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Laura MRCOG Part 2 > 9) Maternal Medicine - Cardiology > Flashcards

9) Maternal Medicine - Cardiology Flashcards

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1
Q

Heart disease classed as “low risk” for pregnancy (2.5-5% chance of cardiac event)

A
  • Uncomplicated/mild pulmonary stenosis, PDA, mitral valve prolapse
  • Repaired ASD, VSD, PDA, AVPD
  • Atrial/ventricular ectopic beats
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2
Q

Heart disease associated with small increase in mortality, moderate increase in morbidity for pregnancy (5-10% chance of cardiac event)

A
  • Unrepaired ASD/VSD
  • Repaired ToF
  • Most arrhythmias
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3
Q

Heart disease associated with moderate mortality/severe morbidity (10-20% chance cardiac event)

A
  • Most valvular disease
  • Mild LV dysfunction, HCM
  • Repaired coarctation
  • Marfan’s without aortic dilatation
  • Bicuspid aortic valve diameter <45mm
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4
Q

Heart disease associated with significantly increased risk of mortality (20-40% chance cardiac event)

A
  • Mechanical valves
  • Unrepaired cyanotic heart disease
  • Fontan circulation
  • Marfan’s with aorta 40-45mm
  • Aorta 45-50mm with bicuspid aortic valve
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5
Q

Extremely high risk heart diseases (>40% chance of cardiac event) - pregnancy contraindicated

A
  • Pulmonary hypertension
  • Severe LV impairment (<30%)
  • NYHA 3/4
  • Previous PPCM with any residual impairment
  • Severe mitral stenosis
  • Severe aortic coarctation
  • Symptomatic aortic stenosis
  • Marfan with aorta >45mm
  • Bicuspid aortic valve >50mm
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6
Q

Mortality rate associated with pulmonary hypertension

A

10-25%

17% Idiopathic, 33% Associated with other conditions

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7
Q

Diagnosis of pulmonary hypertension

A
  • Doppler USS

- Mean pulmonary artery pressure >25mmHg at rest

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8
Q

Mortality rate associated with termination in pulmonary hypertension

A

7%

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9
Q

Reason for mortality in PH

A
  • Right heart failure
  • Escalating pulmonary hypertension with crisis
  • Increased shunt in Eisenmengers
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10
Q

Commonest congenital heart defect in women

A

ASD

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11
Q

PDA in pregnancy

A
  • Most cases corrected and so no problems

- Uncorrected do well but risk CCF

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12
Q

ASD in pregnancy

A
  • Well tolerated
  • Risk of paradoxical embolus (low risk)
  • May deteriorate and become hypotensive if increased L->R shunt following blood loss
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13
Q

VSD in pregnancy

A
  • Well tolerated unless Eisenmengers
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14
Q

Congenital aortic stenosis - most cases associated with what?

A
  • Bicuspid aortic valve (therefore risk of dilatation of ascending aorta)
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15
Q

What is classed as significant obstruction in aortic stenosis?

A

Valve <1cm2 or gradient >50mmHg

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16
Q

Risks of aortic stenosis

A

Angina, hypertension, heart failure, sudden death.

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17
Q

Treatment for aortic stenosis in pregnancy

A

B-blockers provided LVF normal (controls symptoms and hypertension)
Balloon valvotomy.

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18
Q

Management of coarctation of aorta in pregnancy

A
  • Usually repaired pre-pregnancy
  • MRI to exclude any aneurysms/dilataiotn
  • B-blockers and strict BP control
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19
Q

Main causes of cyanotic congenital heart disease

A
  • Pulmonary atresia

- Tetralogy of fallot

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20
Q

Problems with cyanotic heart disease in pregnancy

A
  • Worsening cyanosis due to increased R–>L shunting due to falling peripheral resistance
  • Thromboembolic risk due to polycythaemia
  • Chance of live birth <20%
  • Associated pulmonary hypertension
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21
Q

Features which improve pregnancy outcomes in congenital cyanotic heart disease

A

Resting O2 sats >85%
Hb <18
Haematocrit <55%

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22
Q

Features of Tetralogy of Fallot

A
  • Pulmonary stenosis
  • Ventricular septal defect
  • Over-riding aorta (aorta lies over VSD therefore non-oxygenated blood gets into aorta)
  • Right ventricular hypertrophy
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23
Q

Main concern in operated ToF

A

Tolerate pregnancy well.

Right ventricular dysfunction.

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24
Q

When is Fontan procedure done?

A

Tricuspid atresia/transposition with pulmonary stenosis.

