Cardiovascular Disease During Pregnancy ESC Valvular heart disease in pregnancy

Question 1

Which conditions are mWHO IV and consider contraindications to pregnancy?

Answer 1

PAH

EF <30%

Prv PP cardiomyopathy with any residual LV impairment

Severe mitral stenosis

Severe symptomatic aortic stenosis

Severely decreased RV function

Sebere aortic dilatation (>45mm in marfan, >50 bicuspid, Turner >25, tetralogy fallout >50)

Vascular ehlers-danlos

Severe coarctation

Fontan circulation with any complication

Question 2

Risk of material cardiac event in mWHOIV

Answer 2

40-100%. high risk marneral mortality/morbidty

Question 3

If mWHOIV, how often should be reviewed in pregnancy?

Answer 3

Monthly

Question 4

Where should mWHOIV delivery?

Answer 4

Expert centre for pregnancy and cardiac disease

Question 5

Which conditions are considered mWHO II-III?

Answer 5

Mild LV impairment >45%

Hypertrophic cardiomyopathy

Native/tissue valve disease (mild mitral stenosis, moderate aortic stenosis)

Marfan or other HTAD syndrome without aortic dilatation

Aorta <45mm in bicuspid aortic valve pathology

Repaited coarctation

AV septal defect

Question 6

For mWHO II-III was is risk of maternal cardiac event?

Answer 6

10-19%
Intermediate risk of maternal mortality/severe increase to morbidity

Question 7

How often should women with mWHO II-III be reviewed? Where should deliver?

Answer 7

Review bimonthly
Care and delivery at referral hospital

Question 8

What conditions are mWHOII?

Answer 8

Unoperated arterial or ventricular septal defect

Reapired tetralogy of allot

Most arrhythmia (SVT)

Turner syndrome without aortic dilatation

Question 9

What is the maternal cardiac event risk?

Answer 9

5-10.5%
Small increased risk of maternal mortality/morbidity

Question 10

How often should be seen in pregnancy? Care and location for delivery?

Answer 10

once per trimester
Care and delivery at local hospital

Question 11

Which conditions are consider mWHOI

Answer 11

Mild pulmonary stenosis

Patent ductus arteries

Mitral valve prolapse

Successful repaired simple lesions (arterial septic defect, patent ductus arterosis)

Atrial or ventricular ectopic beats, isolated

Question 12

mWHOi risk of maternal cardiac event?

Answer 12

2.5-5%

No detectable risk of maternal mortality and no mild increased morbidity

Question 13

mWHOI How often should be reviewed in pregnancy? Location of care and delivery?

Answer 13

1-2 x in pregnancy
Local hospital

Question 14

Management of new supra ventricular tachycardias?

Answer 14

Vagal manoeuvres
Adenosine
If instability or pre-excited atrial fibrillation → electrical cardio version

Consider - Metoprolol or bisoprolol

Question 15

If mechanical heart valve and high dose aspirin >5mg, how to manage anticoagulation in pregnancy?

Answer 15

Change to LMWH between weeks 6-12 with factor Xa monitoring.

Other regimes include continuing warfarin throughout prengnancy or switching to warfarin.

Question 16

What INR aims with mechanical heart valve on warfarin?

Answer 16

2.5-3.5

Question 17

What factor Xa aims for mechanical heart valve on LMWH?

Answer 17

4-6 hour peak 0.8-1.2U/mL
pre-trough dose >0.6

Question 18

When can warfarin be restarted?

Answer 18

5-7 days post delivery

Question 19

How can warfarin be reversed?

Answer 19

Prothrombinase complex
Vitamin K

Question 20

How can heparin/LMWH be reversed

Answer 20

Protamine sulphate

Question 21

Risk of aortic dissection in Marfans syndrome?

Answer 21

<40mm 1%
>40 10%

Question 22

Risk of pregnancy complications with Marfans?

Answer 22

40% risk PROM, IUGR, SGA, mortality

Question 23

What is the inheritance of Marfans? How effective is prenatal diagnosis for Marfans?

Answer 23

AD 700% new mutations

Prenatal Dx - misses 10% genetic mutations that cause Marfans , options CVS, amniocentesis

Question 24

What does a Fontan surgery treat?

Answer 24

Individuals born with a single ventricle

Question 25

What does a fontans procedure do?

Answer 25

Diverts all systemic venous blood into pulmonary arteries
Baby experiences gradual decline in functional capacity and premature death

Question 26

What % of women with fountains procedure have live birth?

Answer 26

45%

Question 27

Most common cardiovascular adverse effect in fontons in pregnancy

Answer 27

Arrhythmia 8%
Hear failure 4%

Question 28

How to manage marfans AN
How often to perform ECHO

Answer 28

MDT with cardio
BP control
ECHO every 4-6 weeks if aortic diameter >40mm until 6 months PP
Cont BB
Discuss anticoagulation
Pre-natal Dx
Fetal ECHO 20/40
Anaesthetic review - ?lumbosacral dural ectasia

Question 29

How to categorise mitral valve stenosis, mild, moderate and severe

Answer 29

Mild >1.5
Moderate 1-1.5
Severe < 1

Question 30

How common is heart failure in moderate and severe aortic stenosis

Answer 30

Moderate: 50%
Severe 1/3

Question 31

How common is AF in mistral stenosis

Answer 31

10%

Question 32

What obstetric complication are seen in mitral stenosis?

Answer 32

Prematurity 20-30%
FGR 30%

Question 33

Which women with mitral stenosis need LMWH

Answer 33

Left atrial enlargement >60mL
CHF

(Mod/severe - related to AF)

Question 34

When is surgical intervention pre-pregnancy offered for mitral stenosis

Answer 34

NYHA III/IV
Systolic pulmonary artier pressure >50 despite medical intervention

Question 35

If mitral valve replacement requireed in pregnancy, which surgery

Answer 35

In pregnancy - percutaneous mitral balloon valvuloplasty

Cardiopulmonary bypass for valvular surge - fetal mortality 30%

Question 36

Risk of heart failure in aortic stenosis asymptomatic vs symptomatic

Answer 36

Asymptomatic 10%
Symptomatic 25%

Question 37

Obstetric risk of moderate-sever aortic stenosis

Answer 37

preterm and FGR 20-25%

10% cardiac defect

Question 38

How often should severe aortic stenosis have ECHO
Medical & surgical treatment

Answer 38

Monthly/bimonthly

BB +/- diuretics

Surgical: Percutaneous valvoplasty or TOP or early delivery and valve surgery

Question 39

Risk cardiac failure moderate to severe aortic or mitral regurgitation.

Obstretric risk

Answer 39

Mild - well tolerated
Mod-severe - cardiac failure 20-25%

FGR 5-10%

Question 40

Chance of ‘event-free’ pregnancy for mechanical valve vs bioprothesis

Answer 40

Mechanical 58%
Bioprosthesis 79%

Question 41

Typical warfarin embryopathy

Answer 41

Nasal hypoplasia
Shortening long bone & digits
Stipple long bone epiphyses

Most common week 6-12, risk 5-6%