Cardiac Disease in Pregnancy

Question 1

Define Peripartum Cardiomyopathy.

Answer 1

New-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum.

Question 2

What is the pathophysiology of cardiac disease in pregnancy?

Answer 2

1. 40% rise in blood volume during pregnancy causing strain
2. Women with cardiac disease cannot increase CO
3. Uterine hypoperfusion and increased pulmonary oedema

Question 3

Why is cardiac disease in pregnancy increasing?

Answer 3

• Increased maternal age
• Increased life expectancy
• Increased immigrant populations

Question 4

What are the signs and symptoms of cardiac disease in pregnancy?

Answer 4

• Classify based on the NYHA classification
• Most women will remain well throughout pregnancy
  
  • ESM in 96% (more CO)
  • 3rd heart sound in 84% (more cardiac volume)
• Peripheral oedema (more volume)
• Forceful apex (more CO)
• Fatigue
• Dyspnoea

Question 5

What are the appropriate investigations for suspected cardiac disease in pregnancy?

Answer 5

• Echocardiogram is usually performed at booking and at 28 weeks
• Chest X-ray
• Bloods - BNP
• Blood pressure

Question 6

What is the management of cardiac disease in pregnancy?

Answer 6

• Anticoagulation for patients with congenital heart disease and pulmonary hypertension, artificial valves or those at risk of AF
  
  • Warfarin is teratogenic if used in the first trimester → LMWH is used as an alternative to warfarin

Question 7

What are the high risk cardiac conditions in pregnancy?

Answer 7

• Systemic ventricular dysfunction
• Pulmonary hypertension
• Cyanotic congenital heart disease
• Aortic pathology - Marfan’s syndrome
• Ischaemic heart disease
• Left heart obstructive lesions - e.g. aortic/mitral stenosis
• Prosthetic heart valves
• Previous peripartum cardiomyopathy

Question 8

What are the foetal risks of a maternal cardiac disease in pregnancy?

Answer 8

• Recurrence of congenital heart disease
• Foetal hypoxia → due to maternal cyanosis
• Iatrogenic prematurity
• FGR
• Effects of maternal drugs
  
  • Teratogenesis
  • Growth restriction
  • Foetal loss

Question 9

How is cardiac disease managed in labour and delivery?

Answer 9

• In most cases, aim to wait for spontaneous labour
• 2nd stage kept short with elective forceps or ventouse delivery → reduces maternal effort and need for an increased cardiac output
  
  • C-section for those where any effort is dangerous
• 3rd stage is managed with syntocinon alone → ergometrine may be dangerous (causes vasoconstriction, hypertension and heart failure)
• Induction may be considered in very high-risk women to ensure that delivery occurs at a predictable time with all the personnel present
• Epidural anaesthesia is usually recommended to reduce pain-related stress
• Prophylactic antibiotics should be given to any woman with a structural heart defect
• Postpartum haemorrhage is dangerous because it can lead to cardiovascular instability