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Year 5 - Obstetrics and Gynaecology > Cardiac disease in pregnancy > Flashcards

Cardiac disease in pregnancy Flashcards

1
Q

What is the pre-conception management of cardiac disease in women wanting to become pregnant?

A
  • Full assessment by obstetrician and cardiologist should be carried out before embarking on pregnancy
  • Optimise medications
  • Surgically correct the heart defect if possible
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2
Q

What symptoms should you check for antenatally in women with cardiac disease?

A
  • Breathlessness particularly at night
  • Change in heart rate or rhythm
  • Increased fatigue
  • Reduction in exercise tolerance

O/E: check HR, BP, JVP, auscultation, ankle/sacral oedema, basal crepitations

NB: should be seen in joint obstetric/cardiac clinic by same physicians for continuity of care and to detect subtle changes in maternal wellbeing. Sometimes these are difficult to distinguish from normal pregnancy symptoms.

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3
Q

What classification is used for assessing stages of heart failure?

A

NYHA classification - New York Heart Association classification

4 classes, mild to severe

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4
Q

Summarise the stages of heart failure according to the NYHA classification

A

1 - mild - no limitation and no symptoms

2 - mild - slight limitation + symptoms during normal activity

3 - moderate - marked limitation + symptoms during light activity

4 - severe - inability to carry out activities without discomform + symptoms at rest + more discomfort during activity

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5
Q

What are the Toronto risk markers for maternal cardiac events?

A
  1. Prior episode of heart failure, arrhythmia or stroke
  2. NYHA class >II or cyanosis
  3. Left heart obstruction
  4. Redced LV function (EF<40%)
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6
Q

How does number of Toronto risks markers correspond to risk of cardiac event during pregnancy?

A

Importance:

  • 0 predictors = risk of cardiac event is 5%
  • 1 predictor = risk of cardiac event is 37%
  • >1 predictor = risk of cardiac event is 75%
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7
Q

When should echocardiograms be done in women with cardiac disease during pregnancy?

A
  1. At booking visit
  2. At 28 weeks
  3. When there is any sign of deteriorating cardiac function
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8
Q

What cardiac conditions warrant anticoagulant use during pregnancy?

A
  • Congenital heart disease - pulmonary hypertension or artificial valve replacement
  • Risk of AF
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9
Q

Why can warfarin not be used in pregnancy?

A

First trimester - teratogenic

Third trimster - linked with fetal intracranial haemorrhage

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10
Q

What anticoagulant is routinely used in pregnancy?

A

LMWH e.g. dalteparin/enoxaparin - this is titrated by measuring factor Xa levels

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11
Q

List 4 high-risk cardiac conditions in pregnancy.

A
  • Systemic ventricular dysfunction (ejection fraction <30%, NYHA Class III–IV).
  • Pulmonary hypertension.
  • Cyanotic congenital heart disease.
  • Aortic pathology (dilated aortic root >4 cm, Marfan syndrome).
  • Ischaemic heart disease.
  • Left heart obstructive lesions (aortic, mitral stenosis).
  • Prosthetic heart valves (metal).
  • Previous peripartum cardiomyopathy.
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12
Q

What are the fetal risks of maternal cardiac disease?

A
  • Recurrence (congenital heart disease).
  • Maternal cyanosis (fetal hypoxia).
  • Iatrogenic prematurity.
  • FGR.
  • Effects of maternal drugs (teratogenesis, growth restriction, fetal loss).
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13
Q

What are the general principles of management of labour in a pregnancy with cardiac disease?

A
  • Avoid IOL if possible - although may be necessary to ensure all relevant personnel are present at time of labour
  • Use prophylactic antibiotics - esp if structural heart defect present, to prevent endocarditis
  • Ensure fluid balance.
  • Avoid the supine position.
  • Discuss regional/epidural anaesthesia/analgesia with senior anaesthetist - to relieve pain-related stress and demand on cardiac function BUT can cause maternal hypotension
  • Keep the second stage short.
  • Use Syntocinon judiciously.
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14
Q

What are the delivery options for a patient with cardiac disease in pregnancy?

A

Await spontaneous labour - minimises risk of intervention.

Consider IOL - to ensure delivery occurs at time when all relevant personnel are present

+/- Instrumental delivery - to shorten 2nd stage of labour if normal delivery does not readily occur

Elective C-section - only done if maternal condition is too unstable to tolerate labour

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15
Q

What are the risk factors for development of cardiac disease in pregnancy?

