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Obgyne > Heart disease with the pregnancy🖤 > Flashcards

Heart disease with the pregnancy🖤 Flashcards

1
Q

Mortality due to heart disease
Decrease or increase

A

Decrease

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2
Q

Pregnancy with heart disease has increase or decrease

A

Increase

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3
Q

Congenital heart disease with pregnancy increase or decrease

A

Increase

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4
Q

Hemodynamic changes in normal pregnancy
1. Plasma volume.
2. Cardiac output.
3. Heart rate.
4. Main arterial pressure.
5. Struck volume.
6. Systemic vascular resistance
7. Pulmonary vascular resistance.
جدول

A

40+
43 +
17 +
4+
27 +
21 -
34 -

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5
Q

What’s the critical period in pregnant women to get cardiac disease ?

A
  1. 6-30 wks
  2. Intra partum period
  3. after delivery
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6
Q

Pregnancy changes mimic cardiac disease? 5

A

• Symptoms – breathlessness, weakness, edema, syncope
• Tachycardia
• Splitting of 1st hear sound
• Murmur – systolic , breast bruit
• Displacement of apex beat – upwards to left

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7
Q

Symptoms of heart disease? 5

A

• Progressive dyspnea or orthopnea
• Nocturnal cough
• Syncope
• Chest pain
• Hemoptysis

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8
Q

Clinical findings of heart disease 9

A

• Cyanosis
• Clubbing of fingers
• Persistent neck vein distention
• Systolic murmur grade 3/6 or greater • Diastolic murmur
• Cardiomegaly
• Persistent arrhythmia
• Persistent split second sound
• Pulmonary hypertension

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9
Q

If you suspect the pregnant women maybe has cardiac disease what’s the investigation you want required?

A

• ECG – cardiac arrhythmias, hypertrophy
• Echocardiography – cardiac status and structural anomalies
• X-ray chest – cardiomegaly, vascular prominence
• Cardiac catheterization - rarely

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10
Q

Functional grading of heart disease?

A

•Grade I: No limitation of physical activity- asymptomatic with
normal activity
• Grade II: Mild limitation of physical activity -Symptoms with
normal physical activity
• Grade III: Marked limitation of physical activity -Symptoms
with less than normal activity, comfortable at rest
• Grade IV: Severe limitation of physical activity- symptoms at
rest

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11
Q

Classification of Heart Disease according to etiology :6

A
  1. Congenital - non cyanotic:
    ASD, VSD, Pulmonary stenosis, coarctation of aorta
  2. cyanotic :
    fallot’s tetralogy
    Eisenmenger’s syndrome
  3. Rheumatic heart disease : – MS, MR, AS, AR
  4. Cardiomyopathy
  5. Ischemic heart disease
  6. conduction defects, syphilitic,
    thyrotoxic, hypertensive
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12
Q

Classification of Heart Disease during pregnancy according to risk :

A
  1. Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-1,2, corrected FT
  2. Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT.
  3. High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement.
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13
Q

Poor prognostic indicators 7.

A

• h/o heart failure, ischemic attack, stroke
• Arrhythmias
• Base line NYHA class 3 and 4
• MV area below 2cm sq, AV area below 1.5
• Ejection fraction less than 40%
• Oxygen saturation less than 80% Increased of fetal growth restriction
• Less than 20% chance

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14
Q

risk factors for pregnant women to get cardiac disease? 9

A

• Anemia
• Infections
• Hypertension
• Physical labor
• Weight gain
• Multiple pregnancy
• Caffeine , alcohol intake
• Pain
• Drugs – tocolytic

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15
Q

Effect of pregnancy on heart disease 6

A

• Worsening of cardiac status
• CCF,
• bacterial endocarditic,
• pulmonary edema,
• pulmonary embolism,
• rupture of aneurism

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16
Q

How are you gonna manage pregnant women with the cardiac disease ? require

A

• High index of suspicion
• Timely diagnosis
• Effective management
• Team Approach : 1.Obstetrician 2. Cardiologist 3 Anesthetist 4. Neonatologist 5. CTV surgeon 6. Nursing Staff

17
Q

Preconceptional counseling 4.

A

• No pregnancy specially in high risk types
• Maternal mortality varies directly with functional classification at pregnancy
onset
• pre-pregnancy Optimal Medical/Surgical treatment
• Counseling- :
• Maternal & Fetal risks
• Prognosis
• Social and cost considerations
• Hospital delivery- Preferable at tertiary care centre
• Use of anticogulants

18
Q

When Medical termination of pregnancy use?

A
  1. early pregnancy in high-risk group only ( 1. Primary pulmonary HTN, 2. Eisenmenger syndrome, 3. Coarctation of aorta, 4. Marfan syndrome with dilated aortic root ).
  2. Only in 1st trim, better before 8 weeks.
  3. Suction evacuation preferred.
  4. MTP also carries risk for life.
19
Q

Patient with the cardiac disease what’s the best method for the medical termination?

A

Suction evacuation.

20
Q

Antenatal care for pregnant women with the cardiac disease 6

A

• Clear counseling of risk and prognosis.
• ANC every 2 weeks up to 30 weeks then weekly.
• On each visit-note-pulse rate, BP, cough dyspnea, weight, anemia, auscultate lung bases, re-evaluate functional grade.
• Ensure treatment compliance.
• Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease.
• Fetal monitoring.

21
Q

The pregnant women with cardiac diseases, what you gonna use as a treatment Anticoagulants

A

Heparin and the first 12 weeks to decrease risk.

