CVD in pregnancy

Question 1

deaths attributable to cardiovascular diseases were

responsible for approximately — percent of all pregnancy-related deaths

Answer 1

deaths attributable to cardiovascular diseases were

responsible for approximately 26 percent of all pregnancy-related deaths

Question 2

hemodynamicCardiovascular Physiological changes during pregnancy

Answer 2

CO increases approximately 40 % during pregnancy, Almost half of this total takes place by 8 weeks’ gestation and is maximal by midpregnancy 28 wks. Mediated by increase preload due to the increase of blood volume due to the estrogen medicated activation of the RAS leading to Na and H2O retention.
reduced afterload due to the decrease of systemic vascular resistance due to increase progesterone production.
a rise in maternal heart rate 10-15 beats per minute .
Red blood cell mass increase by 20-30 % due to the fall in HB concentration Causing physiologic anemia.

Question 3

ECG physiological changes during pregnancy:

Answer 3

15-degree left-axis deviation is found as the diaphragm is elevated in advancing pregnancy, a reduced PR interval, inverted or flattened T waves, and a Q wave in lead III

Question 4

Classification of Functional Heart Disease:

Answer 4

Class I. Uncompromised—no limitation of PA
not have symptoms of cardiac insufficiency or experience anginal pain.
• Class II. Slight limitation of PA: comfortable at rest, but if DLA is undertaken, discomfort in the form of excessive fatigue, palpitation, dyspnea, or anginal pain results.
• Class III. Marked limitation of PA: comfortable at rest, but less than DLA causes excessive fatigue, palpitation,
dyspnea, or anginal pain.
• Class IV. Severely compromised—inability to perform any PA without discomfort: Symptoms of cardiac insufficiency or angina may develop even at rest.

Question 5

modified (WHO) Risk Classification of Cardiovascular Disease and Pregnancy:
WHO 1 ? Where No detectable increased risk of maternal mortality and no or mild increase in morbidity.

Answer 5

• Uncomplicated, small or mild o Pulmonary stenosis
o Patient ductus arteriosus o Mitral valve prolapse
• Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage).
• Atrial or ventricular ectopic beats, isolated

Question 6

Simpson (2012) recommends cesarean delivery for

women with the following Cardiac conditions:

Answer 6

(1) dilated aortic root >4 cm or aortic aneurysm; (2)
acute severe congestive heart failure; (3) recent myocardial infarction; (4) severe symptomatic aortic stenosis; (5) warfarin administration within 2 weeks of
delivery (6) need for emergency valve replacement immediately after delivery.

Question 7

epidural safe in cardiac patient but

Answer 7

Subarachnoid blockade is not generally recommended in women with significant heart disease due to associated hypotension.

Question 8

Mitral valve vegetations—Libman-Sacks endocarditis—are relatively common in women with

Answer 8

antiphospholipid antibodies. These sometimes coexist with systemic lupus erythematosus.

Question 9

In asymptomatic women with ASD, thromboembolism prophylaxis is problematic.

Answer 9

Compression stockings and prophylactic heparin have

also been recommended for a pregnant woman with an ASD who is immobile or has another risk factor for thromboembolism

Question 10

Eisenmenger Syndrome

Answer 10

describes secondary pulmonary hypertension that arises from any cardiac lesion. The syndrome develops when pulmonary vascular resistance exceeds
systemic resistance and leads to concomitant right-to-left shunting. The most common underlying defects are ASD or VSD and persistent ductus arteriosus

Question 11

Pregnant women with Eisenmenger syndrome tolerate hypotension poorly, and death usually is caused by

Answer 11

right ventricular failure with cardiogenic shock.
(Eisenmenger syndrome is considered to be an
absolute contraindication to pregnancy)

Question 12

secondary Pulmonary arterial HTN causes

Answer 12

connective tissue disease.e.g. approximately 1/3 of women with scleroderma and 10 percent with systemic lupus erythematosus, in young women are (HIV) infection, sickle-cell disease, and thyrotoxicosis

Question 13

What is the most common causes of secondary pulmonary venous hypertension In pregnant women?

