B P10 C92 Pregnancy and Heart Disease Flashcards
Normal physiologic changes in pregnancy
______ Plasma flow
______ Cardiac output
______ SVR/PVR
______ GFR
______ Plasma volume
______ Coagulation factors
______ Protein C
______ TG, Total cholesterol, LDL
______ HDL
______ Insulin resistance
All increase in pregnancy except for SVR, protein C, HDL
Early in pregnancy, the peripheral vascular resistance decreases and there is a corresponding small drop in blood pressure (BP) by _____________ below baseline until the third trimester, when the BP increases back to baseline.
5 to 10 mm Hg
Heart rate increases by approximately _____________ above pre-pregnancy levels, and, in combination with increases in stoke volume, there is a resultant increase in cardiac output by _____%
10 beats/min
30% to 50%
Twin pregnancies can increase the cardiac output by a further ____________
10 - 15%
At the time of labor and delivery and immediately postpartum, cardiac output increases a further _____%.
60-80%
Further hemodynamic changes due to:
Catecholamines
Release of inferior vena cava compression
Autotransfusion from uterine contractions
Blood loss
Mobilization of fluid during the first week after delivery can result in heart failure in women with _____
CMP
Severe outflow tract obstruction
Many of the hemodynamic changes resolve in the first ______ after delivery, although complete resolution may take as long as ______
2 weeks
6 months
_____ are symptoms that can be associated with normal pregnancy.
Fatigue, dyspnea, light-headedness, and palpitations
Normal pregnancy results in cardiac examination findings including:
(1) Collapsing arterial pulses
(2) Prominent JV pulsations w/o elevation of JVP
(3) Laterally displaced apical impulse
(4) Palpable right ventricle or pulmonary trunk
(5) Soft, short ejection systolic murmur best heard over the pulmonic area or left sternal border
When it is difficult to differentiate between pregnancy-associated changes versus early cardiac decompensation, echocardiography, or B-type natriuretic peptide (BNP) level can be useful (a BNP value of ____ pg/mL has been proposed as having a positive likelihood ratio of 2.5 and a negative likelihood ratio of 0.1 for heart failure)
111 pg/mL
Pregnant women with heart disease have a higher BNP level than pregnant women without heart disease, and a BNP less than ____ pg/mL in the heart disease group had a 100% negative predictive value for cardiac complications
< 100 pg/mL
Normal pregnancy is associated with electrocardiographic (_____) and chest radiographic (
ECG:
Sinus tachycardia
Premature atrial or ventricular complexes
Left QRS axis deviation
Inferior Q waves
T wave flattening
ST depression
Increased R/S ratio on right precordial leads
CXR:
Pleural effusion
Straightening of left upper cardiac border
Horizontal positioning of heart
Increased lung vascular markings
Echocardiographic changes in pregnancy
(1) increase in dimensions of all four cardiac chambers without changes in _______________________
(2) increase in left ventricular wall ______________
(3) increasing degree of __________________ which usually does not exceed more than moderate in degree
(4) changes in left ventricular mechanics (strain, twist, untwisting) and left atrial strain reflective of adaptive changes in LV volumes, mass, and loading conditions with advancing gestational age
(1) Increase in dimensions of all four cardiac chambers without changes in LVEF
(2) Increase in LVWT
(3) Increasing degree of TR which usually does not exceed more than moderate in degree
(4) Changes in left ventricular mechanics (strain, twist, untwisting) and left atrial strain reflective of adaptive changes in LV volumes, mass, and loading conditions with advancing gestational age
____ echocardiogram is the preferred imaging method in pregnancy, but imaging may be more technically challenging with cardiac displacement.
TTE
When transesophageal echocardiography is performed in pregnancy to obtain data that cannot be obtained by transthoracic echocardiography, the imaging protocol should be abbreviated to minimize the potential risk of vomiting/aspiration due to delayed gastric emptying in pregnancy.
Exercise testing, with or without echocardiography, usually performed prior to pregnancy, should be limited to _____ test if performed during pregnancy (peak heart rate not to exceed _____% of predicted maximum).
The use of _____ as a stress agent should be avoided.
Submaximal
PHR not to exceed 70% to 80%
Dobutamine
The risk of fetal adverse outcome is highest with radiation exposure during the period of organogenesis during the _____ trimester.
