

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28
Q

Most common congenital heart diseases in pregnancy

A

PDA, ASD, VSD (account for 60%)

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29
Q

Signs of decompensation in congenital aortic stenosis

A
  • Development of tachycardia

- Failure for gradient across valve to increase as pregnancy progresses

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30
Q

Risk of congenital cardiac disease in fetus of affected woman?

A

Generally: 2-5%
ASD: 5-10%
Aortic stenosis: 18-20%

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31
Q

Most common acquired heart disease

A

Rheumatic heart disease

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32
Q

Most common abnormality with rheumatic heart disease

A

90% Mitral stenosis

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33
Q

Murmur in mitral stenosis

A

Low pitched, mid-diastolic rumble

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34
Q

Precipitating factor in decline of function in mitral stenosis

A

Tachycardia which shortens diastolic filling and therefore reduces stroke volume further

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35
Q

Mitral stenosis in pregnancy

A

Use b-blockers

Treat pulmonary oedema

36
Q

Inheritance of Marfans

A

Autosomal dominant

37
Q

Proportion of people with Marfan’s who have cardiac involvement

A

80%

38
Q

Cardiac features of marfans

A

Mitral valve prolapse
Mitral regurgitation
Aortic root dilatation

39
Q

Risk of aortic dissection in Marfans

A

3% overall

10% if root >4cm

40
Q

When is pregnancy contraindicated in Marfan’s?

A

Aortic root >4.5cm (consider other RF if 4-4.5cm)

41
Q

When should women with Marfan’s have a CS?

A

> 4.5cm

42
Q

Percentage of cases of HCM which are familial

A

70%

43
Q

Inheritance of hypertrophic ardiomyopathy

A

Autosomal dominant

44
Q

Diagnostic criteria for peripartum cardiomyopathy

A

LVEF <45%
Fractional shortening <30%
LV end-diastolic pressure >2.7cm/m2

45
Q

Mortality of PPCM

A

9-15%

46
Q

Rate of spontaneous full recovery from PPCM

A

50%

47
Q

Risk of worsening heart failure and death if PPCM not recovered and second pregnancy embarked on

A

50%

25%

48
Q

Recurrence risk of PPCM if resolves

A

25%

49
Q

Target INR for metallic valve

A

2.5-3.5

50
Q

Target anti-Xa levels if using high dose LMWH for metallic valves

A

0.8-1.2

51
Q

When to discontinue warfarin

A

10-14d pre-delivery

52
Q

Risk increase of MI in pregnancy

A

3-4 x

53
Q

Death due to IHD

A

1/132,000 pregnancies

54
Q

Mortality of MI in pregnancy

A

1/13

55
Q

Number of pregnancies affected by congenital heart disease (mother)

A

0.8%

56
Q

Most common cardiac complication in pregnancy

A

Arrhythmias

57
Q

Percentage of women with palpitations found to have ectopic beats or non-sustained arrhythmias

A

50%

58
Q

Recurrence risk if previous sustained tachyarrhythmia

A

43%

59
Q

ECG changes in pregnancy

A
  • Left axis deviation
  • Inverted/flattened T waves III, V1-V3
  • Q wave in II, III and aVF
  • 50-60% ectopics
60
Q

Which tachycarrhythmias are benign?

A

Sinus tachy

Atrial and ventricular premature beats

61
Q

Most common non-benign arrhythmia

A

SVT

62
Q

Incidence of SVT in pregnancy

A

24 in 100,000

63
Q

Most common cause of SVT

A

AVNRT

64
Q

Treatment for SVT

A
  • Vagal
  • IV adenosine
  • Direct cardioversion if unstable
  • B blockers for prophylaxis
65
Q

AF/flutter in pregnancy associations

A

Cardiac pathology or electrolyte abnormalities

66
Q

Treatment of AF/flutter in pregnancy

A
  • Direct cardioversion if unstable (need anticoagulation if not new onset)
  • IV flecainide or butilide
  • b blockers as rate control
67
Q

Associations with VT

A

Structural or primary electrical disease

68
Q

Treatment for VT

A

Unstable - electrical cardioversion
Stable - sotalol or flecainide
Prophylaxis - b-blockers or implantable ICD

69
Q

ECG abnormality in WPW

A

Delta wave

70
Q

ECG abnormality in HOCM

A

High voltages in precordial leads with Q waves and ST changes

71
Q

ECG abnormality in long QT

A

QT >460ms

72
Q

Drugs to avoid in long QT

A

Prochlorperazine
Ondansetron
Trimethoprim
Erythromycin

73
Q

Percentage of MI due to coronary atheroma

A

50%

74
Q

Next most common cause of MI

A

Coronary artery dissection

75
Q

Which coronary artery most common dissection?

A

LAD

76
Q

How long to delay delivery for after an MI if possible?

A

2-3 weeks

77
Q

Diagnosis of POTS

A

Symptoms and signs of orthostatic instability within 10 minutes of upright posture associated with persistent increased HR >30bpm

78
Q

POTS in pregnancy

A

60% improvement

20-30% worsen

79
Q

Most common problems in POTS in pregnancy

A

Migraine
Pre-syncopal
Syncopal

80
Q

POTS on pregnancy

A

No adverse outcomes.

50-60% rate of hyperemesis.

81
Q

Oral intake in POTS

A

Aim 2-3L fluid per day and 10-12g salt per day

82
Q

Fludrocortisone in pregnancy

A

Safe

83
Q

Midodrine in pregnancy

A

Insufficient data

84
Q

Ivabradine in pregnancy

A

Contraindicated

85
Q

Ocreotide in pregnancy

A

Can be used in refractory cases and probably safe

86
Q

Clonidine in pregnancy

A

Safe

87
Q

Pyridostigmine in pregnancy

A

Safe

Laura MRCOG Part 2 (56 decks)

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