Answer 13

caused by left-sided atrial, ventricular, or valvular disorders. A typical example is mitral stenosis.

Question 14

pulmonary HTN symptoms:

Answer 14

dyspnea with exertion is the most frequent. orthopnea and nocturnal dyspnea are also usually present. Angina and syncope occur when right ventricular output is fixed, and they suggest advanced disease.

Question 15

the standard way to measure pulmonary Pressure:

Answer 15

cardiac catheterization remains the standard

for measurement.

Question 16

primary cardiomyopathies Examples

Answer 16

hypertrophic cardiomyopathy, dilated cardiomyopathies, and peripartum cardiomyopathy

Question 17

Secondary cardiomyopathies

Answer 17

Diabetes, systemic lupus erythematosus, chronic hypertension, and thyroid disorders

Question 18

peripartum (pregnancy-induced) cardiomyopathy diagnostic criteria:

Answer 18

1. Development of cardiac failure in the last month of pregnancy or within 5 months after delivery,
2. Absence of an identifiable cause for the cardiac failure.
3. Absence of recognizable heart disease prior to the last month of pregnancy.
4. Left ventricular systolic dysfunction demonstrated by classic echocardiographic criteria, such as depressed ejection fraction or fractional shortening along with a dilated left ventricle.

Question 19

findings from the Registry on Pregnancy and Cardiac Disease indicate that women with preexisting heart
disease who develop preeclampsia have a __percent risk of developing heart failure during pregnancy

Answer 19

findings from the Registry on Pregnancy and Cardiac Disease indicate that women with preexisting heart
disease who develop preeclampsia have a 30-percent risk of developing heart failure during pregnancy

Question 20

The most common arrhythmia seen in reproductive-aged women is

Answer 20

paroxysmal SVT. The prevalence during pregnancy is 24 cases per 100,000 hospital admissions, and approximately 20 percent will experience symptomatic
exacerbations during pregnancy.
approximately half of women with paroxysmal SVT had an initial onset during pregnancy

Question 21

maternal paroxysmal SVT was associated with a —fold greater risk of septal cardiac defects, particularly secundum atrial septal defects, in their offspring.

Answer 21

maternal paroxysmal SVT was associated with a twofold greater risk of septal cardiac defects, particularly secundum atrial septal defects, in their offspring.

Question 22

new-onset atrial fibrillation during pregnancy should prompt a search for underlying etiologies that include

Answer 22

cardiac anomalies, hyperthyroidism, pulmonary

embolism, drug toxicity, and electrolyte disturbances

Question 23

aortic dissection risk factors:

Answer 23

1) Marfan syndrome or EDS.
2) aortic coarctation/bicuspid aortic valve
3) pregnancy > half of dissection cases in young women are related to pregnancy.
4) Turner or Noonan syndromes.

Question 24

differential diagnosis of aortic dissection in pregnancy INCLUDES ?

Answer 24

myocardial
infarction, pulmonary embolism, pneumothorax, aortic valve rupture, and
obstetrical catastrophes, especially placental abruption and uterine rupture.

Question 25

Marfan Syndrome, MODE OF INHERITANCE :

Answer 25

autosomal dominant connective tissue disorder has an incidence of 2 to 3 cases per 10,000 individuals

Question 26

Marfan Syndrome CHARACTERSTICS

Answer 26

characterized by generalized tissue weakness that can result in dangerous cardiovascular
complications. joint laxity and scoliosis. Progressive aortic dilation causes aortic valve insufficiency, and there may be infective endocarditis and mitral valve prolapse with insufficiency.

Question 27

Associated lesions with Aortic coarctation:

Answer 27

1/4 of affected patients have a bicuspid aortic valve, and another 10 percent have cerebral artery aneurysms. Other associated lesions are persistent ductus arteriosus, septal defects,
and Turner syndrome.

Question 28

Major complications with aortic coarctation include:

Answer 28

CHF after long-standing severe HTN, bacterial endocarditis of the bicuspid AV, and aortic rupture. Because HTN may worsen in pregnancy,
antihypertensive therapy using β-blocking drugs is usually required. Aortic rupture is more likely late in pregnancy or early puerperium. Cerebral hemorrhage from circle of Willis aneurysms may also occur.