First
A fetal exposure dose of less than 50 mGy is considered to be negligible risk.
The fetal dose from chest radiography is less than 0.0001 mGy; however, maternal shielding should be used.
Lung imaging with point of care ultrasound is an alternative when assessing for possible pulmonary edema or pulmonary pathology
When cardiac catheterization is performed during pregnancy, it should be delayed until after period of organogenesis (____________ gestational age)
Preferred approach (other than for suspected SCAD)
12 weeks
Radial approach
Electrophysiologic procedures for arrhythmias should best be deferred until after pregnancy or performed using a _____ system during pregnancy for refractory cases.
Nonfluoroscopic
CAPREG risk score
History of heart failure, stroke, or arrhythmias
Baseline NYHA III-IV or cyanosis
Systemic ventricular ejection fraction < 40%
Left heart obstruction
-Aortic valve area < 1.5 cm 2 or
-Peak LVOT gradient > 30 mmHg
-Mitral valve area < 2.0 cm2
CAPREG II Risk Score
3 pts each
* History of heart failure, stroke, or arrhythmias
* Baseline NYHA III-IV or cyanosis
* Mechanical valve
2 pts each
* Ventricular dysfunction
* High-risk left-sided valve disease/LVOTO
* PH
* CAD
* High-risk aortopathy
1 pt each
No prior cardiac intervention
Late pregnancy assessment
Score
0-1: 5%
2: 10%
3: 15%
4: 22%
>4: 41%
Class IV Cardiac Lesions based on Modified World Health Organization Classification of Maternal Cardiovascular Risk
Maternal cardiac risk ______
Class IV - 40 - 100% maternal cardiac risk
- PAH
- Severe systemic ventricular dysfunction (EF <30% or NYHA class III–IV)
- Previous PPCM with any residual left ventricular impairment
- Severe MS
- Severe symptomatic AS
- Systemic RV with moderate or severely decreased ventricular function
- Severe aortic dilatation (>45 mm in Marfan syndrome or other HTAD, >50 mm in BAV, Turner syndrome ASI >25 mm/m2 , Tetralogy of Fallot >50 mm)
- Vascular Ehlers-Danlos
- Severe (re)coarctation
- Fontan with any complication
True or False
Pregnancy should be discouraged in women with high cardiac lesions and termination should be considered if pregnancy occurs
True
Preconception counseling provides opportunities to optimize risk by:
(1) Better defining the nature of the cardiac lesion and or functional capacity by exercise or cardiopulmonary testing, imaging, or cardiac catheterization;
(2)** Stopping medications that are contraindicated** in pregnancy (e.g., afterload reducing agents in heart failure treatment) for a trial period prior to pregnancy to ascertain clinical stability;
(3) Interventions such as smoking cessation or intervention for severe aortic/mitral stenosis (MS);
(4) Genetic consultation if the women, her first-degree relative, or her partner has congenital a heart defect.
Site of pregnancy care/delivery: There are three possible options:
(1) Exclusive care and delivery at referral center by maternal heart team (recommended for high-risk pregnancies)
(2) Joint care by local cardiology or obstetric practitioners with delivery at local center, after initial evaluation by pregnancy heart team (non–high-risk pregnancies)
(3) Initial review by pregnancy heart team and local obstetric care (for low-risk pregnancies)
Women at low risk for cardiac complications are often seen ____ during pregnancy with plans to deliver at a local obstetric center.
1-2 during the pregnancy
Women at moderate or high risk for cardiac complications are followed more closely
Women with congenital heart disease should be offered a fetal echocardiogram at _____ weeks’ gestation to assess for congenital cardiac malformation.
18-22 weeks AOG
Drugs contraindicated in pregnancy
SGLT2i
Statins
Atenolol
ACEi, ARB
Aldosterone antagonists
Amiodarone
Bosentan (endothelin receptor antagonists)
Ivabradine
Direct oral anticoagulants
S2 4A BID
Warfarin is associated with an embryopathy when exposure occurs between ______________ gestation and needs to be discontinued prior
6 and 12 weeks
Classic NSAIDs (ibuprofen, indomethacin, naproxen) or high-dose ASA can be used early in the pregnancy.
After the _________ gestational week, all NSAIDs (except enteric coated ASA [ECASA] ≤100 mg daily) have the potential of causing ________ and ________ and should be withdrawn by the ________ gestational week.
