Heart Disease in Pregnancy

Question 1

Antenatal management of heart disease in pregnancy

Answer 1

• Joint obs. + cardio care
  assess level of HF
  -echo at booking and 28wks

Question 2

NYHA HF

Answer 2

1 (mild) - no limtiation
2 (mild) - slight limitation on physical activity, comfortable at rest
3 (mod) - marked limitation, comfortable at rest, less than ordinary activity causes Sx
4 (Sev) - physical activity impossible w/o Sx, Sx at rest

Question 3

Routine physical exam in women w/heart disease in pregnancy

Answer 3

PR, BP
JVP
HS
ankle + sacral odema
lung bases

Question 4

Anticoagulation in women w/heart disease in pregnancy

Answer 4

essential in cong. HD w/pHTN or artificial valve or risk of AF

Question 5

Warfarin in pregnancy

Answer 5

teratogenic in T1

LMWH used as alternative (esp.T1+3)

Question 6

High risk cardiac conditions in pregnancy

Answer 6

Systemic ventricular dysfunciton
pHTN
Cyanotic CHD
Aortic pathology (Marfans)
IHD
Left heart obstruction eg A/MS
Prosthetic valves
Previous peripartum cardiomyopathy

Question 7

Foetal risks of maternal cardiac disease

Answer 7

Recurrence of CHD
maternal cyanosis (foetal hypoxia)
Iatrogenic prematurity
FGR
Effects ofdrugs (teratogens, IUGR, loss)

Question 8

Mx of labour and delivery in women w/heart disease in pregnancy

Answer 8

• Aim to wait for spontaneous labour
• Induction in v high risk women to ensure predictability
• Epidural anaesthesia recommended (red. pain related stress)
• ?Prophylactic Abx
• If labour progressing normally keep 2nd stage short w/ventouse/forceps
• C-sec only if mother too unstable for labour
• Ergometrine CI

Question 9

Risk of epidural in women w/heart disease in pregnancy

Answer 9

maternal hypotension

Question 10

Indication for prophylactic Abx in women w/heart disease in pregnancy

Answer 10

any woman w/structural heart defect to reduce bacterial endocarditis

Question 11

Why ventouse/forceps in women w/heart disease in pregnancy

Answer 11

Reduces maternal effort and thus CO

Question 12

Risk PP in women w/heart disease in pregnancy

Answer 12

PPH -> CVS instability

Question 13

Why is ergometrine CI in women w/heart disease in pregnancy

Answer 13

vasocontriction, htn, HF
active Mx of third stage is syntocinon alone
- syntocinon is a vasodilator so intrpduce slowly

Question 14

Summary of women w/heart disease in pregnancy

Answer 14

1. Echo at booking + 28wks
2. ?anti-coag
3. Avoid labour induction if poss
4. ?Proph. Abx
5. Fluid balance
6. Avoid supine position
7. Discuss anaesthesia w/senior anaesthesiologist (epidural/regional)
8. Keep the second stage short
9. CI: ergometrine, syntocinon wth caution