Question 29

the risk of acute myocardial infarction is approximately —-fold higher in pregnant women compared with nonpregnant women of similar age

Answer 29

the risk of acute myocardial infarction is approximately Threefold higher in pregnant women compared with nonpregnant women of similar age

Question 30

What the incidence of cardiac disease in pregnancy?

Answer 30

1-4%

Question 31

What are the structural changes in the heart in pregnancy ?

Answer 31

Left ventricular end diastolic volume by 10%.
Left and right ventricular mass by 50 % and 40%.
the structural changes return to normal postpartum in Less than a year.

Question 32

What should counseling include for mother with cardiac dis?

Answer 32

1) pregnancy can contribute to a decline in cardiac status that may not return to baseline after the pregnancy.
2) Maternal morbidity and mortality is possible.
3) Fetal risk of congenital heart or genetic conditions , fetal growth restriction , preterm birth , IUFD and perinatal mortality.

Question 33

What are the physiological cardiovascular changes related to labor ?

Answer 33

CO increase by 50 % with each contraction.
Mean systemic pressure rises due to the catecholamines released due to pain and anxiety. Blood pressure and HR decrease 48 hours postpartum.

CO at it highest level where Dramatic increase in cardiac output due to uterine involution.

Question 34

What increases the risk of pulmonary edema at the time of delivery and postpartum ?

Answer 34

Increase hydrostatic pressure and decrease colloid osmotic pressure.

Question 35

Approach to pt with cardiac disease?

Answer 35

History :
Family history ( structural , vascular or rythm disorders and sudden unexplained death) Any genetic testing performed ( MYH7 for cardiomyopathy ).
Any current cardiovascular symptoms
Medication history.
Physical examination
Noninvasive testing : ECG ,Chest X-ray ( to check for cardiomegaly and pulmonary vascular prominence ) , echo ( mild valvular regurgitation and chamber enlargements are normal echo changes ) , exercise stress test , CT , MRI ( rarely when echo is non-diagnostic ) , Holter monitor ( if there is palpitations , light headedness, syncope).
+ BNP and NT-pro BNP, troponin.

Question 36

In what conditions does BNP increase significantly in pregnancy ?

Answer 36

In pregnant women with SOB related to HF from left ventricle systolic dysfunction. Diastolic dysfunction Hypertensive disorders including pre-eclampsia.

Question 37

Who are the candidates for infective endocarditis prophylaxis?

Answer 37

Prosthetic valve prosthetic or material used for cardiac valve repair
Prior endocarditis
Patients with CHD
Unrepaired cyanotic CHD, including palliative shunts and conduits.
Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure.
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization)
Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve.

Question 38

What is the risk for fetal congenital heart disease in mothers with CHD?

Answer 38

3% With single gene defect and autosomal dominant ( Marfan syndrome ) 50 %.

Question 39

What are the minimal risk cardiac lesions?

Answer 39

VSD 
ASD
Bicuspid aortic valves without stenosis 
Aortic insufficiency  
Aortic enlargement .

Question 40

Moderate risk cardiac lesions?

Answer 40

Repaired TOF W/O significant pulmonary stenosis or insufficiency .
Complex CHD with an atomic right ventricle
Mild left side valve stenosis

Question 41

High risk cardiac lesions?

Answer 41

Eisenmenger syndrome
Severe Pulmonary hypertension
Severe aortic stenosis
left ventricle outflow tract dysfunction
Marfan syndrome with aortic dialation more than 45 mm
Symptomatic ventricular dysfunction with EF < 40%.

Question 42

What does TOF consists of ?

Answer 42

Right Ventricle Outflow obstruction
VSD
Right ventricle hypertrophic Overriding aorta Right to left shunt cyanosis.

Question 43

For Which group of pulmonary HTN pregnancy is contracindicated? What is its mortality rate?

Answer 43

Group 1, 23 %.