20th gestational week
Constriction of the ductus arteriosus and impact fetal renal function
Withdrawn by 32nd week
When possible, a spontaneous vaginal delivery is preferred.
Cesarean delivery is rarely required for cardiac indications except for cases such as:
- Women who do not have warfarin discontinued at least 2 weeks prior to delivery due to the risk of neonatal intracranial hemorrhage
- Severely dilated thoracic aortas
- Severe refractory HF
- Hemodynamic instability
Electrical cardioversion is safe during p nancy, and women with tachyarrhythmias who are hemodynamically unstable require cardioversion.
__________________ are less common during pregnancy.
Pacemaker and implantable cardioverter defibrillators are safe during pregnancy and delivery.
Bradycardias
Cardiac arrest during pregnancy is managed similarly to the non- pregnant arrest, with the following modifications:
(1) Lateral uterine displacement during an arrest is required after 20 weeks’ gestation;
(2) Intubation may be more difficult due to changes in airway mucosa;
(3) Emergency cesarean delivery should be initiated if there has been no return of spontaneous circulation within 4 minutes of the onset of arrest in a pregnant women with a fundus height at or above the umbilicus
Hypertension in pregnancy is defined as _____, with the proviso that the second measurement can be obtained within 15 minutes if the BP is severely elevated (_____)
≥140/90 on two measurements at least 4 hours apart
Severe:
≥160/110
The BP should be remeasured from the arm with the higher BP after an interval of at least 15 minutes if there is nonsevere elevation of BP.
_____ monitoring can separate white coat versus chronic hypertension for women with persistent BP elevation of 140/90 mm Hg or less at less than 20 weeks’ gestation.
Ambulatory BP monitoring
Patients with preexisting hypertension may have a falsely normal BP due to the reduced systemic vascular resistance that manifests by the _____th gestational week.
12th week AOG
Pregnant women with severe hypertension (BP _____) should be triaged expeditiously and pharmacotherapy initiated to reduce risk of heart failure, stroke, or renal disease
≥160/110 persistent for 15 minutes
__________________ is gestational hypertension with proteinuria (>0.3 g/24 hr, protein/creatinine ratio >0.3, or urine dipstick reading of 2+)
Pre-eclampsia
Hypertension diagnosed or present before pregnancy or before 20 weeks of gestation, or hypertension diagnosed for the first time during pregnancy and that does not resolve in the postpartum period
Chronic hypertension
Treatment of nonsevere hypertension in pregnancy
- Start single anti-HTN
MEthyldopa, LAbetalol, NIfedipine - Maternal and fetal assessments
- Regular BP reassessments
- 2nd line: HCTZ or combination
Treatment for severe hypertension in pregnancy
- Consider admission
- IV HYdralazine, IV LAbetalol, Oral short acting NIfedipine (if no IV access)
- IV MgSO4 - prevent seizures in preeclampsia with severe features
- IV NTG - edema in preeclampsia
Currently, the optimal goal for BP therapy varies between United States, EU and Canada
US: 140 - 150/90 - 100 mm Hg
EU: < 140/90
Canada: < 85 mm Hg DBP
For prevention of preeclampsia, low-dose ASA should be initiated between _____ and continued until at least _____ weeks’ gestation in women in women with any high risk factors (_____) or in women with more than 1 moderate risk factor (nulliparity, body mass index >30, family history of preeclampsia, age ≥35 years, socioeconomic status, or personal history factors)
Initiated: 12 and 16 weeks’ gestation (and ideally, no later than 20 weeks)
Until: at least 36 weeks
High risk factors:
Chronic hypertension
Prior pre- eclampsia
Multifetal gestation
Diabetes mellitus
Renal disease
Autoimmune disease
Preterm birth <34 weeks’ gestation
Pregnancy is contraindicated in women with DCM with
Severe left ventricular systolic dysfunction
Factors related to pregnancy/delivery that can worsen outflow obstruction in HCM
Epidural anesthesia
Oxytocin
Valsalva maneuver
______________ is a cardiomyopathy that occurs de novo during pregnancy. Women typically present later in pregnancy or in the first few months postpartum with left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] <45%), heart failure, and embolic events.
PPCM
Risk factors:
Older maternal age
African American race
Multigestation pregnancy
Preeclampsia
Hypertension
The cause of PPCM is not known, but proposed mechanisms have included nutritional deficiencies, viral myocarditis, and autoimmune and vascular-hormonal processes.