22
Q

What’s the advantage of the heparin?

A

Doesn’t cross the placenta.

23
Q

What’s the disadvantage for Heparin?

A

maternal osteoporosis, hemorrhage, thrombocytopenia, thrombosis

24
Q

Why we doesn’t use Warfarin in the pregnant woman with the cardiac disease?

A

abnormalities of fetal bone and cartilage formation

25
Q

What’s you gonna use for pregnant women with cardiac disease, heparin, or warfarin?

A

Heparin in the first 12 weeks to the decrease the risk.

26
Q

How you gonna treat pregnant women with prosthetic valves?

A
  1. Heparin in the first trimester.
  2. Then converted to warfare at 13 weeks tell 36 weeks.
  3. Then converted to heparin at 36 weeks till delivery.
27
Q

Special Advice pregnant women with cardiac disease? 8.

A

• Rest, Avoid undue excitement/strain • Diet/ Iron and vitamins
• Hygiene, dental care to prevent any infection
• Dietary salt restriction (4-6g/d)
• Avoid smoking, drugs – betamimetics
• Early diagnosis and treatment of PIH, infections
• Therapeutic/prophylactic cardiac interventions as applicable :
1. Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of
rheumatic fever
2. Diuretics, Beta Blockers, Digitalis, Anticoagulants.
3. Surgical treatment as applicable - balloon mitral valvotomy

28
Q

What’s the indication to admit pregnant women with cardiac disease: 2 type.

A

Elective admission:
1. NYHA 1 – 2 weeks before EDD
2. NYHA 2 – 28 to 30 weeks
3. NYHA-III/IV- Irrespective of POG as soon as patient comes
4. To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant.

Emergency admission:
1. Deterioration of functional grade
2. Symptoms and signs of complications- Fever/ persistent cough/ basal crept/ tachyarrhythmia’s (P/R >100 min)/
JVP>2cm/Anemia/ Infections/ PET/Abnormal weight gain /other medical disorders

29
Q

Labor and Management for pregnant women with the cardiac disease?

A

• Institutional delivery
• Induction of Labor:
1. Only for obstetric indications
2. Oxytocin preferred- Higher concentration with restricted fluid
3. Intracervical Foley instillation specially in congenital heart
disease
4. PGE2 Gel may be employed- Vasodilatation - use with caution

30
Q

Management in first stage of labor in the pregnant woman with the cardiac disease

A
  1. Confined to bed- propped up or semi recumbent
  2. Intermittent oxygen inhalation 5-6 l/min
  3. Sedation and analgesia- (Epidural, pethidine)
  4. Cautious use of I.V. fluids
  5. Stop anticoagulants
  6. Digitalise if in : (( CHF,P.R.>110/ min,
    R/R >24/min ))
  7. Diuretics in pulmonary congestion
  8. Deriphyllin if bronchospasm
  9. Prevention of infective endocarditic
  10. Cardiac monitoring and pulse oximetry ±pulmonary artery catheterization- continuous
    hemodynamic monitoring
  11. Evaluation by Anesthetist and cardiologist
31
Q

SAPE prophylaxis not recommended in the patient has? 2

A
  1. At risk For the infection
  2. Severe lesion.
32
Q

SAPE prophylaxis

A

Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg (max120)
6 hours later
Ampicillin-1G I.V./IM or 1G P.O.
If
Allergic to Penicillin
Vancomycin-1G I.V. or Clindamycin – 600mg IV + Gentamicin-1.5mg/kg

33
Q

Management of second stage of labor

A

• Delivery in propped up position
• Avoid forceful bearing down
• Adequate pain relief-epidural/pudendal block
• avoid spinal/Saddle block
• Cut short second stage of labor:
• episiotomy, vacuum, forceps – not always must
• Strict Cardiovascular monitoring

34
Q

Third stage of labor management of the pregnant women with cardiac disease

A

• AMTSL-10 U oxytocin IMI
• Avoid bolus syntocinon/Ergometrine • Propped Up, oxygen inhalation
• Furosemide I.V. 40 mg
• Pethidine/morphine (15mg)
• Watch for signs of CHF & Pul. Edema • Treat PPH energetically

35
Q

First Hour After Delivery for pregnant women with the cardiac disease

A

•Propped up/sitting position,
• oxygen
•Watch for signs of pulmonary edema •Sedation
•Antibiotics

36
Q

Indications for LSCS for pregnant women with cardiac disease

A

• Mainly obstetrical
• Coarctation of aorta
• Marfan syndrome with dilated root of aorta:
1. Prefer epidural anesthesia
2. Narcotic conduction analgesia
3. GA in Pulmonary hypertension and pts having intracardiac shunts

37
Q

Advice at time of discharge for pregnant lady her delivered baby with cardiac disease

A
  1. Continue medical treatment
  2. Avoid infection
  3. Reassessment after 6 weeks or earlier if some complication
    occurs
  4. Iron supplementation
  5. Cardiological consultation for definitive management of heart
    disease
38
Q

Contraceptive advice at time of discharge:

A

• Contraception- Barrier.
• Progesterone – good option- DMPA, Norplant
• IUCD-Less preferred
• COC – contraindicated
• Sterilization- vasectomy- ((best ))
• Tubal ligation-Interval, puerperal can be done

39
Q

Effect of heart disease on pregnancy? 5.

A

• Abortion
• Preterm labor
• IUGR
• Congenital heart disease in baby – 5%
• Intrauterine fetal demise

Obgyne (26 decks)

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