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OB > Cardiac Disease > Flashcards

Cardiac Disease Flashcards

1
Q

Only require standard monitoring
Early cardiac eval
Antibiotic prophylaxis during l&d

A

For congenital heart disease

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2
Q

4 major defects with ToF

A
  • RV outflow obstruction
  • VSD
  • RV hypertrophy
  • overriding aorta
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3
Q

Anesthetic goals with TOF

A

Maintain SVR to prevent increased RL shunt (phenylephrine)

Maintain venous return - high filling pressures that improve RV output and pulmonary blood flow

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4
Q

Preferred anesthetic with ToF

A

Epidural analgesia

Spinals do not maintain SVR and want to maintain intravascular volume

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5
Q

What does ToF look like repaired?

A

Asymptomatic
VSD closed
Widening pulmonary outflow tract
Small VSD may recur or hypertrophy of outflow tract

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6
Q

VSD and ASD (left to right shunts) repaired =

A

No problem

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7
Q

T or F small asymptomatic VSD and ASD tolerate labor

A

T

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8
Q

What does pain do to VSD/ASD

A

Increases SVR increasing L to R shunt and causing pulmonary hypertension

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9
Q

What anesthetic management is preferred for VSD/ASD

A

Epidural decreases SVR and decreases L to R shunt

Slowly to prevent rapid decrease in SVR causing a R to L shunt, cyanosis, hypoxemia

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10
Q

VSD/ASD all have…

A

Increased risk of systemic emboli
All air out of IV lines (LOR with air should not be used with epidural)
Mild hypoxemia leads to increased PVR thus R to L shunting
Supplemental O2

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11
Q

What is seen in large VSD/ASD

A

Pulmonary HTN and increased pulmonary blood flow

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12
Q

Anesthetic management for large VSD/ASD

A

A-line, PAC
Avoid HR increase and increase/decrease SVR and PVR
Pain control
Titrate epidural slowly
CSE only with intrathecal opioids (minimizes decrease in SVR)

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13
Q

Development of eisenmenger’s syndrome

A
  • chronic pulmonary overload from uncorrected L to R shunt = Pulm HTN
  • initially shunt is bidirectional, SVR and PVR determine direction
  • pulmonary HTN irreversible, shunt flow reverses
  • R to L shunt, PAP exceed systemic
  • hypoxia
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14
Q

Eisenmenger syndrome becomes _____ to ______

A

Acyanotic to cyanotic

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15
Q

Eisenmenger’s effects on pregnancy

A

Don’t tolerate pregnancy well
Decreased SVR may increase shunt
Decreased FRC and increased O2 consumption exacerbates hypoxemia
Compromised O2 to fetus

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16
Q

Anesthetic management for eisenmenger’s syndrome

A 
Regional to decrease catecholamines
Supplemental O2
Pulse ox, a-line
CVP for maintenance of preload
PAC not recommended, difficult insertion and pulmonary HTN
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17
Q

Regional management considerations in ES

Epidural, CS, CSE

A

Epidural - higher concentrations of LA and used for labor, some motor block to prevent pushing and straining that will increase workload of heart
CS - intrathecal opioid dosing 1st stage, minimizes hemodynamic changes, small doses of LA in stage 2, high incidence of PDPH
CSE- adequate analgesia with minimal hemodynamic effects, intrathecal opioids then small doses or dilute doses of LA ropi or bupi via epidural, continuous monitoring, phenylephrine infusions to treat SVR

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18
Q

Why is epidural preferred for ES

A

Prevent sudden drop in svr
Slow epidural level
Avoid chloro

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19
Q

Why is single shot spinal not recommended for ES

A

Precipitous hemodynamic changes

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20
Q

GETA considerations for ES

A
  • decreased venous return with PPV problematic
  • slow induction (no RSI) high dose opioids for cardiac stability
  • risk of aspiration takes a back seat, aspiration prophylaxis, cricoid pressure, no RSI/quick intubation
  • neonatal respiratory depression is a consequence of high dose opioids
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21
Q

PP goals with ES

A

Risks of mortality still persist
ICU for 24-48 hours
Prophylactic anticoag

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22
Q

AS usually results from

A

Congenital bicuspid valve or rheumatic heart disease

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23
Q

What are the recommendations for moderate to severe AS in pregnancy

A

Replacement before conception

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24
Q

With cardiac changes happen with pregnancy and AS

A

Increased CO, O2 consumption

Decreased SVR

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25
Q

AS ob management

A

CO increased by increased HR (fixed SV)
Tachycardia is decreasing diastolic coronary perfusion and increases myocardial O2 demand
Increased CO in labor and delivery further increases risk

Increased LVEDP and LV hypertrophy

Decreased myocardial perfusion
Decreased coronary filling during diastole and decreased perfusion to LV hypertrophy
Increased risk of MI

Vaginal and instrument assisted delivery preferred to avoid valsalva and pushing
CS also preferred to avoid hemodynamic stress of labor

26
Q

AS anesthetic management

A

NSR
Tachycardia not well tolerated, fixed SV, atrial kick contributes 40% to ventricular filling and CO
SVR avoid severe drops to ensure myocardial perfusion
Venous return maintain EDV and LV SV
A-line
PAC or CVP consideration

27
Q

Analgesia for L&D AS

A 
Slow titration of epidural
Phenylephrine over ephedrine
Intrathecal opioids CSE
Continuous spinal same as ES
Invasive monitors
28
Q