Question 44

What is the most common CHD in adults?

Answer 44

ASD

Question 45

What is the mortality rate of Eisenmenger syndrome ?

Answer 45

50 % with cyanosis.

Question 46

How would manage labor in patients with idiopathic hypertrophic subaortic stenosis?

Answer 46

1) inotropic Agents may exacerbate obstruction.
2) Medications that decrease systemic vascular resistance should be avoided or limited.
3) Cardiac rhythm should be monitored and tachycardia treated promptly.
4) The patient should undergo labor in the left lateral position with the second stage shortened by operative delivery .

Question 47

Pregnancy in women after surgical correction of TGA is associated with?

Answer 47

Arrhythmia HF NYHA class deterioration High incidence of serious obstetrics Complications 65%/ Mortality is 11%.

Question 48

is pregnancy discouraged after heart transplant?

Answer 48

No , if stable for 1 year post transplant.

Question 49

Whats the incidence of peripartym cardiomyopathy ?

Answer 49

25-100 per 100,000 patient.

Question 50

Peripartum cardiomyopathy presents as?

Answer 50

1) Late in pregnancy of the first few months postpartum.
2) EF less than 45%
3) No previous history of heart disease.
4) No ischemic cardiomyopathy

Question 51

whats the outcome of peripartum cardiomyopathy ?

Answer 51

Most women recover mostly if EF is more than 30%.. Some will develop chronic cardiomyopathy and heart failure if EF less than 30%.

Question 52

What is the most common cause of pregnancy associated acute coronary syndrome?

Answer 52

Coronary artery dissection.

Question 53

What is the most common cause for maternal cardiac arrest in women admitted for delivery ?

Answer 53

Hemorrhage , 38.1% followed by amniotic fluid embolism 13.3% Coronary artery syndrome is 10% Venous thromboembolism 4%.

Question 54

antepartum management principles of cardiac patient?

Answer 54

• Delivery at a tertiary hospital.
• A comprehensive plan for pregnancy , delivery and postpartum should be available in the medical record.
• Should be treated by pregnancy heart team.
• Fetal echocardiograph in women with CHD at 18-22 weeks.
• Fetal growth assessment either by serial clinical examination or ultrasound.
• Daily lose dose asprin prophylaxis for women with high risk for developing pre eclampsia started at 12-28 weeks and continued till delivery .
• Antihypertensives if needed.
• Echo for women with pulmonary edema.

Question 55

Intra-partum management principles for cardiac patient?

Answer 55

• detailed delivery plan should be determined between 20-30 weeks.
• Should include management of induction , delivery and postpartum concerns and a surveillance plan.
• Women with stable cardiac disease can undergo vaginal delivery at39 weeks , with cesarean delivery for obstetric indications.
• In the absence of spontaneous labor , a scheduled induction should be done at 39-40 weeks.
• For women who are receiving LMWH d/c at least 12 hours before induction or cesarean section.
• For women with arrhythmia , intrapartum cardiac monitoring.
• IE prophylaxis as indicated.

Question 56

What is the most common intra-partum cardiac complication?

Answer 56

Pulmonary edema.

Arrhythmia.

Question 57

Cardiovascular assessment and follow up at 3 months postpartum is recommended in women with which conditions?

Answer 57

• Hypertension, chronic/essential or hypertensive disorder of pregnancy (ie, gestational hypertension, preeclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelet syndrome, chronic hypertension [with or without superimposed preeclampsia])
• Gestational diabetes mellitus- Intrauterine fetal growth restriction (particularly less than the 5th percentile for gestational age or less than 2,500 g at term)
• Idiopathic preterm birth
• Placental abruption
• Obesity/excessive pregnancy weight gain/post- partum weight retention
• Sleep disorders/moderate-to-severe obstructive sleep apnea (193–197)
• Maternal age older than 40 years

Question 58

ongoing postpartum care after the 3 month cardiovascular assessment visit should include? .