A
  • Respiratory or urinary infections
  • Anaemia
  • Obesity
  • Corticosteroids
  • Tocolytics
  • Multiple gestation
  • HTN
  • Arrhythmias
  • Pain-related stress
  • Fluid overload
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16
Q

How common is MI in pregnancy and what is the pathophysiology?

A

1 in 15,000 risk of MI during pregnancy

Usually not atherosclerosis but rather coronary artery dissection is the primary cause, occurring in the postpartum period.

17
Q

What treatments for MI can be used in pregnancy?

A

Percutaneous transluminal coronary angioplasty (PTCA) - only use when absolutely necessary and avoid outside of 8-15 weeks where fetus is most susceptible to effects of radiation

Thrombolysis - little evidence but apparently safe, although increases risk of fetal and maternal haemorrhage

NB: MI is often missed in pregnancy

18
Q

Why are obstructive lesions of the left heart problematic in pregnancy?

A

Left heart defects include mitral and aortic stenosis

These are problematic as there is inability to increase CO to meet the demands of the pregnancy

19
Q

What is the aetiology of most left heart obstructive lesions?

A

Mitral stenoiss - rheumatic in origin

Aortic stenosis - usually congenital

20
Q

How does pregnancy affect mitral stenosis?

A
  • 40% experience worsening symptoms
  • average time of onset of pulmonary oedema is 30 weeks
  • maternal mortality is 2% and fetal mortality depends on severity of MS
21
Q

What is the management of mitral stenosis in pregnancy?

A

Aim is to reduce HR:

  • Bed rest
  • Beta blockers, duiretics
  • Balloon mitral valvotomy after delivery
22
Q

What are the complications of AS in pregnancy?

A

Pregnancy usually well-tolerated in those with mild/moderate AS with normal exercise tolerance and good ventricular function

Severe AS increases maternal mortality to 17% and fetal mortality to 30%

23
Q

What is the management of AS in pregnancy?

A
  • Bed rest
  • Medical treatment to reduce heart rate to allow time for ventricular filling
  • Balloon or surgical aortic valvotomy - if condition deteriorates.
24
Q

What are the effects of Marfan syndrome on the heart?

A
  • Mitral valve prolapse
  • Aortic regurgitation
  • Aortic root dilatation
  • Aortic rupture or dissection

Marfan’s is a connective tissue abnormality.

25
Q

What is the inheritance pattern of Marfan’s?

A

Autosomal dominant

26
Q

How does pregnancy complicate Marfan’s syndrome?

A

Maternal mortality increases because pregnancy increases risk of aortic rupture or dissection when aortic root dilatation is present (–> 50% mortality)

27
Q

What are the complications of Marfan’s on pregnancy?

A
  • Early pregnancy loss
  • Preterm labour
  • Cervical weakness
  • Uterine inversion
  • PPH
28
Q

What investigation should be carried out throughout pregnancy in a patient with Marfan’s?

A

Echocardiography to monitor for aortic root dilatation - serially throughout pregnancy (esp if already >4cm)

If aortic root is <4cm then reassure the patient that risk of adverse event is ~1%.

29
Q

What is pulmonary hypertension? Which side of the heart is affected?

A

PH is characterized by an increase in the pulmonary vascular resistance resulting in an increased workload placed on the right side of the heart.

Usually mean pulmonary arterial pressure ≥25 mmHg at rest with pulmonary capillary wedge pressure ≤15 mmHg and PVR >3 Woods units.

30
Q

What are the symptoms of PH?

A
  • Fatigue
  • Breathlessness
  • Syncope
  • Right heart failure signs
31
Q

What is the median survival in PH?

A

<3 years from diagnosis

32
Q

Which treatments improve symptoms and survival in PH?

A
  • Endothelin blockers e.g. bosentan
  • Phosphodiesterase inhibitors e.g. sildenafil
33
Q

What is the major complications associated with PH in pregnancy?

A

Maternal death (30-50%)

  • Demands of increasing blood volume and CO cannot be met by the compromised right ventricle
  • Any decline in cardiac function should be treated as a life-threatening event
  • Women are likely to deteriorate in 2nd trimester or in the immediate postpartum period

Year 5 - Obstetrics and Gynaecology (87 decks)

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