Regional considerations for AS

A

No single shot spinal
Preferred is slow epidural or continuous spinal w. Invasive monitors
CSE with spinal opioids and slow epidural later
Phenylephrine > ephedrine

29
Q

GA considerations for AS

A

Induction use etomidate, opioids, sux (slower induction, mod RSI)
Inhalation decreases SVR and increases myocardial depression
High dose opioids are better (infant will need resuscitation)

30
Q

AS PP concerns

A

Increased CO = decompensation
Careful Fluid management
Analgesia to avoid tachycardia
Invasive monitoring 24 hours post op

31
Q

Most common cause of chronic AI

A

Rheumatic heart disease

Endocarditis can also cause it

32
Q

AI characteristics

A

LV volume overload from regurg
LV hypertrophy and dilation; function declines
Pulmonary edema
Changes occur over many years with chronic insufficiency - asymptomatic

33
Q

Mild/moderate AI and pregnancy

A

Beneficial
Decreased SVR improving forward SV
Increased HR less time for diastolic filling and smaller EDV

34
Q

Severe AI and pregnancy

A

Decline in LV function

Extensive management

35
Q

AI anesthetic management

A 
Analgesia avoids pain and increased SVR
Epidural ideal 
PAC recommended for severe
Maintain preload, avoid hypotension
Ephedrine!
Tachy is good, brady and increased SVR are bad
GA: mild/moderate tolerates RSI, severe slow induction, high dose opioids
Avoid myocardial depressants
36
Q

Most common lesion associated with RHD

A

MS

37
Q

T or F first symptoms of MS occur in pregnancy bc precipitation of CV changes of pregnancy

A

T

38
Q

Why do you want to avoid increased CO/HR in MS

A

Pulmonary edema

39
Q

Cardiology management of MS

A

BB to maintain slow HR

A-fib detrimental, aggressive therapy of dig BB and cardioversion

40
Q

Mild/moderate MS and pregnancy

A

Tolerates labor well

Invasive monitoring not warranted

41
Q

Severe MS

A

PAC
Avoid fluid overload increased risk of pulmonary edema
Instrument assisted vaginal delivery usually planned (avoid valsalva)
CSE or continuous spinal with opioids for first and low dose LA for second stage

42
Q

Regional considerations with MS

A 
Epidural preferred
Analgesia 
Dense block for instrument assisted
CSE, epidural, CS
Phenylephrine > ephedrine
43
Q

GA considerations with MS

A

RSI or high dose opioids based on ventricular function
BB with RSI to avoid tachycardia and HTN
Remi for hemodynamics and minimize neonatal depression
Avoid large fluid intake

44
Q

PP for MS

A

Monitor for 24 hours
Continue epidural - increased preload associated with resolution of sympathectomy will not coincide with pp increased preload

45
Q

What causes mitral insufficiency

A

RHD and MV prolapse

46
Q

What is seen in mitral insufficiency

A

Dilation of LA and increased LAP

47
Q

MI has an increased risk of what during pregnancy

A

A. Fib

48
Q

Incidence of pulmonary edema and pulmonary HTN is higher or lower than with stenosis

A

Lower

49
Q

T or F decreased SVR and increased HR are advantageous to MI patients

A

T

50
Q

Most MI patients tolerate pregnancy well T or F

A

T

51
Q

Considerations for mitral insufficiency and L&D

A

Epidural
Avoid increased SVR and valsalva
Instrument assisted delivery
Decreased SVR reduces regurg, improves forward flow, decreases likelihood for pulm edema

52
Q

CS considerations for mitral insufficiency patients

A

Epidural
Ephedrine
GA decreases afterload and slightly increases HR, avoid myocardial depressants

53
Q

Hemodynamic goals for AS and AI

A

AS- normal HR and rhythm, avoid decrease in SVR, normal venous return
AI: normal to mild increase in HR, avoid increase in SVR

54
Q

Hemodynamic goals for MS and MI

A

MS: slow HR and SR, normal SVR, normal venous return
MI: SR and normal to increase HR, avoid increase in SVR and venous return

55
Q

Definitions for peripartum cardiomyopathy

A
  • HF in the last month of pregnancy or within 5 months of delivery
  • absence of identifiable cause of HF
  • absence of recognizable heart disease prior to last month of pregnancy
  • LV dysfunction via echo (decreased EF)
56
Q

Peripartum cardiomyopathy risk factors

A 
Advanced maternal age
Multiparity
Obesity
Multiple gestation
Pre-eclampsia
Chronic HTN
African american
57
Q

Etiology for peripartum cardiomyopathy

A

Unknown
Myocarditis
Abnormal immune response to pregnancy
Maladaptive responses to hemodynamic stresses of pregnancy

58
Q

S/S of peripartum cardiomyopathy

A

LV failure

Fatigue, orthopnea, pedal edema, cardiomegaly, pulmonary edema, increased LVEDV, decreased EF

59
Q

Medical OB management for cardiomyopathy

A 
Preload optimization
Afterload reduction
Increased contractility
If stable - induction of labor recommended
Acute cardiac decompensation = CS
60
Q

Anesthetic management for cardiomyopathy

A

Invasive monitoring
Vasoactive drugs
Early labor analgesia to minimize cardiac stress
Epidural to reduce afterload, slowly titrate
CSE, CS
GA high dose opioids or remi

OB (10 decks)

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