Oh’s (66) - Cardiac Disease In Pregnancy

Question 1

Percentage of pregnancies with cardiac disease

Answer 1

0.2 to 4%

Question 2

Types of cardiac disease that cause of maternal death

Answer 2

Sudden Adult Death Syndrome (31%)
Ischaemia 22%
Cardiomyopathy 18%
Dissection 14%
Valves 7%
Essential Hypertension 4%
Other 5%

Question 3

Are patients who die in pregnancy usual known to have cardiac disease?

Answer 3

No - on 17% had pre-exisiting cardiac disease

Question 4

Cardiovascular changes in pregnancy

Answer 4

Blood volume rises by 50%
Red cell mass rises but more slowly (dilution all anaemia)

CO increases by 50% (increased SV, in HR in 3rd tri)

SVR and BP falls in first trimester, rising to term

Question 5

Factors that increase CO/DO2 etc during labour

Answer 5

Anxiety, pain, contractions

Post delivery - increased intra cardiac pressure as caval pressure released (auto transfusion)

Question 6

WHO Risk Classification for cardiac disease in pregnancy

Answer 6

Classes 1 to 4
Low, medium, high
Class 4 - DO NOT GET PREGNANT

Question 7

European Society Class 1 (modified WHO)

Answer 7

No detectable increase in mortality

Uncomplicated:
pulmonary stenosis
PDA
MV prolapse

Successfully repaired lesions (ASD, VSD, PDA)

Isolated ectopic

Question 8

European society class 2

Answer 8

Small increase in mortality

Operated ASD/VSD
Repaired TOF
Arrhythmia

Question 9

European Society Class 2-3

Answer 9

Mild LV impairment
HOCM
Marfans without dilatation

Question 10

ESC Class 3

Answer 10

SIgnificant risk of severe mortality

Mechanical valve
Fontan
Systemic RV
Unprepared cyanotic disease

Question 11

ESC Class 4

Answer 11

Extremely high risk of death

PAH (any cause)
LVEF <30% 
NYHA 3-4
Severe mitral stenosis
Aortic root >45mm

Question 12

Antenatal approach

Answer 12

Joint cardiac, obs and anaesthetic clinic
Routine antenatal appts
Deliver at 32-34/40
Plan for VTE

Question 13

Intrapartum principles

Answer 13

Have appropriate cardiology support
Aim vaginal delivery (less fluid shifts, less thrombosis)
Planned CS if condition worsening

Goals:
Reduce CVS stress - early epidural
Limit the length of the second stage
Consider ECG, IABP and CVP monitoring

Question 14

Problems is mitral disease and management

Answer 14

Stenosis is poorly tolerated
Risk of pulmonary oedema, AF (LA enlarges)

Tx-
Anticoag (high risk of thrombus)
Dieretics
Beta block - sinus rhythm

Delivery - IABP, treat drops in SVR with vasoconstrictors/volume

Question 15

Problems and management with aortic disease

Answer 15

Do not tolerate blood loss, tachycardia or caval compression
Avoid fluid depletion

Strict BP control in dissection (B-blockers, methyldopa)
Serial echos (use valve areas and not flows, altered in pregnancy)

Question 16

Issues with the fontan circ

Answer 16

Palliates a singles ventricle circulation that cannot be repaired into two ventricle circ.

Decompensation - arrhythmia, failure, chest pain, hypoxia

Maintain pre-load and forward flow through pulmonary vessels

Question 17

Issues with IHD in pregnancy

Answer 17

3-4x risk of MI in pregnancy

Mortality 45%

Look out for any patient with chest pain
DD - aortic dissection, PE

Treat as per non-preg: Angio + PCI
Aspirin, clopoidogrel and b blockers safe in pregnancy

Question 18

Commonest cause of MI post parturition

Answer 18

Coronary artery dissection
80% of pts have no risk factors
Use of ergometrine - RISK OF CORONARY VASOSPASM

Question 19

Considerations in ventricular dysfunction

Answer 19

May be unmasked by pregnancy
Pricipitates a peripartum cardiomyopathy

Tx:
	In failure:
		Bed rest
		Dieuretics
		Anti coag
		Early delivery
		Inotropic support
		(This may be a bridge to transplant)

Question 20

Peripartum Cardiomyopathy definition:

Answer 20

Rare idiopathic heart failure that presents in the last month of pregnancy

OR

Within 5 months of delivery.

Diagnosis of exclusion
LVEF almost always <45%

Question 21

Risk factors for peripartum cardiomyopathy

Answer 21

Multip
Twins
Extremes of age

Question 22

Symptoms of peripartum cardiomyopathy

Answer 22

SOB
Peripheral oedema
Fatigue

May mimiic normal pregnancy or pre-eclampsia

Question 23

Treatment of peri-partum cardiomyopathy

Answer 23

Salt restriction
Dieurtetics
Beta blockers
Peripheral vasodilator

Risk of thrombotic complications

If in shock -
IABP
ECMO
?Bromocriptine