Heart Disease in Pregnancy Flashcards

Flashcards on Heart Disease in Pregnancy

Normal hemodynamic changes during pregnancy

Blood volume increases by 30%, Plasma volume increases by 50%, Red cell mass increases, Cardiac output increases by 40%.

Hemodilution anemia during pregnancy

Due to increased plasma volume greater than red cell mass.

Timing of maximum cardiac output increase during pregnancy

Starts at 5 weeks, reaches maximum at 24-28 weeks.

Changes in heart rate during pregnancy

Increase in heart rate by 10-15 beats/min.

Changes in peripheral vascular resistance during pregnancy

Decrease in PVR, pulmonary vascular resistance, and colloid oncotic pressure.

Supine hypotension during pregnancy

Due to pressure of gravid uterus on the main vessels.

Blood pressure changes during pregnancy

Systolic and diastolic BP falls throughout the first 2 trimesters reaching a nadir at 24-28 weeks before increasing to non-pregnant levels at term.

Effect of cardiovascular physiology on heart lesion in pregnancy

Peripheral dilatation and fall in systemic vascular resistance leads to an increase in plasma volume and 40% increase in cardiac output.

Cardiac output increase during the first stage of labor

Increases by 15% due to uterine contractions increasing venous return.

Cardiac output increase during the second stage of labor

Increases by 50% due to increase in intra-abdominal pressure (Valsalva's).

Effect of normal blood loss during delivery

Leads to decrease in blood volume and cardiac output.

Cardiac output changes after delivery

Increases again immediately: 60-80%.

Effects of heart lesion on pregnancy

Tendency of preterm delivery and prematurity; IUGR is common in cyanotic heart diseases.

Cardiac disease as a cause of maternal mortality

Remains the most common cause of indirect and overall maternal death.

Red flags for cardiovascular disease in pregnancy

Sudden onset of pain, breathlessness with chest pain, haemoptysis or syncope, orthopnoea.

Pre-pregnancy counseling for women with heart disease

Should be fully assessed by an MDT to optimize medication and consider surgical correction before pregnancy.

Issues to discuss during pre-pregnancy counseling of women with heart disease

Risk of maternal death, effects of pregnancy on cardiac disease, risk of fetal congenital heart disease, and other options like contraception.

Antenatal management of pregnant women with heart disease

Should be managed in a joint obstetric/cardiac clinic with experienced cardiologists/physicians and obstetricians.

Routine physical examination for pregnant women with heart disease

Include pulse rate, blood pressure, jugular venous pressure, heart sounds, ankle and sacral oedema, and basal crepitations.

Essential anticoagulation in pregnant patients with heart disease

In those with congenital heart disease who have pulmonary hypertension (PH) or artificial valve replacements, and in those in or at risk of atrial fibrillation; LMWH preferred.

New York Heart Association (NYHA) classification - Class 1

No limitation of physical activity. Ordinary physical activity does not precipitate fatigue, palpitations, dyspnoea or angina

New York Heart Association (NYHA) classification - Class 2

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnoea

New York Heart Association (NYHA) classification - Class 3

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnoea

New York Heart Association (NYHA) classification - Class 4

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased

Risk factors for the development of heart failure in pregnancy

Respiratory or urinary infections, anaemia, obesity, corticosteroids, multiple gestation, hypertension, arrhythmias, pain-related stress, fluid overload

High-risk cardiac conditions in pregnancy

Systemic ventricular dysfunction (ejection fraction <30%, New York Heart Association classes III–IV), Pulmonary hypertension, Cyanotic congenital heart disease

Fetal risks of maternal cardiac disease

Recurrence (congenital heart disease), Maternal cyanosis (fetal hypoxia), Iatrogenic prematurity, FGR

Management of labor in women with heart disease

Avoid induction of labor if possible, Use prophylactic antibiotics to reduce the risk of bacterial endocarditis, Ensure fluid balance

Additional management of labor in women with heart disease

Avoid the supine position, Discuss regional/epidural anaesthesia/analgesia with senior anaesthetist, Keep the second stage short

Ergometrine in postpartum hemorrhage for cardiac patients

May be associated with intense vasoconstriction, hypertension and heart failure, therefore active management of the third stage is usually with Syntocinon™ (synthetic oxytocin) alone

Risk of myocardial infarction (MI) during pregnancy

Estimated to be 1 in 10,000, with a peak incidence in the third trimester

Risk factors for MI during pregnancy

Multiparity, age >40 years, increased BMI, smoking, hypertension/pre-eclampsia and multiple pregnancy.

Maternal mortality from an acute MI

Approximately 20%

Diagnosis of MI in pregnant women

Often missed, and prompt diagnosis and therapy are necessary

Mitral and Aortic Stenosis - maternal risks

Obstructive lesions of the left heart are well-recognized risk factors for maternal morbidity and mortality, as they result in an inability to increase cardiac output to meet the demands of pregnancy

Marfan syndrome

a rare, autosomal dominant, connective tissue abnormality. May lead to mitral valve prolapse, aortic regurgitation and aortic rupture or dissection.

Aortic dissection presentation

classically presents with severe sudden-onset pain in the chest, back, neck or abdomen. The pain may be tearing in nature, and typically between the shoulder blades.

Pulmonary Hypertension

characterized by an increase in the pulmonary vascular resistance resulting in an increased workload placed on the right side of the heart.

Termination of pregnancy with Pulmonary Hypertension

should be discussed with women who conceive with PH or who are diagnosed with PH in pregnancy, as the mortality of the condition is high, at 30–50%.

Peri-partum cardiomyopathy

rare condition and is the development of heart failure without an obvious cause late in the third trimester and in the first few months after birth

PPCM diagnostic criteria

Heart failure develops in the last month of pregnancy or within 5 months of delivery, Heart pumping function is reduced, with an ejection fraction (EF) less than 45% (typically measured by an echocardiogram),No other cause for heart failure with reduced EF can be found.