9) Maternal Medicine - Cardiology Flashcards
Heart disease classed as “low risk” for pregnancy (2.5-5% chance of cardiac event)
- Uncomplicated/mild pulmonary stenosis, PDA, mitral valve prolapse
- Repaired ASD, VSD, PDA, AVPD
- Atrial/ventricular ectopic beats
Heart disease associated with small increase in mortality, moderate increase in morbidity for pregnancy (5-10% chance of cardiac event)
- Unrepaired ASD/VSD
- Repaired ToF
- Most arrhythmias
Heart disease associated with moderate mortality/severe morbidity (10-20% chance cardiac event)
- Most valvular disease
- Mild LV dysfunction, HCM
- Repaired coarctation
- Marfan’s without aortic dilatation
- Bicuspid aortic valve diameter <45mm
Heart disease associated with significantly increased risk of mortality (20-40% chance cardiac event)
- Mechanical valves
- Unrepaired cyanotic heart disease
- Fontan circulation
- Marfan’s with aorta 40-45mm
- Aorta 45-50mm with bicuspid aortic valve
Extremely high risk heart diseases (>40% chance of cardiac event) - pregnancy contraindicated
- 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
Mortality rate associated with pulmonary hypertension
10-25%
17% Idiopathic, 33% Associated with other conditions
Diagnosis of pulmonary hypertension
- Doppler USS
- Mean pulmonary artery pressure >25mmHg at rest
Mortality rate associated with termination in pulmonary hypertension
7%
Reason for mortality in PH
- Right heart failure
- Escalating pulmonary hypertension with crisis
- Increased shunt in Eisenmengers
Commonest congenital heart defect in women
ASD
PDA in pregnancy
- Most cases corrected and so no problems
- Uncorrected do well but risk CCF
ASD in pregnancy
- Well tolerated
- Risk of paradoxical embolus (low risk)
- May deteriorate and become hypotensive if increased L->R shunt following blood loss
VSD in pregnancy
- Well tolerated unless Eisenmengers
Congenital aortic stenosis - most cases associated with what?
- Bicuspid aortic valve (therefore risk of dilatation of ascending aorta)
What is classed as significant obstruction in aortic stenosis?
Valve <1cm2 or gradient >50mmHg
Risks of aortic stenosis
Angina, hypertension, heart failure, sudden death.
Treatment for aortic stenosis in pregnancy
B-blockers provided LVF normal (controls symptoms and hypertension)
Balloon valvotomy.
Management of coarctation of aorta in pregnancy
- Usually repaired pre-pregnancy
- MRI to exclude any aneurysms/dilataiotn
- B-blockers and strict BP control
Main causes of cyanotic congenital heart disease
- Pulmonary atresia
- Tetralogy of fallot
Problems with cyanotic heart disease in pregnancy
- 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
Features which improve pregnancy outcomes in congenital cyanotic heart disease
Resting O2 sats >85%
Hb <18
Haematocrit <55%
Features of Tetralogy of Fallot
- Pulmonary stenosis
- Ventricular septal defect
- Over-riding aorta (aorta lies over VSD therefore non-oxygenated blood gets into aorta)
- Right ventricular hypertrophy
Main concern in operated ToF
Tolerate pregnancy well.
Right ventricular dysfunction.
When is Fontan procedure done?
Tricuspid atresia/transposition with pulmonary stenosis.
What happens in Fontan procedure?
Right ventricle is bypassed and left ventricle provides pump for both circulations.
Risk of congenital cardiac disease in fetus of woman affected by congenital cardiac disease
2-5% (double general population risk)
ASD: 5-10%
Aortic stenosis: 18-20%
Risks in unoperated ToF
- Paradoxical embolism through R–>L shunt
- Effects of cyanosis on fetus (growth restriction, miscarriage, prematurity)
Most common congenital heart diseases in pregnancy
PDA, ASD, VSD (account for 60%)
Signs of decompensation in congenital aortic stenosis
- Development of tachycardia
- Failure for gradient across valve to increase as pregnancy progresses
Risk of congenital cardiac disease in fetus of affected woman?
