Cardiac Disease Flashcards
how many maternal deaths are due to cardiac disease?
60%
leading cause of indirect maternal death
list the changes of the cardiac system in pregnancy:
fall in systemic vascular resistance to 30-70% by 8/40 - results in fluid retention and an increase in blood volume
increased cardiac output - begins to rise in 1st trimester and rises to peak at 32/40 by 30-50%. Achieved by rise in stroke volume and HR
increased blood volume and cardiac output and reductions in systemic vascular resistance and BP
plasma volume reaches a maximum of 40% above baseline at 24/40
what happens to blood pressure during pregnancy?
remains almost pre pregnant levels
slight tendency to fall, particularly during mid trimester as the vascular resistance falls
what do these changes effect?
absorption, excretion and bioavailability of all drugs
raised renal perfusion, higher metabolism
what intrapartum changes occur to BP and cardiac output?
SBP increases 15-25%
DBP increases 10-15% during uterine contractions
cardiac output- increases by 15% in early labour, 25% during 1st stage and 50% during pushing
80% increase in CO in early postpartum due to auto transfusion related to uterine involution and leg oedema
what are the symptoms of cardiac disease?
can be easily disguised as normal pregnancy changes
fatigue, dyspnea, light headedness
there would be abnormal findings on an ECG or echo
How should collaborative care be involved with cardiac disease?
MBRACE 2016- women with CHD should ideally be managed by an MDT, obstetricians, cardiologists, anaesthetists, neonatologists, midwives.
pre pregnancy counselling is very important (RCOG 2011)
what should be involved in pre-conceptual counselling?
transition from paediatric cardiology inclusive of contraceptive advice (MBRACE, 2016)
obstetrician and cardiologist should work together to help make an informed decision
prevent an unwanted pregnancy and avoid the risks associated with pregnancy continuation or termination
what is the risk/likelihood of a cardiac event during pregnancy?
no other risk factors- 5%
one risk factor- 25%
2 risk factors - 75%
what plans should be in place for labour and delivery?
appropriate timing of delivery is crucial to balance the risks and benefits to mother and baby
clear plan of management should be established in advance, clearly documented and widely disseminated. generally- vaginal examination with low dose of epidural anaesthesia
careful monitoring of mother and fetus, careful BP monitoring and blood loss monitoring
nursing in left lateral ideally, never lying flat
forceps or vents delivery can be used to shorten maternal expulsive effort in second stage
antibiotic prophylaxis should be given during labour and delivery for most women
increased cardiac output in second stage - reduce time in second stage
pain induces sympathetic response, causing increased HR
what are the indications for ELLSCS?
aortopathy with aortic root >4cm
aortic dissection or aneurysm
warfarin treatment within 2 weeks
what is the plan for 3rd stage of labour?
return of uterine blood into systemic circulation results in further increase in cardiac output
bolus 10IU of oxytocin should be avoided as can cause severe hypotension
ergometrine, syntometrine avoided (hypertension)
misoprostol use is unclear of safety
low dose oxytocin infusion is preferred
what is the plan immediately after birth?
stroke volume, HR and CO remain high for 24 hours post delivery, high risk for pulmonary oedema
careful haemodynamin monitoring postpartum for 24-72 hours, should extended up to 2 weeks with pulmonary hypertension
what is the postnatal care?
lactation encouraged - reduces fluid retention .. unless woman in cardiac failure
cardiac output not compromised during lactation
MDT follow up should take place 6 weeks PN
what forms of contraception are advised?
barrier methods - unreliable
COC contraindicated
progesterone only pills have better side effects
mirena coil is good
sterilisation is ideal
