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Maternal Medicine > Maternal Cardiac Disease > Flashcards

Maternal Cardiac Disease Flashcards

2012 Simpson – ACOG Clinical Expert Series. Berghella, Evidence Based MFM

1
Q

What is NYHA (New York Heart Association) class 1?

A

No cardiac symptoms

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2
Q

What is NYHA (New York Heart Association) class II?

A

Cardiac symptoms with greater than normal activity

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3
Q

What is NYHA (New York Heart Association) class III?

A

Cardiac symptoms with normal activity

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4
Q

What is NYHA (New York Heart Association) class IV?

A

Cardiac symptoms with bedrest

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5
Q

With which two NYHA classes is pregnancy not advised?

A

NYHA 3-4

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6
Q

How does cardiac dysfunction present?

A

Fatigue, limited activity, palpitations, tachycardia, SOB, chest pain, dyspnea on exertion, cyanosis

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7
Q

What 4 cardiac conditions are contraindications to pregnancy?

A

Pulmonary hypertension
Severe ventricular dysfunction
Aortic root dilation (>4cm)
Severe left-sided obstructive lesions

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8
Q

While cardiac disease complicates 1-4% of pregnancies, it accounts for what % of maternal mortality?

A

Up to 25%

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9
Q

For women with congenital heart disease, what is the risk of fetal transmission?

A

5% (from 8/1000 background risk)

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10
Q

What features of pregnancy physiology can exacerbate cardiac disease?

A

Increased intravascular volume
Hypercoagulability
Decreased SVR

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11
Q

What are the general guidelines for pregnancy management in women with cardiac disease

A 
Relative bedrest
Treat other medical conditions
Multidisciplinary approach
Monitor fetal growth q 4-6w
NST >34w
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12
Q

What are the general guidelines for labor management in women with cardiac disease?

A 
Lateral decubitus position
Epidural
O2
\+/- Endocarditis prophylaxis
Avoid hypotension (keep women ?wetter?) C/S for obstetric indications
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13
Q

While most cardiac conditions benefit from relative hypervolemia and relative hypotension intrapartum, what is the exception?

A

Mitral stenosis

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14
Q

Why is fluid overload (ie post-partum autotransfusion) bad for mitral stenosis?

A

The associated restricted LV filling can lead to pulmonary edema

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15
Q

What are the indications for c/s with maternal cardiac disease?

A

Aortic root dilation >4cm
Maternal Coumadin
Recent MI
Severe aortic stenosis

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16
Q

Which cardiac patients may benefit from invasive monitoring in labor?

A

Women with preload dependent conditions (aortic stenosis, PHTN)

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17
Q

Should women with prospthetic cardiac valves receive endocarditis prophylaxis?

A

Yes

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18
Q

After what time period after repair of CHD with prosthetic material should women receive endocarditis prophylaxis with delivery?

A

6 months

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19
Q

Does completely repaired CHD (with repair >6m ago) require endocarditis prophylaxis?

A

No

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20
Q

Does unrepaired cyanotic CHD require endocarditis prophylaxis?

A

Yes

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21
Q

If your patient had repair of CHD with prosthetic material remotely but there are residual defects, should they receive endocarditis prophylaxis?

A

Yes

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22
Q

How do we manage a patient with prior infective endocarditis in labor?

A

With endocarditis prophylaxis

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23
Q

When endocarditis prophylaxis is indicated, what antibiotic is used?

A

Ampicillin 2g IV

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24
Q

For PCN allergic women who need endocarditis prophylaxis, what antibiotics can be used?

A

Clinda, Ancef, cetriaxone

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25
Q

Is there an ACOG resource to guide endocarditis prophylaxis?

A

Yes - committee opinion 421, Antibiotics prophylaxis for infective endocarditis

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26
Q

What is the workup for palpitations?

A

Thyroid function
Rule out drugs/caffeine/tobacco
EKG
Echo

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27
Q

Are PACs and PVCs more common in pregnancy and typically benign?

A

Yes

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28
Q

What is the risk of complication or death in pregnancy with isolated VSD, repaired or unrepaired (high, moderate, or low)?

