Cardiac conditions

Question 1

What are the most common cardiac conditions in pregnancy?

Answer 1

Atrial Septum Defect or Ventricle Septum Defect

Question 2

What is an ASD or VSD?

Answer 2

A congenital hole in the heart that allows blood to flow between atriums or ventricles.

Question 3

What is the treatment for ASD and VSD?

Answer 3

For minor holes, they may heal spontaneously, or may not cause any problems.

For more severe - surgical closure of the hole is required.

Question 4

What is a patent ductus arterious?

Answer 4

The ductus arteriosus is a fetal structure of the heart that allows blood to bypass the lungs while in utero. It should close after birth (by 10 days) to allow blood to flow to the lungs and become oxygenated. A PDA results if it does not close spontaneously.

Question 5

What is tetralogy of fallot?

Answer 5

A congenital heart defect consisting of four abnormalities:

1. VSD
2. Aorta dextroposition (overriding a VSD)
3. Right ventricular outflow tract obstruction
4. Right ventricular hypertrophy

Question 6

If the woman has had her congenital defects closed/repaired by surgery, what are the considerations in pregnancy?

Answer 6

These women are generally low risk!

• specialised ultrasound to monitor fetus (risk of recurrence);
• VSD: occasional arrythmias and possible increase in risk of preeclampsia;
• ToF: generally tolerated well, but needs cardiac supervision
• PDA: treat as normal

Endocarditis no longer routine - but consider case by case.

Question 7

Midwifery management for women with hx of congenital heart problems?

Answer 7

Early booking and referral to specialist;
Careful hx taking and baseline obs for RR and pulse;
Advice for diet to keep Hb normal;
Need for antibiotic prophylaxis for any procedures undertaken;
Close observation for worsening tiredness and breathlessness;

Question 8

Active issues with congenital heart defects - considerations in labour?

Answer 8

Increased risk of thromboembolism - compression stockings and consider anticoag medication if immobile;

Anaesthetic review prior to labour;
Antibiotic prophylaxis for ROM or active labour considered case by case.
Consider monitoring of Spo2 and ECG.

Question 9

Postnatal care for congenital conditions?

Answer 9

Encourage ambulation;
Is fluid balance required? - VSD or corrected ToF if potential for congestive cardiac failure;
Contraceptive advice - Standard unless open ASD/concerns re: pulmonary hypertension;
Alert to signs in the neonate;

Question 10

What is coarctation of the aorta?

Answer 10

Congenital narrowing of the aorta - results in upper body hypertension and lower body hypoperfusion.

Mostly repaired in childhood - but can be found in adulthood and pregnancy.

Lifelong risk of aneurysm formation and aortic dissection even after repair.

Question 11

What is transposition of the great vessels?

Answer 11

Right ventricle gives rise to aorta and the left ventricle the pulmonary artery (which is backwards!). Usually repaired in childhood with good results.

Question 12

What are the risks with coarctation of the aorta?

Answer 12

Hypertension in 30% of pregnancies;
Additional risk of preeclampsia;

If uncorrected - risk of dissection and cerebral haemorrhage.

Question 13

What are the risks of transposition of the great vessels?

Answer 13

Well tolerated if good systemic ventricular function and competent valves.

Pregnancy may exacerbate or unmask systemic ventricular dysfunction.

Recurrence risk for baby low

Question 14

Management consideration for coarctation of aorta?

Answer 14

Control of blood pressure with medication;

Elective LSCS for aneurysm formation or uncontrollable hypertension.

Question 15

Management of transposition of the great vessels?

Answer 15

Monitor for signs of heart failure and arrhythmia;
Diuretics for oedema;
Beta-blockers for tachycardia

Question 16

What is severe structural heart disease?

Answer 16

Conditions where there is significant risk to mother or fetus - pregnancy is very high risk, or contraindicated. Examples include:
Unoperated/palliated cyanotic or complex congenital heart disease
Women with poor systemic ventricular function;
Eisenmenger’s syndrome;
Marfan’s syndrome.

Question 17

What monitoring is required for someone with severe heart disease?

Answer 17

Regular careful supervision of a cardiologist in a tertiary centre:

• monitor oxygen sats and Hb estimation
• ECG, CT/MRI as required;
• regular monitoring for arrythmias
• regular fetal monitoring

Question 18

What is recommended in labour for women with severe heart disease?

Answer 18

Epidural for pain relief;
Shorten the second stage if NVB; (instrumental)
If aneurysm or severe ventricular dysfunction - LSCS;
Avoid supine position as restricts pulmonary blood flow;
Avoid bolus of syntocinon in third stage as can cause severe hypotension;
Ergometrine not recommended due to hypertensive risk

Question 19

What risk increases postpartum for severe heart disease?

Answer 19

Pulmonary oedema due to increased cardiac output - close supervision/monitoring for 48 hours after birth.
Review medications;
Observations for longer - including O2 sats.

Question 20

What is rheumatic heart disease?

Answer 20

Complication of rheumatic fever where acute valve damage occurs to the heart.

Caused by Group A Strep (?) - Can be treated with antibiotics to prevent heart disease.

Commonly seen in indigenous australians, or immigrant populations (more common in developing countries).

Question 21

What is cardiomyopathy?

Answer 21

Inflamed, enlarged and weakened heart muscle.

Causes:

• hereditary;
• viral, bacterial or fungal/parasitic infection;
• Ischaemia;
• Alcohol/drugs;
• obesity;
• chemotherapy/radiation.

Symptoms:
Dyspnea, tiredness and peripheral oedema.

Question 22

What is marfan syndrome?

Answer 22

Disorder affecting connective tissue, and may affect the heart. People are tall and thin.