Cardiac disease pregnancy

Question 1

What are the cardiovascular adaptations in pregnancy

Antenatal

Answer 1

Peripheral vasodilation
This is mediated by nitric oxide synthesis, regulated by estradiol and prostaglandins
This drops systemic vascular resistance and to compensate cardiac output increases by 40% x big increase in stroke volume, small increase in heart rate
Begin by 8 weeks, max 28 weeks
Contracility increases and physiological dilatation
Increase in wall muscle mass
SV reduces near term but HR stays elevated
Supine drops CO 25%
Pulmonary vascular resistance decreases
Central venous pressure and pulmonary capillary wedge pressure don’t change
Serum colloid pressure reduces (and as PCWP not changes then increases risk pulmonary oedema)

Question 2

Intra partum and post partum haemodynamical changes

Answer 2

Further increase in cardiac output
15% in first stage and 50% in second stage
CO increased with sympathetic activation of contractions to pain and a 500 ml autotransfusion

Post partum the relief on IVC and contraction empties blood back into the circulation - CO increases up to 80% then settled within an hour
High risk time for pulmonary oedema
Normal back to baseline 2 weeks post natal

Question 3

Cardiac exam in a pregnancy woman

Answer 3

Bounding or collapsing pulse
ESM 90%
Loud first heart sound
Third heart sound
Peroipheral oedema 
Ectopic beats
Relative sinus tachycardia

Question 4

ECG in pregnancy

Answer 4

Atrial and ventricular ectopic
Q wave and inverted T in lead 3
ST segment depression and t wave inversion in inferior and laternal leads
QRS axis left shift

Question 5

What factors about heart disease affect the ability to tolerate pregnancy

Answer 5

Presence of pulmonary hypertension
Haemodynamic significance of a lesion
Functional class (NYHA)
Presence of cyanosis

Other predictors 
Hx TIA or arrhythmia 
Hx heart failure 
Myocardial dysfunction (EF<40%)
Left heart obstruction

Question 6

What are the worst lesions for pregnancy

Answer 6

MS/ symptomatic AS - risk pulmonary oedema
Severe coarctation
marfans risk of dissection or aortic rupture
Pulmonary hypertension risk of death
Complex congenital heart disease
Mechanical values - risk of thrombus

Question 7

How to manage cardiac pathology in pregnancy

Answer 7

MDT
Documented plan
Specialist unit 
Plan around
Anticoagulation
MOD
Place of delivery
Uterotonics 
Guidance about IVF

Question 8

Pulmonary hypertension

Risk
Management

Answer 8

Risk death 25%
Progesterone implants good contraceptives for them
Termination has a mortality of 7%
Death occurs soon after delivery as there is an increased right to left shunt, RHF and escalating pulmonary hypertension and crises

Management
Thromboprophylaxis 
Elective admission
Continue hypertension target therapy that is safe in pregnancy (sildenafil- phosphodiesterase inhibitors and prostanoid analogues)
Stop endothelium receptor antagonists 
MDT 
ICV
Avoid hypovolaemia
Avoid VTE
Avoid systemic vasodilation

Question 9

Congenial heart disease

Most common patent ductus arteriosus, ASD VSD 60% cases

Answer 9

PDA - most are repaired and have no problem
If unprepared usually fine but can have HF

ASD
Commonest
Usually fine
Risk paradoxical embolismsVT s can develop
Can be compromised if blood loss at delivery

VSD
Usually fine

Question 10

Contraindications of syntocinon?

ergometrine?

Answer 10

Synto- it is a peripheral vasodilator - avoid or give slows in stenosis lesions, HCM

Ergo- avoid if coarctation or risk of dissection or corronary artery disease, it is a vasoconstrictor

Question 11

Cardiac indications for elective LsCS

Answer 11

Dilated or expanding aortic root
Over 5cm with a bicuspid valve or over 4.5 cm with marfans
Severely impaired left systemic vascular function

Question 12

What heart conditions need anticoagualtion

Answer 12

Anything on anticoagulant out of pregnancy eg mechanical valves
AF
Marked left ventricular dysfunction with dilatation
Fontan circulation
L to r shunts with previous stroke

Question 13

Most common arrhythmia in pregnancy?

Answer 13

Sinus tachycardia
Exclude sepsis, hyperthyroid, resp or cardiac pathology, hypovolaemia
Do an ecg to rule out wPW
24 holter if concerns

Paroxysmal SVT commonest usually predates pregnancy
Can increase in frequency in pregnancy

Question 14

Risk factors for aortic dissection in pregnancy

Answer 14

Marfans
Loey-dietz 
Turners syndrome
Ehlers danlos 
Coarctation 
Bicuspid valves

Question 15

Risk factors for peripartum cardiomyopathy

Answer 15

Multiple pregnancy
HTN in pregnancy
Multip
AMA
Afro Caribbean race 

Diagnosis
LVEF<45%
Fractional shortening <30%
Often global enlargement and reduced LVF

Question 16

Management of epripartum cardiomyopathy

Answer 16

Deliver if pregnant
Thromboprophylaxis
conventional treatments for HF (ACEi after delivery)
Immunosuppressive therapy if myositis confirmed on biopsy if not improving after 2 weeks
Intraaortic balloon pumps

Question 17

Peripartum cardiomyopathy
Mortality
Recurrence

Answer 17

Mortality 15%
50% recover fully
If haven’t recovered should avoid pregnancy as 50% will worsen and 25% die in another pregnancy 
If resolves recurrence up to 25%
Future pregnancy high risk

Question 18

MS is bad
Asymptotic pre preg does not mean will cope with pregnancy

What is the warning sign?

Answer 18

Tachycardia is bad as ventricle can’t fill
Late second or third trimester

Confirm Dx and assess severity with ECHO

B blockers to slow HR
Tx AF aggressively

Question 19

Congenital heart disease recurrence

Answer 19

ASD 5-10%
AS 18-20%
Marfans and HCM are autosomal dominant inheritance

Woman with congenital heart disease should have detailed fetal cardiac USS

Question 20

Marfans

What heart defects

Answer 20

Mitral valve prolapse
Mitral regurgitation
Aortic root dilatation (risk dissection 10% if root over 4cm) progressive or FHX
High risk patients should have root replacement before pregnancy

If woman has cardiac lesion the baby will tend to as well