cardiac diseases Flashcards
risk to baby if mother/father has congenital heart disease
Mother: 6 %
Father: 2 %
Sibling: 15 -30 %
Both:
congenital cardiac anomaly, classification
- -
Natural law of transmission of cardiac disease
- high risk anomalies lowest risk of transmission <5 %
- low risk highest risk of transmission: 25 - 40 %
Low risk cardiac congenital anamalies
1 - Small left to right shunt
- ASD
- VSD
- PDA
2 - Coarctation of aorta with raised BP, more with turner syndrome
3 - Tetraloy of Fallot
Pregnancy with Small left to right shunt (ASD, VSD & PDA)
- Due to decrease peripheral vascular resistance, in pregnancy shunting is reduced.
- In absence of pulmonary HTN - pregnancy, labour, delivery well tolerated
- ASD: atrial arrhythmia & paradoxical emboli so low threshold for heparin
- Acute blood loss & acute vasodilation due to regional anesthesia can affect shunt degree & direction acutely, reducing left ventricular output
Pregnancy with Coarctation of aorta
- with raised BP, more with turner syndrome
- 6 - 8% of congenital anomalies
- Well tolerated pregnancy with well repaired coarctation of aorta
- Assess cardiac status before conception to manage complications like HTN, recoarctation, aneurysm at site of repair & associated bicuspid aortic valve.
- Pregnancy associated complication aortic dissection & rupture & HTN
- Poorly controlled HTN : Maternal complication (preeclampsia, HTN crises, rupture of intacranisal aneurysm) fetal complications:FGR, Abrution, premature delivery)
Pregnancy with Tetraloy of Fallot
- the most common form of cyanotic congenital heart disease
- Pregnancy with repaired ToF well tolerated
- Arrhythmia & right ventricular failure specially in (residual shunt, RT ventricular outflow obstruction & pulmonary HTN)
- Many pulm regurgitation symptomatic, occasional need diuretic admission & bed rest
Moderate risk cardiac lesions
- Transposition of great arteries (TGA)
- Cyanotic heart d/s without pulmonary HTN, if pulmonary HTN TOP under clause A
- Fontan procedure
High risk cardiac lesions
- Marfans syndrome
- Pulmonary vascular disease
TGA and pregnancy
- Post- repair:rt ventricle becomes systemic one, long term complications: systemic rt ventricular failure, tricuspid regurgitation, sinus node dysfunction, arrhythmia & baffle obstruction (venous pathway obstruction)
- pregnancy well tolerated following uncomplicated repair, rt ventricular dysfunction &/or atrial arrhythmia, may occur
- If long term complications, pregnancy poorly tolerated, increased risk of cardiac complications
Cyanotic heart d/s without Pulmonary HTN
- Caused by uncorrected transposition of great arteries, truncus arteiorsis, uncorrected ToF with , tricuspid atresia & Ebstein anomaly’s with ASD
- During pregnancy fall in systemic vascular resistance & rise in cardiac output exacerbates any right to left shunting, worsening preexisting cyanosis & hypoxia.
- Maternal complications: haemorrhage, paradoxical embolism & heart failure
- effects on fetus marked: increase miscarriage, 30-50 % premature delivery & LBW
- degree of maternal hypoxemia : most important predictor of neonatal outcome
- Admission for bed rest & oxygen therapy effective for mother & fetus.
Fontan procedure
- definitive palliative procedure for cyanotic heart d/s, characterized by single functional ventricle
- Atrial separation divides systemic & pulmonary circulations & with construction of aortopulmonary connections blood enters pulmonary circulation without pulsatile ventricle.
- Main concern regarding pregnancy is ability augment maintain & adjust cardiac output & heart rate.
- Maternal risks : low in NHYA 1-2, provided ventricular function is good,
Marfans syndrome
- inherited of connective tissue
- autosomal dominant
- thoracic aortic aneurysm leading to aortic dissection, rupture or both increased in pregnancy
- Aortic root <4 cm, overall maternal mortality 1 % during pregnancy, increases 25 % when >4 cm
- pregnancy should be postponed until aortic arch replacement & in unplanned TOP
- Aortic root diameter monitor by serial echo & if aortic root dilatation occurs, prophylactic beta blockade is advised & HTN treated aggressively.
- systolic HTN : most deaths in aortic HTN
Pulmonary vascular disease
- pregnancy poorly tolerated, worsening cyanosis & hypoxia, arrhythmia, heart failure & death
- majority of complications at term & first week postpartum
- maternal mortality depends on underlying cause: 36 % in Eisenmenger syndrome, 30 % in primary pulmonary HTN & 56 % in secondary pulmonary HTN.