A mouse model for PPCM identified a 16-kDa prolactin fragment that resulted in vascular and myocardial dysfunction. Based on that finding and small human studies, _____, a suppressor of prolactin secretion, has been used as a therapy for PPCM
Bromocriptine
Baseline left ventricular ejection fraction _____ and left ventricular end diastolic dimensions less than _____ cm at presentation are prognostic markers associated with good recovery in PPM
LVEF: > 30%
LVEDD: < 6cm
Prognostic factors in DCM in pregnancy:
Good:
Good functional capacity
Mild left ventricular systolic function
Poor:
NYHA functional class III or IV and/or moderate or severe LV systolic dysfunction
(high rates of cardiac complications including heart failure and arrhythmias)
___________________ has been responsible for up to 43% of MI/ischemic heart disease in pregnancy
___________________ more common than NSTEMI and 2/3 of cases involves the ____________
SCAD
STEMI
Anterior wall
Majority of acute MI presented in the third trimester or postpartum period
Majority of acute MI presented in the _____ period.
Third trimester or postpartum
The incidence of MI is estimated to be approximately 3 per 100,000 pregnancies, with a case fatality rate of approximately 5%.
Coronary atherosclerotic disease accounts for up to 40% of cases, spontaneous coronary artery dissection (SCAD) has been responsi- ble for up to 43% of cases, and the remainder have been attributed to intracoronary thrombus (up to 17%) or coronary spasm (approxi-mately 2%)
SCAD: 43%
CAD: 40%
ICT: 17%
CS: 2%
Most common type of SCAD
Type 2
Type 1 (typical appearance, multiple lumens, arterial wall stain) was encountered in <1/3 of cases.
Type 2 (diffuse smooth stenosis, most common)
Type 3 (mimic atherosclerosis; least common)
SCAD usually requires intravascular ultrasound or optical coherence tomography.
Because SCAD is a common cause of ST elevation MI in pregnant women, thrombolysis for acute ST-segment elevation myocardial infarction [STEMI] is not recommended. Thrombolytic agents do not cross the placenta but can cause maternal and placental bleeding.
The risk of iatrogenic catheter-induced coronary artery dissection is higher (approximately 3%) than for standard coronary angiography, attributed to underlying vascular frailty in patients with SCAD.
The risk of iatrogenic coronary dissection was higher with radial approach; thus the femoral approach may be preferred in the pregnant patient.
Although at least 70% of patients with SCAD will have angiographic healing on repeat angiography, these data are not based on consecutive sample or pregnant patients.
_____ is the preferred strategy for SCAD, with inpatient monitoring for an extended period because up to 10% of conservatively managed patients may have extension of dissection within the first 7 days.
Medical therapy
Percutaneous coronary intervention (PCI) in patients with SCAD has consistently been reported to increase risk of complications and poor outcomes, likely related to **increased coronary frailty. **
PCI or coronary artery bypass grafting (CABG) should be considered for those women with active or ongoing ischemia, hemodynamic instability, left main, or severe proximal two vessel dissection
Patients with PCI should be on dual platelet therapy, and ______ is viewed as the only “safe” inhibitor.
Clopidogrel
Patients with MI should be on beta blockers and low-dose ASA.The indications for clopidogrel in patient who have not undergone PCI is less certain due to potential increase in bleeding risk.
Nitrates and calcium channel blockers can be used for angina therapy. ACE-Is/ARBs and statins are not recommended during pregnancy.
Nitrates, beta blockers, or low-molecular-weight or unfractionated heparin can be used for acute MI during pregnancy
______________ is the most common type of valvular heart disease encountered in pregnant women globally
Rheumatic MS
In those with significant MS and who are in sinus rhythm, anticoagulation is a consideration if there is _____.
- Spontaneous echocardiographic contrast in the left atrium
- Large left atrium (≥60 mL/m2)
- Congestive heart failure.
_____ in functional class may be an early warning sign of impending heart failure, and loop diuretics and increasing dose of beta blockers (or digoxin if intolerant to beta blockers) should be initiated along with restriction of activities.
