Cardiovascular disease in pregnancy Flashcards
NYHA classification of heart disease-tell me about it:
Class 1-patient not limited by disease in physical activity
Class 2-slight limitation in physical activity
Class 3-Patient’s CV disease results in marked limitation of physical activity. Comfortable at rest
Class 4-inability to carry out physical activity without discomfort
Left to right shunts in pregnancy: what are they? Will you do neuraxial? If so, what do you need to do differently? Always give what?
ASD
VSD
PDAs
Use loss of resistance wiht saline rather than air
Slow onset of epidural anesthesia is recommended because a rapid decrease in SVR could result in shunt flow rversal
Always give supplemental O2. Even mild hypoxemia can reverse the shunt flow
Coaractation of the aorta in preggo: what is it? what do you need to avoid? What do you need to maintain?
Fixed obstruction to the forward ejection of the LV stroke volume, an increase in CO can be achieved by increasing heart rate
IN uncorrected pts, avoid neuraxial anesthesia. GA is preferred for C section
Maintain a normal to slightly elevated SVR, HR and intravascular volume status
Tetrology of Fallot in preggo: what is it? How are you going to treat these pts?
Intraventricular septal defect
Hypertrophy of RV
Overriding aorta
Pulmonic stenosis with RV outflow tract obstruction -issue with these pts, is that they have a right to left shunt that presents with cyanosis
Even if pt has been asymptomatic, echo should be done before or during early preggo. increased BV, increased cardiac output, and decreased SVR of preggo may unmask any previously asymptomatic complications
12 lead EKG, avoid decreases in SVR which would increase Right to left shunt
Maintain adequate IV volume and venous return
Perform NA block early in labor
C section with slowl titrated regional anesthetic-single dose spinal is not recommeded secondary to the abrupt decrease in SVR which can lead to shunt reversal and hypoxemia.
Eisenmenger syndrome: What is it? How are you going to treat these pts-what needs to be maintained? prevented? What are you giving them/doing during labor? What happens if you go to section?
Chronic and uncorrected L–>R shunt can produce RV hypertrophy, elevated pulmonary artery pressures, RV dysfunction and ultimately-Eisenmegneger syndrome.
Preggo is bad for them d/t decreased SVR that exacerbates the right to left shunt
KO treatment plan:
Pt should initially be counseled to not get preggo
Maintain SVR, maintain intravascular volume, avoid aortocaval compression
Prevent pain, hypoxemia, hypercarbia and acidosis which can increase PVR.
Labor: supplemental oxygen at all times, continuous pulse ox
Arterial line
IF you do NA, titrate slowsy.
Epidural anesthesia is the technique of choice-ketamine is often listed as induction drug of choice
Primary pulmonary HTN i preggo: what are you going to prevent? What invasive line will you place? what is your plan for labor? C section? How long should they be monitored post delivery and why? Which pressors are you going to avoid in this patient population?
Prevent pain, hypoxia, acidosis, and hypercarbia because they can increase PVR Mainitain adequte volume maintain SVR A line Tx: inhaled nitric oxide (not nitrous) NTG CCB
Labor: continuous epidural-slow, continuous catheter.
Avoid single dose spinals! Vasopressors like ephedrine should be used with caution as they can further increase pulmonary artery pressure
C section: avoid single dose spinals, GA is often recommended. Pt needs at least one week of continued monitoring post-delivery secondary to high incidence of sudden death during this period.
HOCM in preggo: what is it? what are your goals? How will you tx this pt in labor vs c section?
LVH, decreased LV size, LV dysfunction
Avoid decreases in SVR
Women who are symptomatic or have a hx of syncope should have a pacemaker or defibrillator plced prior to conception.
Slow HR with beta blocker in preggo and delivery
Single dose spinal is contraindicated, but you could do epidural. These pts handle GA well.
Aortic stenosis in pregnancy: What are your goals, what is your plan for anesthesia?
Okayto place what? AVoid what in soln?
Place an a line early in labor
Miantain HR sinus rhythm, and adequate SVR
Okay to place CVP and maintain it at high levles
Continuous epidural can be safely done. remove epinephrine from soln to avoid risk of intravascular injection wiht resultant tachycardia
avoid drugs that increase HR (ketamine, atropine)
Mitral stenosis in preggo: When does it develop? What are these women at risk for? What are your goals? what procedure should they have done and when? What will you place?
Develops when MV surface area is less than 2 cm (normal valve area is 4-6 cm).
These women are at increased risk for pulmonary embolism and risk of maternal death is greatest during labor and in postpartum period
Beta blocker to prevent tachycardia (aggressive tx of a fib with digoxin or beta blockers or CV)
If symptoms become severe during preggo: mitral commissurotomy should be performed n second trimester or baloon valvuloplasty
Give supplemental oxygen-Eidural recommneded for c section. symptomatic MS place CVP
prevent hypoxia, hypercarbia, acidodsis
Women with a transplanted heart: what is it, what works with it? and what dont’ they have? How are you going to treat them? what is rarely placed? What’s preferred for anesthesia?
Transplanted heart has no afferent or efferent autonomic or soamtic innervation. Lack of vagal innervation causes baseline HR to be 100-120 bpm. Reflex slowing of HR does NOT occur-atropine and neostigmine have no cardiac effect.
Isoproterenol can be used to produce chronoctropic or inotropic effects
Get their exercise tolerance hx, cardiac cath reports, and echos. Maintain adequate intravascular volume and venous return.
Treat hypotension wiht phenylephrine or isoproterenol
CVP rarely placed due to risk of sepsis
Epidural is preferred technique for C section, but GA has been done successfully. Ketamine if GA!!!
CPR during preggo:
Prior to 24 weeks-only concern is the mother
after 24 weeks, baby too
Maintain left uterine displacement
Place pt on hard surface for more efficient cardiac compression
Use standard meds and procedures without modification.
If after 4-5 minutes, initial resucitation measures aren’t cutting it, and baby is greater than 24 weeks-deliver the baby
Peripartum cardiomyopathy in preggo: What is it? how does it present? what are risks? what is the treatment?How are you doing labor? C section?
Rare form of heart failure that happnes in last month of pregnancy or in first 5 mos postpartum-presents with mild upper ri symptoms, chest congestion and fatigue. progresses to cardiac failure and low cardiac output. 20% chance of relapse with subsequent pregnancy.
Risks: Multiple gestation Pre-eclampsia Obesity Advanced maternal age Women who breast feed
Tx: digitalis, and diuretics, prompt vaginal delivery or c section. Continous labor epidural rec for labor and vaginal delivery
GA: remi and prop
