Cardiac diseases

Question 1

Why does pregnancy impose great effort on the heart?

Answer 1

due to increased
- cardiac output
- stroke volume
- heart rate

Question 2

What are the types of heart disease?

Answer 2

Acquired
- Rheumatic heart disease: mitral stenosis (90%)
- coronary heart disease

Congenital
- atrial septal defect
- ventricular septal defect
- tetralogy of fallot

Question 3

What should be done is preconception counseling in case of suspected heart disease?

Answer 3

• assessment done by obstetrician & cardiologist
• assess ejection fraction & cardiac function
• optimization of medication
• check need for surgical correction

Question 4

What are the risks of heart disease in pregnancy?

Answer 4

on MOTHER
- increased mortality
- frequent admissions
- interventions

on FETUS
- congenital heart disease
- preterm labour
- FGR
- effects of drugs

Question 5

What are the high risk heart conditions that increase the rate of maternal mortality?

Answer 5

1- pulmonary hypertension
2- ischemic heart disease
3- Eisenmenger’s syndrome
4- Marfan syndrome with aortic root >40mm diameter
5- peripartum cardiomyopathy
6- prosthetic heart valves (metal)

Question 6

How does a patient present in case of heart pathology in pregnancy?

Answer 6

• breathlessness (progressive dyspnea)
• decreased exercise tolerance
• fatiguability
• palpitation
• peripheral edema
• hemoptysis
• chest pain
• syncope
• nocturnal cough

Question 7

What are the markers for cardiac events?

Answer 7

1- prior episode of heart failure, arrhythmia, stroke
2- NYHA > class 2 or cyanosis
3- left heart obstruction
4- reduced left ventricular function (EF < 40%)

Question 8

How should a mother with known heart disease be managed during pregnancy?

Answer 8

1- frequent ANC visits to check for symptoms of heart failure
2- routine physical: PR, BP, JVP, heart sounds, ankle & sacral edema, basal crepitations
3- reduce physical activity
4- LMWH in: pulmonary hypertension, prosthetic heart valves, & atrial fibrillation
5- serial maternal ECHO: at booking & at 28 weeks
6- in women with congenital heart disease -> fetal cardiac ultrasound

Question 9

What anticoagulants should be used in case of prosthetic heart valves?

Answer 9

• First trimester -> LMWH
• Second trimester -> Warfarin
• from 36 weeks -> LMWH
• Postpartum -> heparin & warfarin

Question 10

How should a patient with cardiac disease deliver their baby?

Answer 10

1- aim for vaginal delivery with spontaneous onset
2- administer oxygen & epidural analgesia
3- give prophylactic antibiotic for structural heart defects to guard against subacute bacterial endocarditis
4- elective instrumental delivery to shorten 2nd stage of labour
5- in 3rd stage of labour give oxytocin with low infusion rate
avoid ergometrine

Question 11

When is C section indicated in case of heart disease & what are the risks associated with it?

Answer 11

recommended for:
- dilated aortic root >4cm or aortic aneurysm
- acute severe congestive failure
- recent myocardial infarction
- need for emergency valve replacement immediately after delivery

risk of hemorrhage, infection, & thromboembolism

Question 12

What is the cause of postpartum intravascular overload?

Answer 12

sudden emptying of uterine venous sinuses after placental delivery

Question 13

What are the risk factors for heart failure in pregnancy?

Answer 13

OB
- multiple pregnancy
- hemorrhage
- tocolytics
- corticosteroids
- pain related stress

MEDICAL
- anemia
- hypertension
- respiratory infections
- obesity
- arrhythmias
- fluid overload

Question 14

What is the cause of ischemic heart disease in pregnancy?

Answer 14

Coronary artery dissection postpartum rather than atherosclerosis in women above 40 years
- peaks in 3rd trimester parous ladies

manage by percutaneous transluminal coronary angioplasty (PTCA)

Question 15

What is the cause of mitral stenosis and how is it treated?

Answer 15

• acquired rheumatic
• 40% worsens during pregnancy at 30 weeks

Treated by: bed rest, diuretics, oxygen, beta blockers
Definitive: Balloon mitral valvotomy (post partum)

Question 16

What is the cause of aortic stenosis and how is it treated?

Answer 16

• congenital

treated by: bed rest + medical treatment to reduce heart rate
Balloon or surgical aortic valvotomy can be done

Question 17

What are the effects of Marfan syndrome on pregnancy?

Answer 17

• mitral valve prolapse, aortic root regurgitation, aortic root dilatation, aortic dissection & rupture -> 50% mortality rate
• early pregnancy loss, preterm labour, cervical weakness, uterine inversion, & postpartum hemorrhage

ECHO should be done to determine size of aortic root (esp if > 4cm from the beginning)

Question 18

How is pulmonary hypertension managed during pregnancy?

Answer 18

1- endothelin blockers (bosentan)
2- phosphodiesterase inhibitors (sildenafil)
3- in women who wish to continue their pregnancy: targeted pulmonary vascular therapy ]

median survival: <3years from diagnosis
mortality rate: 30-50%

Question 19

What are the symptoms of pulmonary hypertension?

Answer 19

increased pulmonary vascular resistance
- fatigue
- breathlessness
- syncope