Cardiac conditions

Question 1

Risk factors

Answer 1

• FHx
• hypertension
• high cholesterol
• obesity
• diabetes
• smoking
• advanced maternal age
• multiparity

Question 2

Symptoms

Answer 2

• breathlessness at rest, severe breathlessness or syncope on exertion
• difficulty breathing when lying down (orthopnea) or during night
• palpitations, chest pain (especially during exertion)

Question 3

signs

Answer 3

• syncope
• haemoptysis –> coughing up blood
• irregular pulse, persistent tachycardia
• isolated systolic hypertension
• heart murmur
• neck vein distention
• change in heart sounds
• clubbing

Question 4

5 S+S that are not part of normal pregnancy

Answer 4

• SOB when lying flat
• chest pain
• tachycardia
• high resps
• fainting on exertion

Question 5

Maternal complications

Answer 5

• decompensation in pregnancy
• pre eclampsia
• permanent decline in cardiac function
• death

Question 6

Fetal complications

Answer 6

• prematurity
• IUGR
• IUD/neonatal death
• increased risk of CHD

Question 7

Non-invasive monitoring

Answer 7

• BP monitoring via cuff
• heart rate
• temperature
• oxygen sats
• resps
• capillary refill
• ECG
• AN check and CTG >26/40, or PN check

Question 8

Invasive monitoring

Answer 8

• arterial line
• central venous pressure

Question 9

Blood tests

Answer 9

FBC
U+Es
Clotting
LFT
Arterial blood gases
Troponin level –> protein released from heart during heart attack
BNP –> hormone builds up from pressure in heart during heart failure

Question 10

Investigations

Answer 10

• auscultation of heart sounds
• echo
• chest x-ray
• 24 hr holter ECG
• cardiac CT
• MRI
• coronary angiogram
• exercise testing

Question 11

ASD + VSD
- definition
- S+S

Answer 11

hole in the atrial septum or ventricular septum
most common form of CHD

S+S: feeding difficulties, poor weight gain newborn, irritability, excessive sweating, cyanosis.

Generally tolerates pregnancy well unless large and untreated

Question 12

Patent ductus arteriosus (PDA)

Answer 12

persistence of a normal fetal structure between the left pulmonary artery and the descending aorta bypass pulmonary circulation.
Presence beyond 10 days of age abnormal and needs repair.

Question 13

Tetralogy of Fallot

Answer 13

4 structural anomalies: VSD, pulmonary valve stenosis, right ventricular hypertrophy, overriding aorta.

Can be diagnosed antenatally during USS and/or fetal echo.
Sometimes associated with chromosomal abnormalities.

Question 14

ToF S+S and treatment

Answer 14

Tet spell = arterial oxygen saturation drops markedly after feeding, crying or being agitated.
Heart murmur, cyanosis/low sats, unresponsiveness, poor weight gain.

Treatment: flex the knees forward and upward to increase the blood flow.

Question 15

Coarctation of the Aorta (CoA)

Answer 15

a narrowed portion of the aorta, that forces the heart to pump harder to get blood through the aorta and onto the rest of the body.

Question 16

Differential diagnosis for CoA

Answer 16

PIH

Question 17

Maternal and fetal complications/risks of CoA

Answer 17

Maternal: hypertension –> increasing risk of PET, miscarriage, heart failure, rupture of aorta, stroke.

Newborn: if severe, will develop severe heart failure in first few days. Additional signs; pale/grey, poor feeding and weight gain, cold feet or legs, lower BP in lower limbs.

Question 18

Transposition of the Great Arteries (TGA)

Answer 18

aorta and pulmonary artery are swapped around. Deoxygenated blood not pumped to lungs for gas exchange and oxygenated blood not being pumped to the body. A baby will benefit from ductus arteriosus being open to mix blood (but this closes around 1 week)

Question 19

S+S of TGA

Answer 19

difficult to see on USS
cyanosis in first few hours of life
babies more likely to be premature or SGA

Question 20

3 severe congenital heart defects which carry significant risk

Answer 20

• unoperated cyanotic (ToF) or complex CHD (univentricular conditions)
• cardiomyopathies
• pulmonary hypertension (can also be acquired)

Question 21

Valve stenosis

Answer 21

valve opening is narrower than normal. poorly tolerated in pregnancy (especially mitral/aortic)

Question 22

Valve regurgitation

Answer 22

valve is unable to close properly, allowing blood to flow back into the previous chamber. mild to moderate regurgitation is tolerated in pregnancy if good heart function.