Answer 58

-contraception-Weight reduction to pre-pregnancy weight ( referral to dietician , peer support , physical activity , programs that provides child care with no or low cost ).-Counseling regarding risk of future CVS-disease and overt diabetes in women who had pregnancy complications such as PET or GDm.-Considering low dose asprin with patients with history of PET for future pregnancies.-Early screening for GDM if positive history.-Breastfeeding

Question 59

Patients should be counseled to avoid pregnancy or consider induced abortion if they have severe heart disease, including an

Answer 59

ejection fraction less than 30% or class III/IV heart failure, severe valvular stenosis, Marfan syndrome with aortic diameter more than 45 mm, bicuspid aortic valve with aortic diameter more than 50 mm, or pulmonary arterial hypertension.

Question 60

Cardiac patient counselling

Answer 60

Discussion of cardiovascular disease with the woman should include the possibilities that 1) pregnancy can contribute to a decline in cardiac status that may not return to baseline after the pregnancy; 2) maternal morbidity or mortality is possible; and 3) fetal risk of congenital heart or genetic conditions, fetal growth restriction, preterm birth, intrauterine fetal demise, and perinatal mortality is higher when compared with risk when cardiovascular disease is not present.

Question 61

Whats the incidence of early pregnancy loss ?

Answer 61

10%. 80% of cases in the first trimester. For women aged 20-30&raquo_space; 9-17%. At 35 yo 20%. At 40 yo 40%. At 45 yo 80%.

Question 62

Patients with Marfan syndrome (MS) face a high risk of aortic dissection during pregnancy. A dilated aortic root (———) is considered a relative contraindication for pregnancy

Answer 62

Patients with Marfan syndrome (MS) face a high risk of aortic dissection during pregnancy. A dilated aortic root (>40 to 45 mm) is considered a relative contraindication for pregnancy

Question 63

In a patient with Marfan syndrome, the risk of aortic dissection associated with pregnancy has been estimated as approximately ? percent

Answer 63

In a patient with Marfan syndrome, the risk of aortic dissection associated with pregnancy has been estimated as approximately 3 percent

Question 64

management for atrioventricular (AV) conduction disorders

Answer 64

pacing during pregnancy usually not needed

vaginal delivery reportedly not associated with adverse outcomes in women with congenital AV block

Question 65

The Five Groups of pulmonary HTN

Answer 65

Group 1: Pulmonary Arterial Hypertension (PAH)
Group 2: Pulmonary Hypertension Due to Left Heart Disease.
Group 3: Pulmonary Hypertension Due to Lung Disease.
Group 4: Pulmonary Hypertension Due to Chronic Blood Clots in the Lungs.
Group 5: Pulmonary Hypertension Due to Unknown Causes.

Question 66

Modified WHO classification of maternal cardiovascular risk

Answer 66

(cardiac lesions classification)

Question 67

Stage I cardiac lesions of Modified WHO classification of maternal cardiovascular risk

Answer 67

Question 68

the most frequent cause of heart failure in pregnancy

Answer 68

Chronic hypertension with superimposed preeclampsia

Question 69

Heart failure diagnosis

Answer 69

Echocardiography may show an ejection fraction <0.45 or a fractional shortening <30 percent, or both, and an end-diastolic dimension >2.7 cm/m2

Question 70

merican College of Cardiology and the American Heart Association estimate that the risk of embryopathy is dose dependent, and the risk is < ?percent if the warfarin dose is ≤5 mg/d

Answer 70

merican College of Cardiology and the American Heart Association estimate that the risk of embryopathy is dose dependent, and the risk is <3 percent if the warfarin dose is ≤5 mg/d, If the dosage is >5 mg/d, the risk of embryopathy exceeds 8 percent.

Question 71

Effect of normal pregnancy physiology on patient with mitral Stenosis

Answer 71

With more severe stenosis, the left atrium dilates, left atrial pressure is chronically elevated, and significant pulmonary hypertension develops. These women have a relatively fixed cardiac output, and thus the increased preload of normal pregnancy and other factors that raise cardiac output may cause ventricular failure and pulmonary edema.

Question 72

most mitral stenosis lesions caused by

Answer 72

Rheumatic endocarditis