Cards: Pregnancy Flashcards
What are the physiologic changes to the cardiovascular system during pregnancy?
During a normal pregnancy, there is an increase in plasma volume and a lesser increase in erythrocyte mass, resulting in increased total blood volume and relative anemia. The systemic vascular resistance decreases during pregnancy, but the heart rate and cardiac output rise; as a result, there is generally a slight reduction in mean arterial pressure. Maternal cardiac output peaks at approximately 40% above the prepregnancy level by the 32nd week of pregnancy and then plateaus until delivery.
What cardiac conditions place women at highest risk for death during pregnancy?
- severe pulmonary hypertension
- HFrEF <40%
How do you manage women who are pregnant with mitral or aortic valve stenosis?
Patients with severe obstructive cardiac disease, such as mitral or aortic valve stenosis, are generally considered for intervention before pregnancy, even if asymptomatic.
Women with what CV conditions should have a cesarean delivery versus vaginal delivery?
Vaginal delivery is generally preferred for patients with cardiovascular disease because it results in a shorter and less marked hemodynamic derangement than cesarean delivery. To reduce the risk of fetal intracranial hemorrhage, cesarean delivery is recommended in women receiving warfarin anticoagulation therapy. Cesarean delivery is also recommended for obstetric reasons and in select patients with severe pulmonary hypertension or a markedly dilated aorta.
What is a peripartum CM?
Left ventricular systolic dysfunction identified toward the end of pregnancy or in the months following delivery in the absence of another identifiable cause is known as peripartum cardiomyopathy
What are the risk factors for a peripartum CM?
This occurs with increased frequency in women who are multiparous, older (age >30 years), and black; in those with multifetal pregnancy, gestational hypertension, or preeclampsia; and in those treated with tocolytic agents.
How do you manage women with peripartum CM?
START: Prompt initiation of medical therapy is recommended for women with peripartum cardiomyopathy and includes β-blockers, digoxin, hydralazine, nitrates, and diuretics.
AVOID: ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists should be avoided until after delivery owing to teratogenicity.
BLOOD THINNER: Anticoagulation with warfarin is recommended for women with peripartum cardiomyopathy with left ventricular ejection fraction below 35%, owing to the increased risk of thromboembolism related to this disorder; the duration of anticoagulation is individualized, and anticoagulation is discontinued when the ejection fraction improves.
What is the role of bromocriptine in peripartum heart failure?
In women with acute severe peripartum cardiomyopathy, bromocriptine, which blocks prolactin secretion, has been shown to improve left ventricular ejection fraction and clinical outcomes when added to peripartum-related heart failure therapy. Bromocriptine inhibits lactation and may increase risk of thromboembolism; therefore, anticoagulation is suggested in conjunction with bromocriptine.
What are women with Marfan syndrome at increased risk for during pregnancy?
Women with Marfan syndrome have been reported to have an increased risk of aortic dissection during pregnancy.
How do you manage pregnant women with an ascending aorta diameter of >4.5cm?
Women with Marfan syndrome and an ascending aortic diameter of 4.5 cm or greater are recommended to have aortic repair surgery before considering pregnancy to reduce this risk. Some women with Marfan syndrome and aortic diameter less than 4.5 cm are at high risk for dissection during pregnancy and are counseled to have aortic valve replacement before pregnancy; these include patients with rapid dilatation of the ascending aorta or a family history of aortic dissection.
What are the side effects of BB during pregnancy? What about atenolol specifically?
When β-blockers are used during pregnancy or lactation, periodic fetal and newborn heart rate monitoring and initial newborn blood glucose assessment are indicated because β-blockers cross the placenta and are present in human breast milk. Atenolol is usually avoided during pregnancy because it has been reported to cause small fetal gestational size, early delivery, and low birth weight. Patients taking atenolol are usually transitioned to a different β-blocker.
How do you manage a supra ventricular tachycardia during pregnancy?
The treatment of choice for acute symptomatic supraventricular tachycardia during pregnancy is adenosine. Recurrent tachycardia symptoms are often treated with β-blockers and digoxin; sotalol and flecainide have also been safely used. Amiodarone is rarely used owing to toxicity concerns.
Can women take spironolactone while breastfeeding?
Spironolactone is considered compatible with breastfeeding; although spironolactone and its active metabolite, canrenone, appear in breast milk, the concentrations are pharmacologically insignificant.
What cardiac meds should be specifically avoided during pregnancy?
ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists are teratogenic and should be avoided during pregnancy. Some ACE inhibitors are safe to use while breastfeeding. Angiotensin receptor blockers are generally avoided during lactation because data are inconclusive regarding infant risk when used during breastfeeding.
How is anticoagulation managed in women with mechanical valves during pregnancy
Guidelines from the American College of Cardiology/American Heart Association on the management of anticoagulation during pregnancy conclude that intravenous unfractionated heparin, LMWH, or warfarin may be used for anticoagulation of pregnant women with mechanical heart valves. Intravenous unfractionated heparin is the drug of choice for patients with mechanical valve prostheses around the time of delivery.