A

Low, <1%

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29
Q

When you have a patient with a long-standing large VSD, what should you rule out prior to becoming pregnant?

A

Pulmonary hypertension

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30
Q

Why is decreased SVR bad with pulmonary HTN caused by a VSD?

A

If pulmonary pressures exceed systemic pressures, the typical L-> R shunt can reverse, resulting in cyanosis

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31
Q

How should patients with VSD be managed intrapartum?

A

Avoid fluid overload

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32
Q

How is pulmonary hypertension defined? (What peak pulmonary artery pressures and mean PA pressures?)

A

Pulmonary artery pressure >30 mmHg, or mean pulmonary artery pressure >25 mmHg

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33
Q

What % of women with PHTN on echo have a normal pulm artery cath? (Ie. What is the false + rate of a TTE?)

A

30%

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34
Q

What is thought to cause the delayed PP death in pulm HTN?

A

Loss of pregnancy associated hormones and increased pulm vascular resistance

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35
Q

Why is hypotension dangerous with PHTN?

A

Pulmonary perfusion depends on preload

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36
Q

Are patients with PHTN better managed wet or dry?

A

Wet (to avoid hypotension and decreased preload)

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37
Q

How is inhaled NO helpful in PHTN?

A

Inhaled NO selectively reduces pulmonary vascular resistance while sparing SVR (maintaining preload)

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38
Q

What are the goals for medical management of pulmonary HTN (think PVR and ventricular function)?

A

Avoid increasing pulmonary vascular resistance
Maintain RV preload
Maintain RV contractility

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39
Q

What medication is used in the treatment of pulmonary HTN by decreasing pulmonary vascular resistance?

A

Inhaled NO (which causes selective vasodilation of the pulmonary vascular bed)

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40
Q

What is the maternal mortality associated with pulmonary HTN?

A

17-28%

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41
Q

What is the ideal mode of delivery for patients with pulmonary HTN?

A

Vaginal

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42
Q

What are the genetic causes of dilated aortic roots?

A

Marfans
Ehlers-Danlos
Loeys-Dietz
Turner syndrome

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43
Q

When is aortic root repair recommended (what dilation, and rate of dilation)?

A

Repair outside of pregnancy is recommended for dilation >5.0cm, or a rapidly dilating dilation (>0.5cm per year)

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44
Q

Does pregnancy accelerate pathologic aortic root dilation?

A

Yes

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45
Q

What medication is used in pregnancy to reduce strain on the ascending aorta and reduce the rate of aortic dilation, ie in cases of Marfans?

A

B-blockade

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46
Q

When is vaginal delivery safe for a patient for Marfans

A

With epidural, aortic root <4cm, and assisted second stage

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47
Q

What is the mortality associated with Marfans if aortic root is <4cm?

A

<1%

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48
Q

What is the risk of aortic dissection or death associated with Marfans if aortic root is >4cm?

A

20-50%

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49
Q

How should we evaluate patients with Marfans (or FH of Marfans) on initial presentation (cardiac, ophtho?)?

A

Echocardiogram

Slit lamp study for ectopia lentis

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50
Q

How should we follow patients with Marfans in pregnancy

A

Serial evaluation of the aortic root by echo
B-blockade
Avoid HTN

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51
Q

What spinal anomaly is present in 90% of pt with Marfans that may affect epidural placement?

A

Dural ectasia (widening of the dural sac at the lumbar spine)

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52
Q

Which genetic condition is associated with aortic dissection at diameters smaller than Marfans

A

Loeys-Dietz

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53
Q

What non-genetic conditions predispose women to aortic dissection?

A

Bicuspid aortic valve, CHTN, coarctation

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54
Q

What is the pregnancy outcome with corrected asymptomatic aortic coarctation?

A

Good

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55
Q

When is aortic coarctation associated with increased risk for maternal mortality

A

With aneurysmal dilation and associated cardiac disease

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56
Q

How should cases of aortic coarctation be managed in labor?

A

Avoid hypotension and bradycardia

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57
Q

In general, how is cardiomyopathy treated?

