Cardiac

Question 1

What are the risk factors of a cardiac condition?

Answer 1

• Pre existing medical problems
• Overweight
• 35 years old or more
• Socially deprived
• Smoking
• Congenital heart disease
• BAME
• Previous C/S
• Family history
• Assisted conceptions: comes with factors above

Question 2

What are the red flags of CVD?

Answer 2

• Raised respiratory rate
• Severe chest pain spreading to the jaw, arm or back
• Tachycardia
• Severely breathless when resting, especially if it happens when laying flat (orthopnoea): Orthopnea is caused by increased pressure in the blood vessels of your lungs. When you lie down, blood flows from your legs back to the heart and then to your lungs. In healthy people, this redistribution of blood doesn’t cause any problems.
• Experience fainting while exercising/ exerting oneself (syncope)

Question 3

What are the cardiac changes in pregnancy?

Answer 3

• The heart moves- Heart increases in size to keep up with demands, and moves upwards and to the left to make room for enlarging uterus.
• O2 consumption increased to give to baby, so RBC increase by 30%
• Plasma volume – haemodilution (40-50% above baseline by 32 weeks)
• Decreased resistance in circulation – increase in progesterone (muscle relaxant) causes the heart to compensate for it’s relaxed state which leads to increased cardiac output, increases by 10-20bpm.
• Increased stroke volume
• Cardiac output increase by 20% at 8 weeks, peak increase by 40% at 20-28 weeks
• At term, heart is physiologically dilated and myocardia contractility is increased
• BP drops in 2nd trimester (increased levels of progesterone leads to vasodilation of blood vessels) but will reach or exceed pregnancy levels by term
• CVP unchanged – haemodilution
• Colloid oncotic pressure falls by 10-15% (hydrostatic pressure pushes out), which makes pulmonary oedema more likely
• increase oedema of hands, feet and ankles
• Inferior Vena Cava pressure by the gravid uterus
• Pregnancy is a hypercoagulable state: increase in venous embolic event
• Changes in pharmacokinetics- what the body does to the drug: might not be as effective in pregnancy

Question 4

What are the cardiac changed in labour?

Answer 4

• 15% increase in 1st stage as a result of pain/adrenaline which increases anxiety and HR. Women with cardiac conditions should be offered epidural as causes drop in BP due to vasodilation
• 50% increase in cardiac output in 2nd stage as woman pushes and holds breath (Valsalva manoeuvre) so need an increase to get O2 around the body. Women with cardiac disorders shouldn’t have c/s as more likely to bleed so use instrumentals for short 2nd stage
• Following delivery (3rd stage), relief of IVC compression and contraction of the uterus = autotransfusion of blood back into the maternal circulatory system, which increases cardiac output by 60-80%.
• This is the most risky time for pulmonary oedema as increased cardiac output as placenta delivered and the uterus contracts which is full of blood and blood is pushed back into the maternal circulation

Question 5

What are the general principles of management of pregnancy in women with heart disease?

Answer 5

• Ideally all women with congenital or acquired heart disease should receive multi-disciplinary preconception counselling before pregnancy
• Termination of pregnancy is only beneficial under 16 weeks before significant increase in cardiac output has occurred.
• Guidance must be given early.
• Early review and risk assessment by MDT (obstetricians, anaesthetists & cardiologists) required.
• Optimise mother’s CV status during pregnancy
• Monitor for deterioration
• Careful fluid management
• Continuous ECG and continuous oxygen saturations.
• Address fetal issues (regular scans/ specialist cardiac fetal echo): stillbirth, IUD, IUGR
• Develop a clear, well documented and widely distributed plan for labour and the puerperium AND COMMUNICATE WITH THE WOMAN
• Avoid the supine position as associated caval compression reduces venous return and thus cardiac ouput by upto 25%
  Effective pain relief important
• Reduces rise in CO from pain and anxiety
• Low-dose regional anaesthesia
  Limit maternal effort:
• The managed second stage
• Assisted delivery (Ventouse/Forceps)
• Place of delivery: is a cardiac theatre appropriate
• Exercise caution with oxytocic drugs.
  o Syntocinon infusion -> fluid retention
  o Ergometrine -> contraindicated due to its vasoconstrictive and hypertensive disorders
• Post labour HDU/ICU/CCU: usually 24 to 48 hours
• Senior post-partum obstetric and cardiology review important
• Early cardiology follow up (heart teams’ approach)
• Early discussion about risks of future pregnancy & robust contraception

Question 6

What are the changes to an ECG in pregnancy?

