Pregnancy

Question 1

Pregnancy induced HTN/Gestational HTN

Answer 1

No HTN prior to 20 weeks, HTN during pregnancy and up to 6 weeks post delivery

Question 2

Pre-eclampsia

Answer 2

HTN in 2nd half of pregnancy with >0.3gm protein (24 hour urine)
Proteinuria >2.0g 24 hrs
low plts
epigastric pain

Indication for delivery - HELLP, >38weeks, bad fetal testing, olgiohydraminos, fetal growth restriction

Question 3

Aortic coarcation

Answer 3

Radial-femoral delay

Question 4

HELLP

Answer 4

pre-eclampsia, elevated liver enzymes, hemolytic anemia and thrombocytopenia (platelets)

Question 5

Symptomatic MS in pregnancy

Answer 5

FIRST - medical therapy - BB/Anticoag (inc’d HR in 3rd trimester increses MS gradient has diastolic filling time decreases)
then interventional options

Perc Balloon Mitral Valvuloplasy - increased need for CO via inc in HR and SV in 3rd trim - if HR increased, MS gradient worsens

Question 6

Treatment of Pre-eclampsia

Answer 6

Urgent delivery - gestation HTN/proteinuria with associated pulmonary edema, coagulopathy, fetal distress

Question 7

Pregnant chronic HTN patients

Answer 7

Goal <140/90\

Anti-HTN agents if >160/110 (methyldopa/BB ie labetolol)

Question 8

Coronary artery dissection

Answer 8

CP/dypnea
ST elevations
JVP
tachycardia, HTN

Question 9

Post partum CM

Answer 9

Mech support
Transplant eval
ACEi/BB once stable BP/euvolemic
A/C

Question 10

MS in pregnancy

Answer 10

1st: Tx with BB increase diastolic filling time, maintain SR
2nd: Balloon valvuloplasty of MV
If afib - rate control with metoprolol or quinidine, digoxin, non-dihydropyridine CCB - need to consider A/C
3rd - surgery - bypass is 20-30% fetal risk so last resort…

Question 11

Pregnancy with Structural Heart Disease

Answer 11

CO dec
SV dec
LV mass dec
dec'd SVR
inc'd plasma vol - inc'd preload - inc'd CO (not well tolerated in patients with Str Heart dz
E/E' ratio increases - elevated PCWP

Question 12

Regurgitant lesions in preg

Answer 12

well tolerated

Question 13

Gestational HTN

Answer 13

2x r/o CAD - aggressive risk factor screening

Question 14

Pregnancy and Marfans

Answer 14

ok if Ao<4.0cm

replace pre-preg if >4.0cm

Question 15

Anticoagulation in pregnancy mechanical valve

-increased mortality or serious complications in pregnancy with mech valves

Answer 15

Warfarin not harmful to fetus at <=5mg daily
change to UFH just prior to delivery

Warfarin dose >5mg daily
1st trimester UFH (two fold control) or LMWH (anti Xa 0.8-1.2) - NOT WEIGHT BASED with inc’d vol of distribution during pregnancy
Warfarin 2nd and 3rd trimesters and UFH just prior to delivery

Question 16

Peripartum CM

Answer 16

Recovered EF
20% risk of recurrence of PPCM

Persistent LV dysfxn
40% recurrence PPCM
20% maternal mortality

Question 17

SVT in preg

Answer 17

metoprolol and propranolol ok (avoid first trimester)
sotolol and flecanide also ok
digoxin also ok
ablation during pregnancy only if refractory to Rx tx