A 
Oxygen
Diuretics
B-blockers (to avoid tachycardia)
Vasodilators
Inotropes (digoxin)
Anticoagulation
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58
Q

What principles should guide intrapartum management of hypertrophic CM?

A

Avoidance of hypotension, hypovolemia, and tachycardia

59
Q

How is hypertrophic cardiomyopathy inherited?

A

AD (with variable penetrance)

60
Q

What is the classic echo finding in hypertrophic cardiomyopathy?

A

Asymmetric LV hypertrophy

61
Q

What physiologic changes in pregnancy result in worsening cardiac function in patients with hypertrophic cardiomyopathy?

A

Decreased SVR worsens outflow obstruction, and tachycardia decreases diastolic filling time -> decreases cardiac output

62
Q

Do young asymptomatic women with hypertrophic cardiomyopathy tolerate pregnancy well?

A

Yes

63
Q

With hypertrophic CM, at what LV gradient do patients become symptomatic?

A

30 mmHg

64
Q

With hypertrophic CM, at what LV gradient are patients at risk for heart failure and sudden death?

A

100 mmHg

65
Q

What are the causes of dilated cardiomyopathy?

A 
Myocarditis
Ischemia
CHTN
Alcohol
Familial
66
Q

With dilated CM, what ejection fraction is concerning for adverse outcome?

A

<40%

67
Q

Peripartum cardiomyopathy is defined as new onset left ventricular dysfunction (EF <45%) at what time points relative to delivery?

A

1 mo prior to delivery and 5 mos post-partum

68
Q

When, relative to delivery, does peripartum CM most commonly occur?

A

2 months postpartum

69
Q

What % of peripartum cardiomyopathy cases occur before delivery?

A

10%

70
Q

What are the risk factors for peripartum cardiomyopathy?

A 
Age >30
Obesity
CHTN
Multiparity
Multiples
Terbutaline
Preeclampsia
Low socioeconomic status
African American race
71
Q

What is the mortality associated with peripartum CM?

A

25-50%

72
Q

What % of patients fully recover from peripartum CM?

A

35-50%

73
Q

What are poor prognostic factors for peripartum cardiomyopathy (LV size, EF, and status at 6 months)?

A

Large LV EDV and EF <30% at initial diagnosis, and failure of LV function to normalize by 6 months

74
Q

What % of women with peripartum CM and EF <25% will require a transplant?

A

57%

75
Q

What is the recurrence risk of peripartum CM?

A

35%

76
Q

What is the medical management of peripartum CM?

A 
Inotropic therapy (digoxin)
Afterload reduction (hydralazine +/- B-blockade)
ACE inhibitors (postpartum)
Anticoagulation (for  EF <35%), Bromocriptine
77
Q

When in pregnancy is the risk of MI the greatest?

A

In the first days post-partum (6x increase)

78
Q

Does pregnancy increase the risk of MI?

A

Yes (by 2-4x)

79
Q

Which study identifies ischemia and ventricular dysfunction in patients at risk for MI?

A

Stress echo

80
Q

Which cardiac enzymes should not be ordered in the peripartum state to assess for cardiac ischemia?

A

CK (as CK is increased 2x in labor)?only TROPONINs are helpful

81
Q

How can we treat stable angina in pregnancy?

A

Nitrates
Ca channel blockers
B-blockers

82
Q

What is “stable” angina?

A

Chest pain with exertion that resolves with rest and nitrates

83
Q

How do we treat ischemic heart disease (MI)?medications and other therapy?

A 
Morphine
Nitrates
B-blockers
Ca channel blockers
Heparin
Low dose Aspirin
Coronary angioplasty
84
Q

If cardiac catheterization is indicated for MI, what should you tell your IR colleagues is the max dose of radiation considered safe in pregnancy?

A

1 Rad

85
Q

Is thrombolysis considered a safe management option for MI in pregnancy?

A

No ? use only if no other options

86
Q

How should women with history of MI be counseled on future pregnancy?

