B P10 C92 Pregnancy and Heart Disease

Question 1

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

Answer 1

All increase in pregnancy except for SVR, protein C, HDL

Question 2

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.

Answer 2

5 to 10 mm Hg

Question 3

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 _____%

Answer 3

10 beats/min

30% to 50%

Question 4

Twin pregnancies can increase the cardiac output by a further ____________

Answer 4

10 - 15%

Question 5

At the time of labor and delivery and immediately postpartum, cardiac output increases a further _____%.

Answer 5

60-80%

Further hemodynamic changes due to:
Catecholamines
Release of inferior vena cava compression
Autotransfusion from uterine contractions
Blood loss

Question 6

Mobilization of fluid during the first week after delivery can result in heart failure in women with _____

Answer 6

CMP
Severe outflow tract obstruction

Question 7

Many of the hemodynamic changes resolve in the first ______ after delivery, although complete resolution may take as long as ______

Answer 7

2 weeks

6 months

Question 8

_____ are symptoms that can be associated with normal pregnancy.

Answer 8

Fatigue, dyspnea, light-headedness, and palpitations

Question 9

Normal pregnancy results in cardiac examination findings including:

Answer 9

(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

Question 10

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)

Answer 10

111 pg/mL

Question 11

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

Answer 11

< 100 pg/mL

Question 12

Normal pregnancy is associated with electrocardiographic (_____) and chest radiographic (

Answer 12

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

Question 13

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

Answer 13

(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

Question 14

____ echocardiogram is the preferred imaging method in pregnancy, but imaging may be more technically challenging with cardiac displacement.

Answer 14

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.

Question 15

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.

Answer 15

Submaximal

PHR not to exceed 70% to 80%

Dobutamine

Question 16

The risk of fetal adverse outcome is highest with radiation exposure during the period of organogenesis during the _____ trimester.

Answer 16

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

Question 17

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)

Answer 17

12 weeks

Radial approach

Question 18

Electrophysiologic procedures for arrhythmias should best be deferred until after pregnancy or performed using a _____ system during pregnancy for refractory cases.

Answer 18

Nonfluoroscopic

Question 19

CAPREG risk score

Answer 19

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

Question 20

CAPREG II Risk Score

Answer 20

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%

Question 21

Class IV Cardiac Lesions based on Modified World Health Organization Classification of Maternal Cardiovascular Risk

Maternal cardiac risk ______

Answer 21

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

Question 22

True or False

Pregnancy should be discouraged in women with high cardiac lesions and termination should be considered if pregnancy occurs

Answer 22

True

Question 23

Preconception counseling provides opportunities to optimize risk by:

Answer 23

(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.

Question 24

Site of pregnancy care/delivery: There are three possible options:

Answer 24

(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)

Question 25

Women at low risk for cardiac complications are often seen ____ during pregnancy with plans to deliver at a local obstetric center.

Answer 25

1-2 during the pregnancy

Women at moderate or high risk for cardiac complications are followed more closely

Question 26

Women with congenital heart disease should be offered a fetal echocardiogram at _____ weeks’ gestation to assess for congenital cardiac malformation.

Answer 26

18-22 weeks AOG

Question 27

Drugs contraindicated in pregnancy

Answer 27

SGLT2i
Statins
Atenolol
ACEi, ARB
Aldosterone antagonists
Amiodarone

Bosentan (endothelin receptor antagonists)
Ivabradine
Direct oral anticoagulants

S2 4A BID

Question 28

Warfarin is associated with an embryopathy when exposure occurs between ______________ gestation and needs to be discontinued prior

Answer 28

6 and 12 weeks

Question 29

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.

Answer 29

20th gestational week

Constriction of the ductus arteriosus and impact fetal renal function

Withdrawn by 32nd week

Question 30

When possible, a spontaneous vaginal delivery is preferred.

Cesarean delivery is rarely required for cardiac indications except for cases such as:

Answer 30

• 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

Question 31

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.

Answer 31

Bradycardias

Question 32

Cardiac arrest during pregnancy is managed similarly to the non- pregnant arrest, with the following modifications:

Answer 32

(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

Question 33

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 (_____)

Answer 33

≥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.

Question 34

_____ 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.

Answer 34

Ambulatory BP monitoring

Question 35

Patients with preexisting hypertension may have a falsely normal BP due to the reduced systemic vascular resistance that manifests by the _____th gestational week.

