cardiac disease in pregnancy Flashcards
who do you give endocarditis ppx on L&D?
- history of prosthetic valve
- cyanotic heart disease
- previous endocarditis
what regimen do you use for endocarditis ppx?
- ampicillin 2 g
or - if pen allergic, vanc 1 g IV over 1-2 hrs
what are the NYHA heart classification?
I: asymptomatic
II: mild fatigue/sx with routine activity
III: fatigue/sx with less than ordinary activity
IV: fatigue/sx at rest
management of cardiac disease on L&D
- good IV access
- goal of euvolemia
- epidural
- notify anesthesia
- continuous pulse oximetry
- delivery: avoid valsalva, labor down, assisted second stage
- watch for 3rd stage
why is 3rd stage risky for cardiac disease
- blood loss during placental delivery
- then uterine contraction and autotransfusion increases blood volume
- net increase in blood volume
when is pregnancy contraindicated?
- pulmonary HTN (eisnemenger syndrome or primary)
- cyanotic heart disease
- severe aortic root dilation
- > marfan > 45 mm
- > bicupsid aortic valve > 50 mm
- > tetralogy > 50 mm
- > Turner with ASI > 25 mm/m2
- severe aortic stenosis (< 1 cm) /mitral stenosis
- severe cardiomyopathy
- any NYHA class 4
- EF < 30%
- fontan circulation
what defects are not with increased risk in pregnancy
- corrected asd/vsd
- uncorrected asd/vsd without pulm HTN
- corrected TOF
- most vavular d/o
- small/uncomplicated/mild: pulm stenosis, PDA, MVP
3 principles going into cousneling of pt with CV disease:
- pregnancy can worsen CV status
- potential maternal mortality/morbidity
- fetal risk of structural/congenital cardiac anomaly, FGR, PTB, IUGR, neonatal mortality
4 RFs linked to CV mortality in pregnancy:
- black race
- age over 40
- obesity
- HTN
Differential for ST segment elevation or depression
- MI
- pericarditis
- pulmonary embolism
- electrolyte abnormalities
acute coronary syndrome - ddx and management
in pregnancy: 1) coronary artery dissection 2) arterosclerosis, embolism, aortic dissection, aspasm
management:
- left lateral tilt (30-90 degrees), EKG, troponins
- O2, nitrates, unfractionated heparin, ASA, beta blocker
- coronary angiography is key study
ddx of cardiac arrest in pregnancy/PP
- hemorrhage 2. AFE 3. ACS 4. VTE 5. drugs, sepsis etc
management of cardiac arrest in pregnancy
all happen simultaneously (different than non-pregnant)
- airway/breathing: bag valve mask 100% O2, consider early intubation
- circulation: left displacement if uterus > 20 weeks, chest compressions 100-120/min. ratio of comp to breath 30:2
- if 4-5 minutes without ROSC or unwitnessed arrest -> perimortem CD. Perform with midline vertical, and prior to transport
postpartum cardiomyopathy prognosis
- EF < 30% is bad
- 5-10% risk of death or cardiac transplant at 1 year
- recurrence rate 20%
what should postpartum care entail?
- early f/u with PCP or cardiologist (7-10 days)
- encourage breast feeding
- strong pt education on symptoms of CV disease
- 3 month f/u for long term care, and many of complications happen > 42 days after
- contraception counseling; IUD is best non-permanent option