Answer 6

• Ectopic beats
• Relative sinus tachycardia
• Ejection systolic murmur
• Loud first beat
• Peripheral oedema
• Q-wave (small) and inverted T-wave in lead III
• ST depression and T-wave inversion infero-lateral leads
• QRS axis leftward shift

Question 7

What are the different cardiac heart disease?

Answer 7

• Congenital heart disease
• Acquired heart disease
• Cardiomyopathies: heart muscle failure
• Heart valves disease (prosthetics)
• Arrythmias
• Myocardial infarction/ acute coronary syndromes
• Dissection of the aorta

Question 8

What are the different types of congenital heart disease?

Answer 8

• Atrial Septal Defect
• Ventricular Septal Defect
• Patent Ductus Arteriosus
• Coarctation of the aorta
• Pulmonary Hypertension
• Eisenmenger’s Syndrome
• Marfan syndrome
• Tetralogy of Fallot

Question 9

What is atrial septal defect?

Answer 9

• An atrial septal defect is a birth defect of the heart in which there is a hole in the wall (septum) that divides the upper chambers (atria) of the heart.
• Common CVD in women

Signs and symptoms

• Shortness of breath, especially when exercising
• Fatigue, migraine
• Swelling of legs, feet or abdomen
• Heart palpitations or skipped beats
• Heart murmur, a whooshing sound that can be heard through a stethoscope
• Stroke

Impact on pregnancy

• Usually well tolerated in pregnancy
• PET, IUGR, Atrial arrhythmias can occur in unrepaired ASD

Question 10

Coarctation of the aorta?

Answer 10

• Constriction of the aorta = marked hypertension
• Usually repaired surgically in infancy but some women may present with undetected CA
• Can be associated with aneurysm of the circle of Willis
• Risks of uncorrected CA in pregnancy = angina, hypertension, congestive heart failure, aortic rupture or dissection

Question 11

What is pulmonary hypertension?

Answer 11

• Unknown (idiopathic)- often first manifested in pregnancy
• Defined by an elevation in mean pulmonary arterial pressure (PAP) >_25 mmHg at right heart catheterisation
• Lung disease e.g. cystic fibrosis
• Congenital heart disease - Eisenmenger’s syndrome

Impact on pregnancy

• Pulmonary hypertension of whatever cause has a maternal mortality of 30-50% (16-30% with treatment)
• The greatest period of risk is the puerperium, especially the early post-partum period
• Avoid pregnancy or offer termination
• Increased fetal and neonatal mortality
• Increased risk of VTE

Question 12

What is Eisenmenger’s Syndrome?

Answer 12

• This refers to a shunt in the heart with blood going from left to right (note reversal of direction)
• Usually as a result of an unrepaired septal defect
• Results in the mixing of de-oxgenated and oxygenated blood causing cyanosis and increased pulmonary vascular resistance
• R-to-L shunting increases in pregnancy because SVR falls

Pregnancy
- Offer termination (also carries risks)

If continues

• High risk of VTE
• May get paradoxical emboli = anticoagulation
• Risk of bleeding, Vit-k deficiency, clotting factors, thrombocytopenia
• Hospital admission likely with activity restriction or bed rest
• Oxygen therapy guided by saturation monitoring
• Any congestive heart failure = diuretics but difficult as they do not tolerate rapid fluid fluctuations
• Intensive fetal monitoring as IUGR common
• 7 days stay in ICU after birth.

Question 13

What is Marfan syndrome?