A

Best not to become pregnant! (but may be considered if EF and coronaries are normal one year s/p MI)

87
Q

What are the main causes of aortic stenosis in developed countries?

A

Bicuspid aortic valve

88
Q

What are the main causes of aortic stenosis in developing countries?

A

Rheumatic heart disease

89
Q

Women with aortic stenosis can expect good pregnancy outcomes if which criteria are met (what symptoms, what testing, what drop in aortic valve peak pressure)?

A

Asymptomatic
Normal EKG/stress test
Good EF
Aortic valve peak pressure drop <80 mmHg

90
Q

When should pt with aortic stenosis undergo repair prior to childbearing (what aortic valve peak gradient, and what EF)?

A

Peak gradient >50 mmHg (possibly >30 mmHg), or EF <30%

91
Q

If aortic valve replacement is required during pregnancy, what is the risk for fetal death with ECMO

A

20%

92
Q

What intervention may be used to temporize patients with severe aortic stenosis during pregnancy in anticipation of valve replacement?

A

Balloon valvuloplasty

93
Q

At what aortic diameter do people become symptomatic from aortic stenosis?

A

<1cm

94
Q

What are the potential bad outcomes associated with aortic stenosis

A

Angina, MI, syncope, sudden death

95
Q

Why is it important to avoid hypovolemia with aortic stenosis

A

In aortic stenosis, cardiac output is preload dependent. Hypovolemia causes decreases CO, and inadequate coronary/cerebral perfusion

96
Q

Why is cardiac output fixed in aortic stenosis

A

Outflow obstruction leads to LV hypertrophy and subsequent poor filling (diastolic dysfunction)

97
Q

Why is the fixed cardiac ouput of aortic stenosis dangerous in pregnant states of increased preload and HR?

A

Without the ability to increase output, coronary and carotid perfusion decreases

98
Q

Is it better to keep pt with aortic stenosis wet or dry?

A

Wet (as preload dependent)

99
Q

What effect does the fixed cardiac output of aortic stenosis have on fetal growth?

A

10%

100
Q

How is aortic stenosis managed in pregnancy

A

Bedrest and B-clockers (to decrease HR and increase LV ejection time to maximize coronary filling)

101
Q

What is the main cause of mitral stenosis?

A

Rheumatic heart disease

102
Q

How does mitral stenosis present?

A

Pulmonary edema and a-fib

103
Q

How is mitral stenosis treated in pregnancy?

A

Restricted activity
Diuretics
B-blockers (rate control)

104
Q

Women with mitral stenosis but valve area greater than what value have a good outcome?

A

> 1.5 cm2

105
Q

How does mitral stenosis lead to a fixed cardiac output?

A

Prevention of LV filling

106
Q

Why should patients with mitral stenosis be managed on the ?dry side

A

With fluid overload, CO cannot increase, and pulmonary edema can result

107
Q

When in pregnancy is mitral stenosis likely to decompensate, due to the peak maternal blood volume levels?

A

30-32w

108
Q

Why should tachycardia be avoided in patients with mitral stenosis?

A

Poor LV filling may result -> hypotension

109
Q

When should B-blockers be given to pt with mitral stenosis to prevent tachycardia-associated poor CO?

A

HR of 90-100

110
Q

At what mitral valve should pt be offered pre-pregnancy intervention?

A

<1.2cm (or if pt is symptomatic)

111
Q

Can balloon mitral valvuloplasty be performed in pregnancy for failed medical management?

A

Yes

112
Q

What is the maternal mortality associated with mitral stenosis?

A

5%

113
Q

What types of mechanical heart valves are the highest risk

A

Ist generation: Starr-Edwards and Bjork-Shiley in Mitral position

114
Q

Do women with mechanical heart valves need prophylactic or therapeutic anticoagulation during pregnancy?

A

Therapeutic (with weekly blood levels)

115
Q

Which types of heart valves require anticoagulation in pregnancy ? bioprosthetic or mechanical?

A

Mechanical

116
Q

Why do mechanical heart valves require anticoagulation?

