Cardiac diseases Flashcards
Why does pregnancy impose great effort on the heart?
due to increased
- cardiac output
- stroke volume
- heart rate
What are the types of heart disease?
Acquired
- Rheumatic heart disease: mitral stenosis (90%)
- coronary heart disease
Congenital
- atrial septal defect
- ventricular septal defect
- tetralogy of fallot
What should be done is preconception counseling in case of suspected heart disease?
- assessment done by obstetrician & cardiologist
- assess ejection fraction & cardiac function
- optimization of medication
- check need for surgical correction
What are the risks of heart disease in pregnancy?
on MOTHER
- increased mortality
- frequent admissions
- interventions
on FETUS
- congenital heart disease
- preterm labour
- FGR
- effects of drugs
What are the high risk heart conditions that increase the rate of maternal mortality?
1- pulmonary hypertension
2- ischemic heart disease
3- Eisenmenger’s syndrome
4- Marfan syndrome with aortic root >40mm diameter
5- peripartum cardiomyopathy
6- prosthetic heart valves (metal)
How does a patient present in case of heart pathology in pregnancy?
- breathlessness (progressive dyspnea)
- decreased exercise tolerance
- fatiguability
- palpitation
- peripheral edema
- hemoptysis
- chest pain
- syncope
- nocturnal cough
What are the markers for cardiac events?
1- prior episode of heart failure, arrhythmia, stroke
2- NYHA > class 2 or cyanosis
3- left heart obstruction
4- reduced left ventricular function (EF < 40%)
How should a mother with known heart disease be managed during pregnancy?
1- frequent ANC visits to check for symptoms of heart failure
2- routine physical: PR, BP, JVP, heart sounds, ankle & sacral edema, basal crepitations
3- reduce physical activity
4- LMWH in: pulmonary hypertension, prosthetic heart valves, & atrial fibrillation
5- serial maternal ECHO: at booking & at 28 weeks
6- in women with congenital heart disease -> fetal cardiac ultrasound
What anticoagulants should be used in case of prosthetic heart valves?
- First trimester -> LMWH
- Second trimester -> Warfarin
- from 36 weeks -> LMWH
- Postpartum -> heparin & warfarin
How should a patient with cardiac disease deliver their baby?
1- aim for vaginal delivery with spontaneous onset
2- administer oxygen & epidural analgesia
3- give prophylactic antibiotic for structural heart defects to guard against subacute bacterial endocarditis
4- elective instrumental delivery to shorten 2nd stage of labour
5- in 3rd stage of labour give oxytocin with low infusion rate
avoid ergometrine
When is C section indicated in case of heart disease & what are the risks associated with it?
recommended for:
- dilated aortic root >4cm or aortic aneurysm
- acute severe congestive failure
- recent myocardial infarction
- need for emergency valve replacement immediately after delivery
risk of hemorrhage, infection, & thromboembolism
What is the cause of postpartum intravascular overload?
sudden emptying of uterine venous sinuses after placental delivery
What are the risk factors for heart failure in pregnancy?
OB
- multiple pregnancy
- hemorrhage
- tocolytics
- corticosteroids
- pain related stress
MEDICAL
- anemia
- hypertension
- respiratory infections
- obesity
- arrhythmias
- fluid overload
What is the cause of ischemic heart disease in pregnancy?
Coronary artery dissection postpartum rather than atherosclerosis in women above 40 years
- peaks in 3rd trimester parous ladies
manage by percutaneous transluminal coronary angioplasty (PTCA)
What is the cause of mitral stenosis and how is it treated?
- acquired rheumatic
- 40% worsens during pregnancy at 30 weeks
Treated by: bed rest, diuretics, oxygen, beta blockers
Definitive: Balloon mitral valvotomy (post partum)