Answer 35

12th week AOG

Question 36

Pregnant women with severe hypertension (BP _____) should be triaged expeditiously and pharmacotherapy initiated to reduce risk of heart failure, stroke, or renal disease

Answer 36

≥160/110 persistent for 15 minutes

Question 37

__________________ is gestational hypertension with proteinuria (>0.3 g/24 hr, protein/creatinine ratio >0.3, or urine dipstick reading of 2+)

Answer 37

Pre-eclampsia

Question 38

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

Answer 38

Chronic hypertension

Question 39

Treatment of nonsevere hypertension in pregnancy

Answer 39

• Start single anti-HTN
  MEthyldopa, LAbetalol, NIfedipine
• Maternal and fetal assessments
• Regular BP reassessments
• 2nd line: HCTZ or combination

Question 40

Treatment for severe hypertension in pregnancy

Answer 40

• 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

Question 41

Currently, the optimal goal for BP therapy varies between United States, EU and Canada

Answer 41

US: 140 - 150/90 - 100 mm Hg
EU: < 140/90
Canada: < 85 mm Hg DBP

Question 42

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)

Answer 42

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

Question 43

Pregnancy is contraindicated in women with DCM with

Answer 43

Severe left ventricular systolic dysfunction

Question 44

Factors related to pregnancy/delivery that can worsen outflow obstruction in HCM

Answer 44

Epidural anesthesia
Oxytocin
Valsalva maneuver

Question 45

______________ 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.

Answer 45

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.

Question 46

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

Answer 46

Bromocriptine

Question 47

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

Answer 47

LVEF: > 30%
LVEDD: < 6cm

Question 48

Prognostic factors in DCM in pregnancy:

Answer 48

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)

Question 49

___________________ 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 ____________

Answer 49

SCAD

STEMI
Anterior wall

Majority of acute MI presented in the third trimester or postpartum period

Question 50

Majority of acute MI presented in the _____ period.

Answer 50

Third trimester or postpartum

Question 51

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%)

Answer 51

SCAD: 43%
CAD: 40%
ICT: 17%
CS: 2%

Question 52

Most common type of SCAD

Answer 52

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.

Question 53

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.

Answer 53

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

Question 54

Patients with PCI should be on dual platelet therapy, and ______ is viewed as the only “safe” inhibitor.

Answer 54

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

Question 55

______________ is the most common type of valvular heart disease encountered in pregnant women globally

Answer 55

Rheumatic MS

Question 56

In those with significant MS and who are in sinus rhythm, anticoagulation is a consideration if there is _____.

Answer 56

• Spontaneous echocardiographic contrast in the left atrium
• Large left atrium (≥60 mL/m2)
• Congestive heart failure.

Question 57

_____ 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.

Answer 57

Deterioration

Question 58

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

Answer 58

BAV

Question 59

Aortic valve replacement is recommended in women with _____.

Answer 59

Symptomatic AS

or

Asymptomatic women with left ventricular ejection fraction less than 50% or abnormalities during exercise testing.

Question 60

____ 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.

Answer 60

AR

Question 61

Bioprosthetic valves are at less risk for pregnancy-related complications as the valves are _________________ and ___________________ is not required.

Answer 61

Less thrombogenic

Anticoagulation

Question 62

The most serious maternal complication is ________________ in patients with mechanical heart valve

Answer 62

Valve thrombosis

Question 63

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:

Answer 63

(a) Warfarin or other vitamin K antagonists
(b) Low-molecular-weight heparins
(c) Intravenous unfractionated heparin

Question 64

_____ 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

Answer 64

Warfarin

Embryopathy: first trimester
Fetopathy: Later

Question 65

Warfarin embryopathy appears to be dose dependent, with lower rates of embryopathy reported in women taking daily warfarin doses

Answer 65

< 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.

Question 66

One treatment strategy is to replace warfarin with low-molecular- weight heparin during embryogenesis (_____ weeks’ gestation) to prevent embryopathy.

Answer 66

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.

Question 67

______________ 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

Answer 67

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.

Question 68

The most frequently detected arrhythmias in pregnancy are _______________________________ and generally these do not require therapy.

Answer 68

Atrial and ventricular premature beats

Question 69

____________________ is the most common arrhythmia in pregnant women and usually occurs in women with structurally normal hearts.

Answer 69

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

Question 70

The risk of VT in women with LQTS, specifically _________ mutation, increases in the postpartum period.

Answer 70

LQT2

Question 71

In general, in women who develop AF or AFL, ___________ is preferred over rhythm control.

Answer 71

Rate control

Question 72

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.

Answer 72

Use of air/particulate filters

Question 73

True or False

Women with PAH should be advised against pregnancy and safe and reliable contraception should be provided

Answer 73

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.

Question 74

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)

Answer 74

45 mm

Vascular Ehlers-Danlos syndrome

50 mm

> 2.5 cm/m 2