Cardiothoracics Flashcards
Prevalence of adult congenital heart disease in pregnancy
0.8% of all pregnancies
Re babies bornin the UK:
9/1000 babies born in the UK ASD (17% of all CHD, most common)
Tetralogy of Fallot (11%)
Transposition of the great arteries (5%)
Pregnancy induced CVS changes
(to meet the increased metabolic demands of the mother and fetus)
- Î total blood volume by 45% on average;
- Î CO by 30-50%. (peak in 2nd trimester)
- hr rises progressively (peak in 3rd TM 25-30% above base)
- Fall in Systemic BP (due to hormonal-induced vasodilatation early in gestation)
peak effects at 24-32 weeks of gestation
Adult congenital heart disease and pregnancy
Factors that increase risk of decompensation with the physiological events of labour/early post partum due to:
- Uterine contraction → autotransfusion of blood into systemic circulation
- Expulsive efforts → î CO ( 50% above baseline)
- Uterine involution → autotransfusion (peak î 80%)
- Resorption of dependent oedema → autotransfusion (peak î 80%)
Scoring systems available to evaulate risk of morbidity and mortality of cardiac disease in pregnancy
- (WHO) classification of maternal cardiovascular risk,
- CARPREG (CARdiac disease and PREGnancy) risk score
- ZAHARA (Zwangerschap bij Aangeboren HARtAfwijkingen [Dutch; English translation: Pregnancy with Congenital Heart Defects])
Neonatal complications of cardiac disease in pregnancy
20-28% of preg w cardiac dis:
- premature birth
- small for gestational age,
- respiratory distress syndrome
1-4%
- Fetal or neonatal death occurs
Other
- Children of women with ACHD are at a higher risk of having CHD themselves
Antenatal care in a mother with cardiac disease (around 6 points)
- MDT involvement with cardiologist
- Delivery to be in a tertiary cardiac centre
- Serial ECHOs and clinical assessment
- +/- MRI for aortopathies
- Plan re delivery: same may need LSCS:
- aortopathy
- severe left ventricular outflow tract obstruction
- severely impaired cardiac function
- If appropriate for SV, early epidural analgesia
- reduce pain, sympathetic drive, and associated anxiety
- facilitate a ‘low CO’ approach
Complete the table for class 1-4:
European Society of Cardiology modified version of the WHO classification of pregnancy risk with cardiac disease, including congenital diseases
1 - no incr risk mat mort/morb
2 - mild incr risk “
3 - significat incr risk. “
4 - Extremely high risk of maternal mortality or severe morbidity
Define pulmonary htn
mean pulmonary artery pressure of >25 mm Hg and encompasses a range of heterogeneous conditions
(mort 20-30%)
Mx obs patient with pulmonary htn in pregnancy
- Mx in an expert centre
- vasodilator therapy during pregnancy
- +/- fluid and salt restriction if right heart failure
- Planned LSCS best (Pulmonary Vascular Research Institute reccomendation)
- labour induced pain, hypoxia, hypercarbia, and acidosis can increase pulmonary vascular resistance
- valsalva can reduce CO
- Avoid GA
- all induction and inhalational agents, except eto- midate, reduce RV contractility,
- PVR is increased in response to laryngoscopy + IPPV
Mx obs patient with severe systemic ventricular impairment
- Mx in expert centre
- Deliver by LSCS - Avoid labour
Causes of severe systemic ventricular impairment
- Congenital causes
- residual dysfunction following surgical correction of conditions such as tetralogy of Fallot
- when the systemic ventricle is a morphological right ventricle e.g. following an atrial switch procedure for transposition of the great arteries
- Acquired
(all its got in the BJA on cardiac condition in preg)
Causes of LV outflow tract obstruction (most common cause)
- aortic stenosis from a bicuspid aortic valve (most common)
Risks of bicuspid aortic valve and associated aortopathy
bicuspid aortic valve and associated aortopathy are at increased risk of
- aortic dissection
- aortic rupture
-> They should have imaging of their aorta before and during pregnancy.
Complications of Severe symptomatic left ventricular outflow tract obstruction in pregnancy
- heart failure
- arrhythmia
Familial conditions that predispose to the risk of aortopathy (and aortic dissection, aneurysm formation and rupture)
- Marfan syndrome
- LoeyseDietz syndrome
- Ehlerse Danlos type IV
- Turner syndrome
- bicuspid aortic valve with aortic dilatation
- previous complex coarctation repairs.
If a patient has pre-existing aortopathy, why are the risks of aortic dissection, aneurysm formation and rupture in greater in pregnancy
The effects of cardiovascular and hormonal changes to the aortic media
Mx obs patient with aortopathy
Once preg
- Counselled of
- the risks of acute aortic syndromes and of
- their children inheriting familial conditions.
- Interval imaging to assess for progressive dilatation of the aorta.
- Oft LSCS safest (deps on condition / extent of dilatation)
Pre pregnancy
- aorta imaged before attempting pregnancy
- Aortic dilatation of 50 mm, or 45 mm with Marfan syndrome, should be regarded as a contraindication to preg- nancy, and may require surgery prepregnancy.
Complications of cyanosis in pregnancy (maternal)
- PE/DVT
- heart failure
- supraventricular arrhythmias
- infective endocarditis
- PPH
First step in CALS algorithm (Cardiac Advanced Life Support)
Complete blanks 0, 1, 2, 3
Second steps in CALS algorithm
Complete 0, 1, 2, 3 in this CALS protocol
Third steps in CALS algorithm
Complete 0, 1, 2, 3 in this CALS protocol
Name the 6 key roles during resusitation in arrest post cardiac surgery
