Cardiology Flashcards
Discuss arrythmias in pregnancy
-Pregnancy affect on arrythmia (2)
-Most common types of arrythmias (2)
-Presentation
-Investigations
- Pregnancy affect on arrythmias:
-Increase in severity and frequency due to increased HR/SV/CO/Blood volume
-Commonest complication in women with congenital heart defects - Most common arrythmias
-SVT most common
-Atrial/Ventricular ectopics 50-60% of pregnancies - Presentation
-Symtpoms of arrythmias do not corelate well with arrythmias
-Only 10% of women with arrythmia sx have an arrythmia - Investigations
-Look and exclude precipitating causes Hyperthyroid, anaemia, PE, infection
-ECG
-Holter monitor
-Echo to exclude structural heart defect
How should different arrythmias be managed
-General principles (3)
-Atrial/Ventricular ectopic beats
-Sinus tachycardia
-Atrial fibrillation
-Supraventricular tachycardia
-Ventricular tachycardia
- General principles
-Beta-blockers = first line
-Digoxin for rate control
-Avoid amiodarone - fetal tachycardia, neonatal hypothyroid, FGR - Atrial/Ventricular ectopic beats
-Reassurance
-Avoid caffeine, smkoing, drugs - Sinus tachycardia
-Investigate for underlying causes
-If no causes then no treatment required - Atrial fibrillaiton (Rare. Seen with ASD or mitral valve disease)
-Beta blockers, digoxin, cardioversion
-Give thromboprophyaxis - SVT
-Vagal manouvers
-Adenosine
-Second line - digoxin, verapamil, flecanide, esmolol, cardioversion - VT
-Cardioversion if unstable
-Flecanide if stable
Discuss myocardial infarction in pregnancy
-Incidence (2)
-Causes (3)
-Risk factors (7)
-Presentation (2)
-Managment (4)
- Epidemiology
-1:10000
-Responsible for 5-7% of maternal death - Main causes
-Atherosclerosis IHD causes < 50% of MI
-Coronary thrombosis
-Coronary artery dissection - Risk factors
-DM, HTN. Hyperlipidemia, smoking
-Cocaine
-Age
-40% have no risk factors - Presentation
-Usually atypical - epigastric pain or nausea
-Usually occurs in 3rd trimester, peripartum or postpartum - Management
-GTN, ASpirin, clopidogrel
-Beta blockers, nitrates, CCB
-Percutaneous coronary intervention
-Offer CS if MI within 2 weeks of delivery
Discus management of pregnant women who have had previous myocardial infarction (5)
- Pre conception stress test and echo to assess LV function
- Stop statins - tetarogenic
- Low dose aspirin and beta blockers for secondary prevention
- Restrict physical activity
- Monitor for arrythmias and CHF
Discuss the association of familial congenital heart defects with risk of congenital heart disease in a fetus and percentages (10 points)
- If mother has a CHD then risk = 5%
- More likely to be outflow tract abnormality
- More likely if mother (5%) affected cf with father (2%)
- ASD - 4-5%
- VSD - 6-10%
- Siblings are affected - 3%
- Mafans or HCM - 50% (Autosomal dominant)
- Rubella infection
- Diabetes
- Maternal age over 40
Discuss maternal patent ductus arteriosus in pregnancy
-Describe pathology
-Clinical features
-Issues in pregnancy
-If corrected
-If not corrected
- Pathology
-Persistant patent duct between decending aorta and pulmonary trunk or L pulmonary artery - Clinical features
-Mainly asymptomatic
-Continuous machinery murmur, LVH - Issues in pregnancy if corrected
-Nil issues - Issues in pregnancy if not corrected
-Congestive heart failure, pulmonary HTN
Discuss maternal atrial septal defects in pregnant women
-Incidence
-Clinical features
-Issues in pregnancy
-Management in pregnancy
-Impact to fetus is unrepaired
- Incidence
-Most common CHD in women - Clinical features
-Usually ASx. Can Have RBBB, ESM, RVH - Issues in pregnancy
-Increase in arrythmias
-Increase in RH volume overload and enlargment - Management in pregnancy
-Avoid hypotension
-Echo and ecg - Impact to fetus if not repaired
-SGA
-Increased PET
-Fetal mortality
List the maternal congenital cardiac anomalies associated with high risk or poor maternal outcome or death (6)
- Pulmonary HTN
- Eisenmengers syndrome
- Coarchtation of the aorta - uncorrected with proximal dilitation of the aorta
- Marfans syndrome with aortic root dilitation >4.5cm
- Severe symptomatic aortic stenosis
- Single ventricle with poor systolic function (fontans or non-fontans)
List the maternal congenital anomalies associated with moderate risk of pregnancy complications (5-15%) (4)
- Unrepaired cyanotic defects (TOF, TGA)
- Systemic R ventricle (Repaired TGA)
