Maternal Medicine - Cardiac Disease (including TOG: MI in pregnancy

Question 1

How many pregnancies are complicated by cardiac disease in the West?

Answer 1

0.2-4%

Question 2

What % of cardiovascular disease is secondary to congenital heart disease?

Answer 2

75-82%

Question 3

What % of cardiovascular disease is secondary to Rheumatic heart disease in developing countries?

Answer 3

56-89%

Question 4

What postpartum precautions should be taken in women with known cardiac disease?

Answer 4

Slow oxytocin (<2u/min)
Caution in PPH mx especially if raised pul. art. pressures
Avoid ergometrine
TEDs, early ambulation
Haemodynamic monitoring in HDU for at least 24 hrs

Question 5

What % of women with peripartum cardiomyopathy present 1/12 postpartum?

Answer 5

75%

Question 6

How common is peripartum cardiomyopathy?

Answer 6

1 in 3-4000 pregnancies

Question 7

How many women with peripartum cardiomyopathy improved/were unchanged/worsened?

Answer 7

62%
25%
13%

Question 8

What is the recurrence rate of peripartum cardiomyopathy?

Answer 8

20% if EF is normal at beginning of pregnancy
45% if EF is abnormal at beginning of pregnancy (generally advise to avoid pregnancy if <40% EF)
If EF <20% - generally advise TOP

Question 9

What is the treatment for mitral stenosis?

Answer 9

Beta blockers (detrimental if increase in HR)
Rest
Diuretics if pulmonary congestion
LMWH
Percutaneous balloon (5% chance severe MS needs surgery)
Open heart surgery last resort - 20-30% fetal death

Question 10

What is the rate of warfarin embryopathy in the first trimester and what are the characteristics?

Answer 10

0.6-10%
Nasal hypoplasia, stippled epiphysis, CNS problems, Eye disorders
Can be given from 14/40

Question 11

What is the most important physiological consideration peripartum in women with mild cardiac disease?

Answer 11

Following delivery 500ml returns to the circulation

Question 12

How many maternal deaths are due to cardiac disease?

Answer 12

1/5

Question 13

What was the rate of cardiac deaths in 2006-08?

Answer 13

2.31 per 100,000 maternities

Question 14

How many maternal deaths were due to MI (mostly 2dry to IHD)?

Answer 14

11

ie 0.48/100,000 maternities

Question 15

How many more times higher is the risk of MI in pregnancy compared to age-specific rates in the reproductive age group?

Answer 15

3-4x higher

Question 16

What % of acute MI occur during the peripartum period?

Answer 16

Up to 50%

Question 17

How much more likely is chance of acute MI in women >40 compared to women <20?

Answer 17

x 30

Question 18

What % of women who died from cardiac disease were overweight or obese?

Answer 18

64%

Question 19

What are the main causes of acute MI in pregnancy?

Answer 19

• Coronary atherosclerosis (50%)
• Non-atherosclerotic causes:
  
  • Coronary artery dissection (22%)
  • Coronary artery thrombosis (8-14%)
• Coronary artery spasm:
  -Spontaneous
  -Drug-induced e.g. terbutaline, ergotamine,
  bromocriptine and cocaine use

Question 20

When is the highest risk of coronary artery dissection in pregnancy?

Which vessel is involved in the majority and what is the mortality rate?

Answer 20

3rd trimester up to 3/12 PP

Usually left anterior descending coronary artery (80%)

Mortality rate 30-40%

Question 21

What are the ECG changes seen in acute MI in pregnancy?

Answer 21

ST elevation/depression
Symmetrical T inversion
New Q waves

Only sensitive in 50% cases of ischaemia

Question 22

What are the normal ECG changes in pregnancy?

Answer 22

15-20deg left axis shift
ST depression
T inversion in inferior and lateral leads
Small Q and inverted T in III
Q in aVF
Inverted T in V1, V2 occasionally V3

Question 23

What is the treatment of STEMI in pregnancy?

Answer 23

PPCI, preferably with bare metal stents

t-PA if delay in accessing PPCI (doesnt x placenta) - but NB 8% risk of maternal haemorrhage

Question 24

What is the treatment of non-STEMI in pregnancy?

Answer 24

Antiplatelet treatment +/- stenting if symptoms don’t settle with medical treatment

Question 25

What is the medical management in acute MI?

Answer 25

Aspirin
LMWH
Labetalol
Nitrates (caution IV GTN on FH)
Can use clopidogrel cautiously - shortest time possible

Avoid:
Nifedipine - avoid after acute attack
ACEI
Statins

Question 26

What are the fetal effects of ACEIs?

Answer 26

1st Trimester: CV and CNS malformations

2/3 T: Renal dysgenesis, oligohydramnios, calvarial and pul hypoplasia, IUGR, fetal demise

Question 27

When should women be delivered following MI?

Answer 27

Individualised; ideally if possible wait 2-3/52 post-event as this is when mortality is highest

Question 28

What are the considerations in women following MI who are attempting vaginal birth?

Answer 28

• Recommend epidural
• Left lateral
• Pulse ox/ECG (consider art line)
• CEFM
• Supplementary O2
• Can use b-blockers, nifedipine, GTN but latter 2 are tocolytic
• Shortened 2nd stage
• Slow IV oxytocin <2U/min to avoid hypotension
• No ergometrine - vasospastic
• HDU 24-48 hours after