Deterioration
Aortic stenosis (AS) most commonly occurs as a result of _____ and limits the ability of the heart to increase cardiac output or adjust to changes in loading conditions during pregnancy, increasing propensity for heart failure, ischemia, or hypotension
BAV
Aortic valve replacement is recommended in women with _____.
Symptomatic AS
or
Asymptomatic women with left ventricular ejection fraction less than 50% or abnormalities during exercise testing.
____ is generally better tolerated than AS, and a small study reported that 29% of pregnancies in women with severe aortic regurgitation were complicated by pulmonary edema. Functional deterioration will usually respond to loop diuretics.
AR
Bioprosthetic valves are at less risk for pregnancy-related complications as the valves are _________________ and ___________________ is not required.
Less thrombogenic
Anticoagulation
The most serious maternal complication is ________________ in patients with mechanical heart valve
Valve thrombosis
The risk of valve thrombosis is related to a number of factors, including the **type of anticoagulant used during pregnancy (warfarin less risk than heparin), the type of valve (newer generation valves less risk than older generation valves) and valve position (aortic position less risk than mitral position). **
The 3 anticoagulation options for pregnant women with mechanical valves:
(a) Warfarin or other vitamin K antagonists
(b) Low-molecular-weight heparins
(c) Intravenous unfractionated heparin
_____ is associated with the lowest risk of valve thrombosis and maternal mortality for the mother but crosses the placenta and can cause warfarin embryopathy when used in the _____ and fetopathy when used later in pregnancy
Warfarin
Embryopathy: first trimester
Fetopathy: Later
Warfarin embryopathy appears to be dose dependent, with lower rates of embryopathy reported in women taking daily warfarin doses
< 5 mg
Heparin does not cross the placenta and is therefore a safer alternative for the fetus but is less effective at preventing valve thrombosis and is associated with higher rates of maternal mortality.
One treatment strategy is to replace warfarin with low-molecular- weight heparin during embryogenesis (_____ weeks’ gestation) to prevent embryopathy.
6 to 12 weeks
Use of low-molecular-weight heparin throughout pregnancy is an option for women who wish to avoid warfarin altogether, but this requires close follow-up throughout pregnancy because many of the reported cases of valve thrombosis were related to inadequate dosing and monitoring of anti-Xa levels.
______________ does not cross the placenta and is therefore a safer alternative for the fetus but is less effective at preventing valve thrombosis and is associated with higher rates of maternal mortality
Heparin
LMWH - need freq ffup, valve thrombosis due to inadequate dosing; Peak an levels should be measured frequently,
Unfractionated heparin is associated with high rates of valve thrombosis when given subcutaneously. Its use is recommended only when administered as a continuous intravenous infusion, in a hospital setting.
The most frequently detected arrhythmias in pregnancy are _______________________________ and generally these do not require therapy.
Atrial and ventricular premature beats
____________________ is the most common arrhythmia in pregnant women and usually occurs in women with structurally normal hearts.
Supraventricular tachycardia (SVT)
Most women with SVT can be treated medically.
In women with acute SVT who are hemodynamically stable, vagal maneuvers and adenosine can used to terminate the arrhythmias.
For women with a contraindication to adenosine or in whom adenosine is ineffective, intravenous beta blockers such as metoprolol or propranolol can be used
The risk of VT in women with LQTS, specifically _________ mutation, increases in the postpartum period.
LQT2
In general, in women who develop AF or AFL, ___________ is preferred over rhythm control.
Rate control
For unrepaired ASD or VSD, repaired ASD or VSD with residual shunting, or patent foramen ovale, we recommend the ________________________ for indwelling IVs at time of labor and delivery, to reduce the chance of paradoxical right-to-left shunt.
Use of air/particulate filters
True or False
Women with PAH should be advised against pregnancy and safe and reliable contraception should be provided
True
Maternal cardiac decompensation occurs because of the volume load on the right ventricle, the increased flow in the high-resistance pulmonary vascular bed, changes in intracardiac shunt flow with resulting desaturations, and thromboembolic events secondary to the prothrombotic effects of pregnancy.
Pregnancy is contraindicated in Marfan and Loeys-Dietz syndrome with an ascending aorta greater than _______, all patients with ________________, bicuspid associated aorta greater than _______, and Turner syndrome with high-risk features (aortic size index [ASI] ______ or history of aortic dissection)
45 mm
Vascular Ehlers-Danlos syndrome
50 mm
> 2.5 cm/m 2
