Cardiovascular Disease During Pregnancy ESC Valvular heart disease in pregnancy Flashcards
Which conditions are mWHO IV and consider contraindications to pregnancy?
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
Risk of material cardiac event in mWHOIV
40-100%. high risk marneral mortality/morbidty
If mWHOIV, how often should be reviewed in pregnancy?
Monthly
Where should mWHOIV delivery?
Expert centre for pregnancy and cardiac disease
Which conditions are considered mWHO II-III?
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
For mWHO II-III was is risk of maternal cardiac event?
10-19%
Intermediate risk of maternal mortality/severe increase to morbidity
How often should women with mWHO II-III be reviewed? Where should deliver?
Review bimonthly
Care and delivery at referral hospital
What conditions are mWHOII?
Unoperated arterial or ventricular septal defect
Reapired tetralogy of allot
Most arrhythmia (SVT)
Turner syndrome without aortic dilatation
What is the maternal cardiac event risk?
5-10.5%
Small increased risk of maternal mortality/morbidity
How often should be seen in pregnancy? Care and location for delivery?
once per trimester
Care and delivery at local hospital
Which conditions are consider mWHOI
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
mWHOi risk of maternal cardiac event?
2.5-5%
No detectable risk of maternal mortality and no mild increased morbidity
mWHOI How often should be reviewed in pregnancy? Location of care and delivery?
1-2 x in pregnancy
Local hospital
Management of new supra ventricular tachycardias?
Vagal manoeuvres
Adenosine
If instability or pre-excited atrial fibrillation → electrical cardio version
Consider - Metoprolol or bisoprolol
If mechanical heart valve and high dose aspirin >5mg, how to manage anticoagulation in pregnancy?
Change to LMWH between weeks 6-12 with factor Xa monitoring.
Other regimes include continuing warfarin throughout prengnancy or switching to warfarin.
What INR aims with mechanical heart valve on warfarin?
2.5-3.5
What factor Xa aims for mechanical heart valve on LMWH?
4-6 hour peak 0.8-1.2U/mL
pre-trough dose >0.6
When can warfarin be restarted?
5-7 days post delivery
How can warfarin be reversed?
Prothrombinase complex
Vitamin K
How can heparin/LMWH be reversed
Protamine sulphate
Risk of aortic dissection in Marfans syndrome?
<40mm 1%
>40 10%
Risk of pregnancy complications with Marfans?
40% risk PROM, IUGR, SGA, mortality
What is the inheritance of Marfans? How effective is prenatal diagnosis for Marfans?
AD 700% new mutations
Prenatal Dx - misses 10% genetic mutations that cause Marfans , options CVS, amniocentesis
What does a Fontan surgery treat?
Individuals born with a single ventricle
What does a fontans procedure do?
Diverts all systemic venous blood into pulmonary arteries
Baby experiences gradual decline in functional capacity and premature death
What % of women with fountains procedure have live birth?
45%
Most common cardiovascular adverse effect in fontons in pregnancy
Arrhythmia 8%
Hear failure 4%
How to manage marfans AN
How often to perform ECHO
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
How to categorise mitral valve stenosis, mild, moderate and severe
Mild >1.5
Moderate 1-1.5
Severe < 1
How common is heart failure in moderate and severe aortic stenosis
Moderate: 50%
Severe 1/3
How common is AF in mistral stenosis
10%
What obstetric complication are seen in mitral stenosis?
Prematurity 20-30%
FGR 30%
Which women with mitral stenosis need LMWH
Left atrial enlargement >60mL
CHF
(Mod/severe - related to AF)
When is surgical intervention pre-pregnancy offered for mitral stenosis
NYHA III/IV
Systolic pulmonary artier pressure >50 despite medical intervention
If mitral valve replacement requireed in pregnancy, which surgery
In pregnancy - percutaneous mitral balloon valvuloplasty
Cardiopulmonary bypass for valvular surge - fetal mortality 30%
Risk of heart failure in aortic stenosis asymptomatic vs symptomatic
Asymptomatic 10%
Symptomatic 25%
Obstetric risk of moderate-sever aortic stenosis
preterm and FGR 20-25%
10% cardiac defect
How often should severe aortic stenosis have ECHO
Medical & surgical treatment
Monthly/bimonthly
BB +/- diuretics
Surgical: Percutaneous valvoplasty or TOP or early delivery and valve surgery
Risk cardiac failure moderate to severe aortic or mitral regurgitation.
Obstretric risk
Mild - well tolerated
Mod-severe - cardiac failure 20-25%
FGR 5-10%
Chance of ‘event-free’ pregnancy for mechanical valve vs bioprothesis
Mechanical 58%
Bioprosthesis 79%
Typical warfarin embryopathy
Nasal hypoplasia
Shortening long bone & digits
Stipple long bone epiphyses
Most common week 6-12, risk 5-6%