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25
What happens in Fontan procedure?
Right ventricle is bypassed and left ventricle provides pump for both circulations.
26
Risk of congenital cardiac disease in fetus of woman affected by congenital cardiac disease
2-5% (double general population risk) ASD: 5-10% Aortic stenosis: 18-20%
27
Risks in unoperated ToF
- Paradoxical embolism through R-->L shunt | - Effects of cyanosis on fetus (growth restriction, miscarriage, prematurity)
28
Most common congenital heart diseases in pregnancy
PDA, ASD, VSD (account for 60%)
29
Signs of decompensation in congenital aortic stenosis
- Development of tachycardia | - Failure for gradient across valve to increase as pregnancy progresses
30
Risk of congenital cardiac disease in fetus of affected woman?
Generally: 2-5% ASD: 5-10% Aortic stenosis: 18-20%
31
Most common acquired heart disease
Rheumatic heart disease
32
Most common abnormality with rheumatic heart disease
90% Mitral stenosis
33
Murmur in mitral stenosis
Low pitched, mid-diastolic rumble
34
Precipitating factor in decline of function in mitral stenosis
Tachycardia which shortens diastolic filling and therefore reduces stroke volume further
35
Mitral stenosis in pregnancy
Use b-blockers | Treat pulmonary oedema
36
Inheritance of Marfans
Autosomal dominant
37
Proportion of people with Marfan's who have cardiac involvement
80%
38
Cardiac features of marfans
Mitral valve prolapse Mitral regurgitation Aortic root dilatation
39
Risk of aortic dissection in Marfans
3% overall | 10% if root >4cm
40
When is pregnancy contraindicated in Marfan's?
Aortic root >4.5cm (consider other RF if 4-4.5cm)
41
When should women with Marfan's have a CS?
>4.5cm
42
Percentage of cases of HCM which are familial
70%
43
Inheritance of hypertrophic ardiomyopathy
Autosomal dominant
44
Diagnostic criteria for peripartum cardiomyopathy
LVEF <45% Fractional shortening <30% LV end-diastolic pressure >2.7cm/m2
45
Mortality of PPCM
9-15%
46
Rate of spontaneous full recovery from PPCM
50%
47
Risk of worsening heart failure and death if PPCM not recovered and second pregnancy embarked on
50% | 25%
48
Recurrence risk of PPCM if resolves
25%
49
Target INR for metallic valve
2.5-3.5
50
Target anti-Xa levels if using high dose LMWH for metallic valves
0.8-1.2
51
When to discontinue warfarin
10-14d pre-delivery
52
Risk increase of MI in pregnancy
3-4 x
53
Death due to IHD
1/132,000 pregnancies
54
Mortality of MI in pregnancy
1/13
55
Number of pregnancies affected by congenital heart disease (mother)
0.8%
56
Most common cardiac complication in pregnancy
Arrhythmias
57
Percentage of women with palpitations found to have ectopic beats or non-sustained arrhythmias
50%
58
Recurrence risk if previous sustained tachyarrhythmia
43%
59
ECG changes in pregnancy
- Left axis deviation - Inverted/flattened T waves III, V1-V3 - Q wave in II, III and aVF - 50-60% ectopics
60
Which tachycarrhythmias are benign?
Sinus tachy | Atrial and ventricular premature beats
61
Most common non-benign arrhythmia
SVT
62
Incidence of SVT in pregnancy
24 in 100,000
63
Most common cause of SVT
AVNRT
64
Treatment for SVT
- Vagal - IV adenosine - Direct cardioversion if unstable - B blockers for prophylaxis
65
AF/flutter in pregnancy associations
Cardiac pathology or electrolyte abnormalities
66
Treatment of AF/flutter in pregnancy
- Direct cardioversion if unstable (need anticoagulation if not new onset) - IV flecainide or butilide - b blockers as rate control
67
Associations with VT
Structural or primary electrical disease
68
Treatment for VT
Unstable - electrical cardioversion Stable - sotalol or flecainide Prophylaxis - b-blockers or implantable ICD
69
ECG abnormality in WPW
Delta wave
70
ECG abnormality in HOCM
High voltages in precordial leads with Q waves and ST changes
71
ECG abnormality in long QT
QT >460ms
72
Drugs to avoid in long QT
Prochlorperazine Ondansetron Trimethoprim Erythromycin
73
Percentage of MI due to coronary atheroma
50%
74
Next most common cause of MI
Coronary artery dissection
75
Which coronary artery most common dissection?
LAD
76
How long to delay delivery for after an MI if possible?
2-3 weeks
77
Diagnosis of POTS
Symptoms and signs of orthostatic instability within 10 minutes of upright posture associated with persistent increased HR >30bpm
78
POTS in pregnancy
60% improvement | 20-30% worsen
79
Most common problems in POTS in pregnancy
Migraine Pre-syncopal Syncopal
80
POTS on pregnancy
No adverse outcomes. | 50-60% rate of hyperemesis.
81
Oral intake in POTS
Aim 2-3L fluid per day and 10-12g salt per day
82
Fludrocortisone in pregnancy
Safe
83
Midodrine in pregnancy
Insufficient data
84
Ivabradine in pregnancy
Contraindicated
85
Ocreotide in pregnancy
Can be used in refractory cases and probably safe
86
Clonidine in pregnancy
Safe
87
Pyridostigmine in pregnancy
Safe

Laura MRCOG Part 2 (56 decks)

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