Generally: 2-5%
ASD: 5-10%
Aortic stenosis: 18-20%
Most common acquired heart disease
Rheumatic heart disease
Most common abnormality with rheumatic heart disease
90% Mitral stenosis
Murmur in mitral stenosis
Low pitched, mid-diastolic rumble
Precipitating factor in decline of function in mitral stenosis
Tachycardia which shortens diastolic filling and therefore reduces stroke volume further
Mitral stenosis in pregnancy
Use b-blockers
Treat pulmonary oedema
Inheritance of Marfans
Autosomal dominant
Proportion of people with Marfan’s who have cardiac involvement
80%
Cardiac features of marfans
Mitral valve prolapse
Mitral regurgitation
Aortic root dilatation
Risk of aortic dissection in Marfans
3% overall
10% if root >4cm
When is pregnancy contraindicated in Marfan’s?
Aortic root >4.5cm (consider other RF if 4-4.5cm)
When should women with Marfan’s have a CS?
> 4.5cm
Percentage of cases of HCM which are familial
70%
Inheritance of hypertrophic ardiomyopathy
Autosomal dominant
Diagnostic criteria for peripartum cardiomyopathy
LVEF <45%
Fractional shortening <30%
LV end-diastolic pressure >2.7cm/m2
Mortality of PPCM
9-15%
Rate of spontaneous full recovery from PPCM
50%
Risk of worsening heart failure and death if PPCM not recovered and second pregnancy embarked on
50%
25%
Recurrence risk of PPCM if resolves
25%
Target INR for metallic valve
2.5-3.5
Target anti-Xa levels if using high dose LMWH for metallic valves
0.8-1.2
When to discontinue warfarin
10-14d pre-delivery
Risk increase of MI in pregnancy
3-4 x
Death due to IHD
1/132,000 pregnancies
Mortality of MI in pregnancy
1/13
Number of pregnancies affected by congenital heart disease (mother)
0.8%
Most common cardiac complication in pregnancy
Arrhythmias
Percentage of women with palpitations found to have ectopic beats or non-sustained arrhythmias
50%
Recurrence risk if previous sustained tachyarrhythmia
43%
ECG changes in pregnancy
- Left axis deviation
- Inverted/flattened T waves III, V1-V3
- Q wave in II, III and aVF
- 50-60% ectopics
Which tachycarrhythmias are benign?
Sinus tachy
Atrial and ventricular premature beats
Most common non-benign arrhythmia
SVT
Incidence of SVT in pregnancy
24 in 100,000
Most common cause of SVT
AVNRT
Treatment for SVT
- Vagal
- IV adenosine
- Direct cardioversion if unstable
- B blockers for prophylaxis
AF/flutter in pregnancy associations
Cardiac pathology or electrolyte abnormalities
Treatment of AF/flutter in pregnancy
- Direct cardioversion if unstable (need anticoagulation if not new onset)
- IV flecainide or butilide
- b blockers as rate control
Associations with VT
Structural or primary electrical disease
Treatment for VT
Unstable - electrical cardioversion
Stable - sotalol or flecainide
Prophylaxis - b-blockers or implantable ICD
ECG abnormality in WPW
Delta wave
ECG abnormality in HOCM
High voltages in precordial leads with Q waves and ST changes
ECG abnormality in long QT
QT >460ms
Drugs to avoid in long QT
Prochlorperazine
Ondansetron
Trimethoprim
Erythromycin
Percentage of MI due to coronary atheroma
50%
Next most common cause of MI
Coronary artery dissection
Which coronary artery most common dissection?
LAD
How long to delay delivery for after an MI if possible?
2-3 weeks
Diagnosis of POTS
Symptoms and signs of orthostatic instability within 10 minutes of upright posture associated with persistent increased HR >30bpm
POTS in pregnancy
60% improvement
20-30% worsen
Most common problems in POTS in pregnancy
Migraine
Pre-syncopal
Syncopal
POTS on pregnancy
No adverse outcomes.
50-60% rate of hyperemesis.
Oral intake in POTS
Aim 2-3L fluid per day and 10-12g salt per day
Fludrocortisone in pregnancy
Safe
Midodrine in pregnancy
Insufficient data
Ivabradine in pregnancy
Contraindicated
Ocreotide in pregnancy
Can be used in refractory cases and probably safe
Clonidine in pregnancy
Safe
Pyridostigmine in pregnancy
Safe