- Well functioning fontans circulation
- Palliated TOF with severe pulmonary regurg and RV dysfunction
List the maternal cardiac congenital anomalies associated with low risk of pregnancy complications (<1%) (4)
- Isolated ASD - repaired or not repaired
- Isolated VSD - repaired or not repaired
- TOF with normal RV function and competent Pulmonary valve
- Coartation repaired with normal proximal aortic size
Discuss maternal ventrical septal defect in pregnancy
-Incidence
-Complications
-Clinical features
-Management in pregnancy
- Incidence
-Large are rare as symptomatic in early life and repaired
-Associated with T21, TOF or isolated - Complications
-L to R shunt worsened with increased peripheral vascular resistance
-Increase in thromboembolism
-Increased Pulmonary HTN and Eisenmengers - Clinical features
-Usually Asx
-PSM, prominant apex beat - Management in pregnancy
-Avoid pregnancy in Eisenmengers syndrome 50% maternal death rate
-Consider thromboprophylaxis
-Isolated VSDlow risk in pregnancy if small. If large fix pre pregnancy
-Avoid hypotension in labour to avoid shunt reversal
Discuss maternal congenital aortic stenosis in pregnancy
-Most common type
-Significant parameters
-Signs of decompensation
-Management in pregnancy
- Most common type
-Bicusip valve - Significant parameters
-AV area <1cm, Gradient >50mmHg - Signs of decompensation
-Tachycardia (HR increases to maintain BP with decreasing SV)
-Fixed gradient
-Angina
-Heart failure - Management in pregnancy
-Consider termination if severe and symptomatic AS
-Beta blockers if LV function is good to increase diastolic filling
-Surgical balloon valvuloplasty in pregnancy if required before value replacement
Discuss maternal coarctation of the aorta in pregnancy
-Risk associated with coarctation during pregnancy (5)
-Presentation (3)
-Management (2)
- Risks
-Usually corrected but correction doesn’t eliminate all risk (10% WHO II-III)
-If uncorrect risk of maternal death >40%
-HTN esp in upper body with uterine hypotension
-Aortic rupture
-Aortic dissection - risk remains even with correction - Presentation
-Difference in upper and lower limb pulses
-CXR shows prominant aortic knob, indentation of proximal thoracic descending aorta - Management
-If uncorrected advise surgical correction pre-pregnancy or TOP
-Assess for aneurysm or post stenotic dilitation
-Strict BP control with beta blockers
Discuss maternal TOF in pregnancy
-Incidence (1)
-Pathophysiology
-Impact to pregnancy (3)
-Impact to fetus (3)
-Management in pregnancy (3)
- Incidence
-Most common cyanotic congenital heart defect - Pathology
-Large LSD
-Over riding aorta
-Pulmonary stenosis
-R ventricular hypertrophy - Impact to pregnancy
-Not repaired
-Increase R to L shunt and hypoxia
-Increase CVA with paroxismal embolism crossing shunt
-If repaired
-Worsening RV function from pulmonary regurg from surgery - Impact to fetus
-If not repaired causes hypoxemia = SGA, pregnancy loss, polychythemia and clotting - Management in pregnancy
-VTE prophylaxis
-Elective admission for bed rest and O2 therapy
-Gentic testing for Di-Goerges syndrome (50% recurrence)
Discuss maternal transposition of the great arteries in pregnancy
-Pathophysiology of TGA
-Surgical corrections
-Risks in pregnancy
-Management
- Pathophysiology
-RV feeds into the aorta
-LV feeds into the pulmonary circulation
-Without correction it is incompatible with life - Surgical corrections
-Switch so that systemic venous return goes to LV then PA
and pulmonry venous return goes to RV then to system. This means RV acts as LV which it is not set up to do and can weaken over time
-Fontan procedure: RV acts as single ventricle for pulmonary and systemic circulation. Needs adequate pre-load but not too much the heart can’t handle. O2 sats low - Risks in pregnancy
-Well tolerated if RV normal and no arrythmia
-Worsening of existing arrythmias
-Pregnancy may have long lasting impact of ventricle function
-Oedema, ascities - Management
-Prenatal assessment of RV function, heart rythum and stress test to check can accommodate increased HR
-Antenatal - serial echos to assess RV and valve function
-Thromboprophylaxis
-Bed rest
-Delivery and peripartum care in an experienced center
What is the incidence in:
-Serious cardiac disease complications in pregnancy
-Maternal deaths from serious cardiac disease
- 1% of pregnancies
- 2.3 per 100,000