Acquired heart diseases
- peripartum Cardiomyopathy
- MI
- valvular / valve replacement during pregnancy
Cardiomyopathy
- Postive family hx
- 25 % mortality rate from 1st attack
- Recurrence risk: 50 %
- Risk facotrs:
1 - Primigravida
2 - overdistended uterus
3 - preeclampsia in current pregnancy
Last month in pregnancy upto 5 months postpartum (total 6 moths)
In questions either family HX or postnatal months
Right side heart failure
- orthopnea
- dyspnoea
- congested neck veins
- bilateral crepitations
- lower limb edema
Left side heart failure
- syncopal attack
- arrhythmia
- palpitation
- TIAs
- dizziness
- chest pain
- Headaches
biventricular failure
both side symptoms, associated with cardiomyoathy
Mx of cardiomyopathy
TOP, regardless of gestation ( main definitive step)
or supportive steps
- Restrict fluid
- heart supporter (digoxin, calcium channel blocker, b- blocker)
- BP control
- MDT
- HDU,/ CCU
- TOP, advice strongly against pregnancy
peripartum Cardiomyopathy 1 of the 5 domains for TOP, under clause A (life threatening diseases)
contraception in cardiomyopathy
Hormonal out
IUCD
MI
not a common presentation with pregnancy, B/c estrogen cardioprotective
- cardiac overload in predisposed woman
- smoker
- Diabetic with vasculopathy
Clinically stabbing pain behind sternum
- referred to base of neck
- could be epigastric pain if infarction is inferior wall
MI types
STEMI:
Non- STEMI
ST elevation , how much MI risk
50 %
Chest pain initial investigation
ECG
The most common EC finding of MI
ST elevation, so EC sensitivity to diagnose MI, 50 %
- St elevation associated with severe ischemia, more fatal than Non STEMI
STEMI MX
2 Ways
- Thrombolytics therapy: Streptokinase ( within first 6 hours of diagnosis of Acute MI. ( safe in pregnancy but increases risk of Abruption, but life saving
- If > 6 hours : Percutaneous intervention or cardiac catheterization
to confirm diagnosis of MI
cardiac enzymes
- LDH
- CKMB
- Troponins ( most accurate and associated with MI)
Non STEMI diagnosis
most difficult diagnosis/ evaluation B/c presents with atypical chest pain
Differential diagnosis of atypical chest pain
1 - Variant angina (more in males, stress adrenaline, dont choose in exam)
2 - coronary artery dissection
3 - unstable angina (more in males, stress adrenaline, dont choose in exam)
4 - Non STEMI
atypical chest pain in woman
1 - coronary artery dissection (HTN/ Preeclamptic uncotrolled, easy diagnosis, referred pain to back)
2 - Non STEMI (if not HTN then Non STEMI)
MX
- First thing: loading dose of Aspirin 300 mg, chewable
- Evaluated: if needed PCI, Cardiac catheterization or stenting
Acute pain refrred to back differentials (interscapular pain)
1 - coronary artery dissection
2 - Aortic dissection (chest pain, main refrred to back)
3 - pancreatitis
4 - main pain to right hypochondrium
MI at 37 weeks
- postpone date of delivery 2- 3 weeks
- decrease cardiac complications
Intrapartum requirement for MI
- Vaginal more appropriate> LSCS
- Vaginal delivery easy
- responds well with IOL, Like preeclampsia b/c of tissue edema
- Instrumentation in 2nd stage
- When to shorten 2nd stage: NYHC, 3/4, HX of MII (New recommendation)
- Proper analgesia
- Restricted fluids
- Antibiotic prophylaxis ( no roles in valve replacements- new)
- Augmentation oxytocin if indicated ( infected endocarditis)
- Lasix with delivery of baby: decrease preload
- 3rd stage: active MX of labour
- Avoid Methergin/ergotamine
- When to shorten 2nd stage
1 - NYHC, 3/4, HX of MII (New recommendation)
2 - Retinal hemorrhage,
3 - Uncontrolled Diabetic vasculopathy
4 - Renal shutdown
CS indication in Cardiac patient
1 - Obstetric
2- Peripartum cardimyopathy
3 - Heart failure
Otherwise press for normal delivery, till last second
If maternal concern: vaginal, if fetal concern: LSCS
MI at 40 weeks
- Postpone 1 week
- LSCS
- MDT, Prepare everything
Infective endocarditis antibiotic prophylaxis, which and when
- 3rd generation cephalosporin
- High risk procedure ( gram negative specially commensals, in oral cavity and respiratory tract e.g . streptococcus viridance)
- If question asking which antibiotic : then give
- Not routine
- HX of endocarditis, or raised temperature