Answer 13

• Rare genetic (autosomal dominant) disorder of the connective
• Inherited disorder
• Increased height with arm span greater than height
• Arachnodactyly (very long, slender digits)
• Pectus excavatum (dip at sternum)
• High arched palate, large bulging eyes
• Joint laxity
• Aortic root dilatation and risk of rupture

In pregnancy

• Pregnancy contraindicated if aortic root is less than 4.0cm (measure with echo)
• If dilated surgical replacement prior to pregnancy
• When a woman with known aortic dilatation (history of) dissection or genetic predisposition for dissection becomes pregnant, strict blood pressure control is recommended
• Repeated ECG imaging every 4–12 weeks (depending on diagnosis and severity of dilatation) is recommended during pregnancy and 6 months post-partum in patients with ascending aorta dilatation
• It is recommended to deliver all women with aortic dilatation or (history of) aortic dissection in an experienced centre with a pregnancy heart team.
• In patients with an ascending aorta <40 mm, vaginal delivery is recommended; In patients with an ascending aorta >45 mm, caesarean delivery should be considered (same with h/o dissection)
• In patients with an aorta 40–45 mm, vaginal delivery with epidural anaesthesia and an expedited second stage should be considered.
• When possible, the use of ergometrine is not recommended in women with aortic disease= the heart is a smooth muscle so ergometrine will effect it.

Management of Marfan’s
- ß-blockers have been shown to reduce rate of aortic dilatation

Question 14

What is tetralogy of fallot?

Answer 14

• Tetralogy of Fallot is a combination of four congenital abnormalities. The four defects include a ventricular septal defect (VSD), pulmonary valve stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy).
• A bluish coloration of the skin caused by blood low in oxygen (cyanosis)
• Shortness of breath and rapid breathing, especially during feeding or exercise
• Loss of consciousness (fainting)
• Clubbing of fingers and toes — an abnormal, rounded shape of the nail bed
• Poor weight gain
• Tiring easily during play or exercise
• Irritability
• A heart murmur

Risk factors of TF

• A viral illness during pregnancy, such as rubella (German measles)
• Alcoholism during pregnancy
• Poor nutrition during pregnancy
• A mother older than age 40
• A parent who has tetralogy of Fallot
• The presence of Down syndrome or DiGeorge syndrome

Pregnancy

• Women with repaired tetralogy of Fallot usually tolerate pregnancy well (WHO risk class II).
• Cardiac complications have been reported in 8% of repaired patients, especially in those taking cardiac medication prior to pregnancy.
• Arrhythmias and HF are the most common complications. Thrombo-embolism and endocarditis are rarer.
• The risk of offspring complications is increased, in particular fetal growth restriction (FGR).
• Maternal screening for 22q11 deletion should be undertaken prior to pregnancy.
• Follow-up every trimester is sufficient in most patients. In women with severe pulmonary regurgitation, monthly or bimonthly cardiac evaluation is indicated.
• If RV failure occurs during pregnancy, treatment with diuretics should be started and bed rest advised.  avoid pulmonary oedema
• Early delivery or, rarely, transcatheter valve implantation could be considered in those who do not respond to conservative treatment.

Question 15

What are the different acquired CVD related to Rheumatic Heart Disease?

Answer 15

• Mitral valve stenosis
• Aortic Stenosis
• Artificial/Prosthetic Heart Valves

Question 16

What is Rheumatic Fever?

Answer 16

• Rheumatic heart disease is a complication of rheumatic fever
• Once endemic but now unusual in developed countries
• Still a significant problem in many other parts of the world
• Autoimmune disease usually contracted in childhood occurring 2-4 weeks after a throat infection caused by Streptococcus Pyogenes
• The antibodies that fight the infection cause the tissue of the heart particularly valves to become inflamed and oedematous
• When these damaged areas heal, they leave thick fibrous tissue altering the shape of the valves leading to stenosis and/or valve incompetence with regurgitation of blood.
• Stenosed valves impede the flow of blood through the heart, causing back pressure which is aggravated by the haemodynamics changes of pregnancy and labour and may lead to heart failures and tachyarrythmias.

Question 17

What is mitral valve stenosis?

