Cardiac

Question 1

Mx for pt with
- Mitral stenosis
- Hx of RHD
- Hx of rheumatic fever

Answer 1

AN
- M risk - AF/APO/HF/VTE
- F risk - IUGR/PTB/SB
- TTE - EF/mitral valve area
- Cease - VKA/ACEI/ARB/Statin
- Optimize anemia
- Tertiary care
- MDI - MFM/Cardiology/Haem
- Tertiary morph, G&S
- VTE prophylaxis as indicated
- IOL by 40/40 (reduce SB/CS rate)
- VD if NYHA Class I-II
- CS if NYHA Class III-IV

IP
1. telemetry/CEFM/strict FB
2. monitor for AF/APO
3. bridging VTE prophylaxis e.g. UH
4. epi, short 2nd, assisted del
5. prophylactic IV Abx

PP
1. avoid ergot
2. VTE prophylaxis
3. reliable contraception
4. card F/U + TTE

Question 2

Mx of APO/AF intrapartum

Scenario 1 - hx of RHD, pushing in 2nd stage with irregular HR/laboured breathing/altered GCS + NRCTG, sat 80%

Answer 2

DDx
- APO

• risk M - T2RF/HF
• risk F - hypoxia/asphyxia/SB
• emergency
• call for help
• simult resus/stabilize/delivery
• MDI - Obs/MW/Card/ano/Paed
• ABC - CPAP + IV frusemide
• IVC - bloods include ABG
• Ax & expedite del - assisted
• Avoid ergometrine
• PP - HDU/Telemetry/Diuretic/CPAP
  …

Question 3

Preg mx w Hx of Marfan

Answer 3

• M risk - HF/arrhyth/VTE/APO
• M risk - A rupture/cervic insuf/inversio
• F risk - marfan’s/cardiac congen/PTB
• TTE + baseline bloods
• BP/rate ctrl/optimize anemia
• MDI - Obs/Card/Gene
• Tertiary Morph/Fetal echo
• Serial G/S, Serial TTE
• Monitor sx of HF/APO/Arrhythmia
• root >45mm = elCS

IP
1. telemetry/CEFM
2. strict FB
3. epi
4. assisted del

PP
1. active 3rd, no ergot
2. HDU/telemetry monitoring
3. card F/U + TTE
4. BF/LMWH/contraception

Question 4

Mx of ARD (HF)

Scenario 1 - 27yo G2P1, LR AN course, p/w acute SOB & chest pain @37/40

Scenario 2 - 27yo G1P0, p/w acute SOB 27/40

Answer 4

DDx
- resp infection
- exac of asthma
- heart failure - DCM/MS/Infarct
- pulmonary embolus

• M risk - decompensate-IOL/emCS
• F risk - NRCTG/PTB/SB/NICU
• Bloods + imaging (CXR/CTAP/VQ/TTE)
• MDI - MFM/Obs Med/Paeds
• Steroid loading +/- MgSo4
• VTE prophylaxis
• RTS/CTG - formal Obs USS
• await Ix for rx plan

Heart failure
- strict FB
- frusemide + CPAP
- urgent TTE
+/- expedite delivery if worsen

IP/PP mx
- same as above
- recurrence risk depends on 6/52 TTE
- LV dysfunction - >50% recur, 30% mort
- LV normal -> 25% recur