A

Due to the shearing effects of the valve on circulating blood (which can result in platelet activation and thrombus formation)

117
Q

When using heparin for anticoagulation, when can an epidural be placed after the last dose?

A

4-6h (good to check a PTT first)

118
Q

Aside from mechanical heart valves, which cardiac conditions may require anticoagulation?

A

Afib and PHTN

119
Q

What is the therapeutic range for heparin?

A

Heparin: PTT 60-80 sec.

120
Q

What is the therapeutic range for Coumadin, and Lovenox?

A

Coumadin: INR 2-3.

121
Q

What is the therapeutic ranges for Lovenox (peak and trough)?

A

Peak (4h after 4th dose) anti-Xa 0.8-1.2. Trough 0.6-0.7

122
Q

What is the risk of warfarin teratogenicity (%) with first trimester exposure?

A

10-15%

123
Q

How does warfarin teratogenicity present after first trimester exposure?

A

Nasal hypoplasia
Optic atrophy
Digital anomalies
Mental impairment

124
Q

Is Coumadin or heparin a better at preventing thromboembolism in women with a mechanical valve?

A

Coumadin

125
Q

To minimize both teratogenicity and risk for VTE with mechanical heart valves, how should women be anticoagulated during pregnancy?

A

Heparin in first trimester and >36w, and Coumadin from 12-36w

126
Q

What is the risk of complication or death in pregnancy with L->R shunt with pulm HTN (high, moderate, or low)?

A

High >25%

127
Q

What is the risk of complication or death in pregnancy with Eisenmenger?s (high, moderate, or low)?

A

High >25%

128
Q

What is the risk of complication or death in pregnancy with Uncorrected aortic coarctation with proximal aortic dilation (high, moderate, or low)?

A

High >25%

129
Q

What is the risk of complication or death in pregnancy with left heart obstructive lesions like severe aortic stenosis and hypertrophic CM (high, moderate, or low)?

A

High >25%

130
Q

What is the risk of complication or death in pregnancy with mild-mod aortic stenosis (high, moderate, or low)?

A

Moderate (5-15%)

131
Q

What is the risk of complication or death in pregnancy with a systemic right ventricle (high, moderate, or low)?

A

Moderate (5-15%)

132
Q

What is the risk of complication or death in pregnancy with well functioning Fontan palliation for hypoplastic ventricles (high, moderate

A

Moderate (5-15%)

133
Q

What is the risk of complication or death in pregnancy with an isolated ASD or VSD, repaired or unrepaired (high, moderate, or low)?

A

Low (<1%)

134
Q

What is the risk of complication or death in pregnancy with pulmonic or tricuspid valve disease (high, moderate, or low)?

A

Low (<1%)

135
Q

What test can be recommended before conception to predict clinical outcome in pregnancy in moms with congenital heart disease?

A

Exercise stress test and echo

136
Q

What is the indication for a FONTAN procedure

A

Any anatomic abnormality in which a two-ventricle repair is unfeasible (tricuspid or pulm atresia, hypoplastic heart)

137
Q

What is the Fontan procedure (ie what vascular structures does it connect, and divert)?

A

From the RA (systemic venous return) to the pulmonary arteries, bypassing the RV

138
Q

What is the risk of maternal death in asymptomatic women s/p Fontan with good vent function and no pulm HTN?

A

2%

139
Q

What are the 4 features of TOF?

A

VSD
Overriding aorta
RVH
Pulmonary stenosis

140
Q

What is the risk of complication or death in pregnancy with uncorrected cyanotic defects like TOF (high, moderate, or low)?

A

Moderate (5-15%) (high with severe pulm regurg or RV dysfunction)

141
Q

What is the risk of complication or death in pregnancy with repaired TOF with normal RV function and competent pulmonic valve (high, moderate, or low)?

A

Low (<1%)

142
Q

What is the risk of complication or death in pregnancy with palliated TOF with pulm regurg and RV dysfunction (high, moderate, or low)?

A

Moderate (5-15%)

143
Q

What complications are seen with repaired TOF in pregnancy?

A

SVT, right heart failure

Maternal Medicine (20 decks)

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