Answer 17

• Narrowing of opening of mitral valve
• Blocks blood flow from left atrium to the left ventricle
• Leads to increased pressure in left atrium leading to pulmonary congestion = pulmonary oedema
• increase size of left atrium, prone to develop atrial fibrillation
• increase thrombus formation

Presentation of MVS

• May first present with pulmonary oedema (cough productive of pink, frothy sputum or haemoptysis)
• Dyspnoea
• Breathlessness
• Rumbling mid-diastolic murmur
• Mitral facies (has characteristic of the condition)

Assessments and tests for diagnosing

• NYHA classification class III or IV
• ECG
• Chest x-ray
• Echocardiogram
• FBC and clotting studies

Effect of pregnancy on MVS

• May become rapidly symptomatic during pregnancy and develop pulmonary oedema
• May be precipitated by a rise in heart rate secondary to infection or exertion
• Tachycardia reduces left ventricular filling time which raises left atrial pressure which may precipitate pulmonary oedema
• Most risky time in the third stage of labour and hypertension with the return of blood from the uterine to the general circulation.
• Mild mitral stenosis (MS) is generally well tolerated
• Absence of stenosis, valvular incompetence and regurgitation tend to improve in pregnancy as decreased arterial resistance facilitates flow of blood through the valves.

Management of MVS

• Clinical and echocardiographic follow-up is indicated monthly or bimonthly depending on haemodynamic tolerance
• Pulmonary oedema treated with diuretics e.g. frusemide
• ß-blockers used to slow heart rate
• Atrial fibrillation treated with digoxin and ß-blockers
• Balloon valvotomy can be performed in pregnancy
• Surgery in pregnancy only in extremis

Delivery with MVS

• MDT
• Prophylactic antibiotics
• Continuity of care
• Pain relief
• Cardiac output increase 15
• Aim for spontaneous labour and vaginal delivery at term (mild MS)
• Should have slow epidural to avoid sudden drop in blood pressure
• Avoid lithotomy= pressure on the big vessels
• Keep second stage short: valsava manoeuvre -> increase cardiac output
• Delay for descend
• Instrumental -> risk of PPH
• 3rd stage- 60-80% increase of cardiac output
• Sit up for third stage and use concentrated oxytocin infusion- work on the natural oxytocin receptors- NO ERGOMETRINE- vasoconstricts everything – higher BP -avoid fluid overloading (strict fluid balance monitoring)
• Syntocinon IV: 40IU -> less chance of bleeding
• Psychology: anxious role of the midwife -> communication

Postnatal

• May be congenital -> baby scans
• PN support groups
• contraceptive advice and family spacing
• monitor vital signs 48 hours
• detection early of infection/maintain prophylactic antibiotics for two weeks

Question 18

What is aortic stenosis?

Answer 18

• Often congenital can be caused by RHD
• Aortic stenosis is a narrowing of the aortic valve opening. Aortic stenosis restricts the blood flow from the left ventricle to the aorta and may also affect pressure in the left atrium.
• Pregnancy causes an ↑in Stroke Volume which can cause left ventricle to fail
• Does not usually cause problems unless severe
• Risks and symptoms are angina, hypertension, heart failure and sudden death

Management

• Symptoms of fluid overload can usually be managed medically.
• Treat hypertension and angina with ß-blocker provided adequate LV function
• Beware tachycardia as may indicate a failing ventricle
• Cannot increase cardiac output so respond badly to drops in blood pressure-slow epidural/ regional anaesthetics if needed
• Follow-up is required every trimester in mild/moderate regurgitation, and more often in severe regurgitation.
• Vaginal delivery with epidural anaesthesia and shortened second stage is advisable.

Impact of condition on pregnancy

• chest pain – associated with activity due to ischemic heart muscle
• shortness of breath – heart unable to circulate blood quickly enough through the lungs to allow sufficient gasous exchange
• fatigue – as heart unable to meet the needs of cells and organs
• hypertension – common sign of cardiac disease
• palpitations – due to heart arrythmias
• peripheral oedema – inadequate venous return