Question 23

apart from age or underlying conditions, what else can valvular heart disease be a result of?

Answer 23

rheumatic fever
develops after throat infection by group A strep –> antibodies cause inflammation and swelling of the heart valves. when they heal, thick tissue is deposited resulting in stenosis.

Question 24

Endocarditis

Answer 24

bacterial infection that causes endocardium of heart to become inflamed, causing valve damage eg. stenosis
Most likely when there is a prosthetic heart valve.

Question 25

Prosthetic heart valves

Answer 25

bioprosthesis --> short longevity, can deteriorate in pregnancy, require anticoagulation mechanical --> durable, high risk of thrombosis, require life long anticoagulation.

Question 26

Aortic dissection

Answer 26

when the lining of the aorta tears and the blood flow escapes between the layers of the aortic vessel wall. Rupture of the aorta can follow, resulting in death from excessive blood loss.

Question 27

Marfan's syndrome

Answer 27

genetic disorder of connective tissue. issues include: aortic dilatation and aneurysm, aortic dissection.

Question 28

Loeys-Dietz syndrome

Answer 28

genetic disorder of the connective tissue. high risk of aortic aneurysm and dissection and also ASD, PDA

Question 29

Ehlers-Danlos syndrome

Answer 29

inherited condition affecting connective tissue. With vascular EDS, blood vessels are fragile and there is risk of aortic aneurysm and dissection.

Question 30

Peripartum cardiomyopathy (PPCM)

Answer 30

pregnancy-specific form of dilated cardiomyopathy, presenting with heart failure between 36/40 and 6 months postnatally, in the absence of a prior cause.

Question 31

Arrythmias what are they? red flag conditions? possible cause

Answer 31

any variation from the normal regular rhythm of the heartbeat (tachycardia, bradycardia, SVT) red flag conditions: Brigade syndrome, Long QT syndrome, Wolf-Parkinson-White syndrome. caused by abnormal concentrations of potassium in the blood.

Question 32

Ischaemic heart disease

Answer 32

due to inadequate myocardial blood flow related to coronary arterial narrowing. Temporary--> angina pectoris Permanent--> myocardial infarction

Question 33

S+S of IHD esp. what it can be confused with in pregnancy

Answer 33

- chest pain radiating to left arm or jaw - feeling of constriction - sweating - nausea - feeling of impending death or collapse **confused with heartburn and innocent breathlessness, and/or masked during labour**

Question 34

Women with which conditions would be advised against pregnancy?

Answer 34

pulmonary hypertension aortic coarctation complicated by dissection or dilatation

Question 35

Antenatal care

Answer 35

- midwife to refer to cardiac clinic - increased risk of PET - regular BP and urinalysis - optimise Hb level to prevent anaemia - medication r/v- eg. warfarin teratogenic in 1st trimester - high risk of IUGR--> regular USS - fetal echo at 16/40 if Fox or maternal CHD

Question 36

Intrapartum

Answer 36

- SVD preferable (CS associated with blood loss, infection and puerperal fluid shifts) - may be beneficial to plan IOL for staffing - CS indicated if aortic dilatation > 40mm, or aneurysm present - preterm --> corticosteroids, care needed as associated with fluid retention --> decompensation - Lateral/upright position --> reduce aortocaval compression (or a wedge if supine is required) - epidural --> to reduce physiological increase in cardiac output in labour, minimise exertion. - fluid balance --> to ensure no hypovolemia/hypervolemia. - Oxytocin safe to use although may need to be concentrated to avoid fluid overload. - CEFM --> poor uteroplacental perfusion, pre term - allow 2 hrs passive 2nd stage - avoid Valsalva manoeuvre as it can increase BP

Question 37

Immediate PN

Answer 37

- oxytocin 3rd stage (avoid ergo, misoprostol, haemobate/carboprost) - regular obs --> after placenta separation, there is an increased intravascular volume. Women could be compromised by fluid shifts. o2 sats can help identify pulmonary oedema. - analgesia --> ensure no tachycardia from pain - LL - CVP or arterial line might need to continue - v high VTE risk - anticoagulants - some drugs contraindicated in BF

Question 38

Dx to community

Answer 38

- NIPE prior to dx - plan for follow up care - GP appt at 2 weeks and 6 weeks, plus cardiologist r/v - contraceptive advice

Question 39

medications

Answer 39

aspirin labetalol / bisoprolol nifedipine digoxine (PN only) diuretics (furosemide) anticoagulants (warfarin, LMWH)