Heart disease

Question 1

Considerations with heart disease

Answer 1

NYHA functional class (1-4)
Pul HTN
Haemodynamic signficance
Cyanosis
Hx of HF, TIAs, arrhythmias
Left heart obstruction: MS <2cm, AS <1.5c
LVEF <40%

Marfans: risk of aortic dissection and death
MS: pul oedema 10-25%
Pul HTN: death
Mechanical valves: thrombosis

Question 2

Pulmonary HTN Management

Answer 2

Phosphodiesterase inhibitors (continue)
Endothelin receptor antagonists (teratogenic - discontinue)
VTE - LMWH
If sx: electively admit, bedrest, O2
MDT team
Tertiary centre
No evidence for CS but often performed
Maintaining pre-load
Avoiding systemic vasodilation eg syntocinon and regional anaesthetics

Question 3

Congenital HD

Answer 3

Risks maternal: Heart failure, arrhythmias, angina, HTN, thrombocytopenia, aortic dissection, death

Risks fetal: SB, IUGR, PTB, miscarriage, congenital heart defect

Concerning ones: AS (often bicuspid valve) if <1cm, coarctation of aorta, Marfans aortic root >4-4.5cm, pulmonary atresia, TOF, HCM

Question 4

Acquired heart disease

Answer 4

RHF resulting MS (diastolic murmur)
- Treat tachycardia and arrhythmias with digoxin and B blockers
- Avoid overload
- Avoid supine positions
- Treat Pulmonary oedema with O, diamorphine and diuretics
- Balloon valvotomy

Cardiomyopathies
HCM: avoid hypovolaemia and stay on B blockers
Peripartum: Mg: delivery, VTE, convential HF tx (duiretics, vasodilators, b blockers, digoxin, ACEi)
Consider myocarditis
Counsel against further pregnancy if LVEF does not return to normal

Artificial heart valves
- Mechanical heart valves require anticoagulation
- Grafted tissue deterioration can accelerate by pregnancy

MI - increasing incidence, PCI preferred from thrombolysis given bleeding risk

Aortic dissection (Marfans, turners, EDS type IV, coarctation, bicuspid aortic valve)

Question 5

Anticoagulation

Answer 5

Warfarin: FWS, miscarriage, SB, intra-cerebral bleeding
Clexane: higher risk of thrombosis for woman (can add aspirin and monitor antiXa levels)
Need to discontinue warfarin for delivery to protect infant

Consider abx

Question 6

Arrhythmias managemetn

Answer 6

Digoxin, b blockers, adenosine
Avoid amiodarone
Flecainide for baby