Question 19

Artificial/Prosthetic Heart Valves

Answer 19

• These cause problems primarily because of the need for anti-coagulation
• All mechanical valves require life-long anti-coagulation
• Warfarin is teratogenic in weeks 6-12 (Warfarin Embryopathy)
• It is also associated with fetal bleeding in later pregnancy
• Heparin is less effective
• In women with mechanical valves, pregnancy is associated with a very high-risk of complications
• Continue warfarin throughout pregnancy
• Heparin weeks 6-12 then warfarin again
• Heparin throughout (LMWH)
• Warfarin must be stopped 10 days prior to delivery and heparin started
• Warfarin can be reversed with FFP and vitamin K, heparin with protamine sulphate

Antibiotic Prophylaxis

• Mandatory for women with artificial heart valves or previous endocarditis
• Amoxycillin 1g iv or IM plus gentamicin 120mg IV or IM at onset labour or ROM
• Plus 500mg amoxycillin 6 hours later
• Cardiologists will often also recommend it in other heart conditions

Question 20

Spontaneous Coronary Artery Dissection (SCAD)

Answer 20

• SCAD occurs when a tear or a bruise develops in one of the coronary arteries resulting in a blockage that prevents normal blood flow.
• This can result in a heart attack

Causes
- Female hormones play a part (80% in Women, mean age 42yrs)
o	Pregnancy
o	Peri-menopause 
o	Menopause

• SCAD also linked to

o Extreme stress
o Extreme physical exertion
o Connective tissue disorders such as FMD (Fibromuscular Dysplasia), Marfan’s
o Migraines
- A combination of factors create a ‘perfect storm’

Management

• Surgical intervention, such as inserting stents, or coronary artery bypass surgery.
• Conservative management with medication such as aspirin, statins, blood pressure pills and beta blockers.
• Current research suggests it is not necessarily appropriate for SCAD patients to be prescribed medication given to those who have had heart attacks caused by plaque/high cholesterol.
• Regular Troponin blood tests are the ONLY way to correctly identify a cardiac event
• SCAD patients can have normal ECGs mid heart attack

Question 21

Cardiomyopathy

Answer 21

• Cardiomyopathy is a disease of the heart muscle.
• Various medical disorders may cause Cardiomyopathy.
• In cardiomyopathy, the heart muscle is weakened.
• It becomes unusually enlarged, thickened, or stiffened.
• As a result, the heart can’t pump blood to the rest of the body, which causes heart failure.
• Sudden death can occur in many people who have heart disease.
• The condition usually begins in the heart’s ventricles (lower chamber), but in some cases it can occur in the atria (upper chamber) also.
  Management
• Deliver early if indicated
• Thromboprophylaxis – may have thrombi in dilated heart
• Conventional heart failure treatment – diuretics, nitrates, digoxin and ACE inhibitors once delivered
• LVAD (Left Ventricular Assist Device)
• Cardiac transplantation may ultimately be needed.

Peripartum Cardiomyopathy

• Heart failure with no other known cause and no heart disease prior to last month of pregnancy
• The cause is uncertain, but potential aetiologies include inflammation and angiogenic imbalance, inducing vascular damage
• Onset commonly in month after delivery, can be up to five months
• Risk factors: multiple pregnancy, hypertension, multiparity, maternal age, Afro-Caribbean ethnic origin, smoking, PET, malnutrition, teenage pregnancy
• mWHO III or IV

Hypertrophic Cardiomyopathy
- Many asymptomatic/ family screening
- Chest pain or syncope (fainting), caused by left ventricular outflow tract obstruction
- Double apical pulsation (palpable 4th heart sound)
- Ejection systolic murmur (LV outflow obstruction)
- Pansystolic murmur (Mitral regurgitation)
- Arrythmias
- Heart failure
Risk factors for sudden death
- Family Hx
- Non-sustained ventricular tachycardia
- Failure of BP to increase during exercise
- LV wall thickness >30mm
- Women with the above may have been fitted with an automated implantable cardia defibrillator.

Management

• Mostly well tolerated in pregnancy because of an increase in left ventricular cavity size = increase in stroke volume
• B–blockers should be continued or started in pregnancy for those women with symptoms
• Care is required with regional analgesia to avoid hypotension with consequent increase LV outflow tract obstruction
• Any hypovolaemia will have the same effect and should be adequately corrected
• Avoid fluid overload as diastolic dysfunction from a stiff ventricle can cause pulmonary oedema.