[MDCU] Heart disease in pregnancy

What is the most common cause of heart disease in pregnancy?

Rheumatic heart disease

Changes in pregnancy

• Cardiac output

• Heart rate

• Vascular resistance

• Blood pressure

• Osmotic pressure

• Cardiac output ↑

• Heart rate ↑

• Vascular resistance ↓

• Blood pressure ↓

• Osmotic pressure ↓

Cardiac output reaches peak at GA ___

Immediately postpartum

Blood pressure reaches nadir at GA ___

GA 24-26 weeks

In pregnancy, heart and apex displace ___

• Heart = upward & left

• Apex = lateral

• Larger cardiac silhouette

Syncope is (normal / abnormal) in pregnancy

Normal

• Abnomal = syncope with exertion

Syncope with exertion is (normal / abnormal) in pregnancy

Abnormal

• Normal = syncope

Dizzy spells is (normal / abnormal) in pregnancy

Normal

Easy fatigability is (normal / abnormal) in pregnancy

Normal

Chest pain related to exertion is (normal / abnormal) in pregnancy

Abnormal

Paroxysmal nocturnal dyspnea is (normal / abnormal) in pregnancy

Abnormal

Normal = dyspnea

Dependent edema in pregnancy is normal if occurs at ___

3rd trimester

Dependent edema in pregnancy is abnormal if occurs at ___

1st & 2nd trimester

Rales in lower lung is (normal / abnormal) in pregnancy

Normal

Engorged neck vein is (normal / abnormal) in pregnancy

Normal

Cardiomegaly is (normal / abnormal) in pregnancy

Normal

Cyanosis and clubbing finger is (normal / abnormal) in pregnancy

Abnormal

Diastolic murmur is (normal / abnormal) in pregnancy

Abnormal

Systolic murmur grade ___ in pregnancy is normal

Systolic murmur grade <=2

Systolic murmur grade ___ in pregnancy is abnormal

Systolic murmur grade ≥3

S3 gallop is (normal / abnormal) in pregnancy

Normal

S3 gallops = heard during early diastolic filling, caused by vibrations of ventricular wall as flow suddenly decelerated

S4 gallop is (normal / abnormal) in pregnancy

Abnormal

Venous hums is (normal / abnormal) in pregnancy

Normal

Venous hum is a benign phenomenon caused by the normal flow of blood through the jugular veins.

Internal mammary flow murmur is (normal / abnormal) in pregnancy

Normal

Which 5 conditions are considered WHO class IV risk of cardiovascular diseases?

• Pulmonary artery hypertension

• Severe ventricular dysfunction (NYHA 3, 4, LVEF <30%)

• Severe left heart obstruction

• Previous peripartum cardiomyopathy with residual left heart dysfunction

• Marfan syndrome with aortic dilation >40 mm

What are 4 risk factors associated with CARPREG score?

• Prior cardiac events

• Baseline NYHA class III & IV

• Left heart obstruction

• LVEF <40%

Left heart obstruction in CARPREG score is defined as:

• Mitral valve area ___

• Aortic valve area ___

• Peak LV outflow tract gradient ___

• Mitral valve area <2 cm2

• Aortic valve area <1.5 cm2

• Peak LV outflow tract gradient >30 mmHg

What are risks of maternal cardiac event during pregnancy in patients with CARPREG score of 0, 1 and 2?

0 risk = 5%

1 risk = 27%

2 risks = 75%

Risk for warfarin embryopathy significantly increases if dose ___

>5 mg/day

What are common presentations of warfarin embryopathy?

• Nasal hypoplasia

• Mental retardation

• Optic atrophy

• Digital abnormalities

In pregnant women with baseline warfarin >5 mg/day, what is the appropriate anticoagulant in during 1st, 2nd, 3rd trimester?

1st trimester = LMWH (anti-Xa) / UFH (anti-Xa & aPTT)

2nd & 3rd trimester = switch back to warfarin

Switch again to LMWH/UFH at GA 36 weeks

In pregnant women receiving warfarin, INR should be kept at ___

2.5 - 3.0

Which coagulogram parameter should be monitored in pregnant woman receiving LMWH and UFH?

• LMWH = anti-Xa

• UFH = anti-Xa & aPTT

Which anticoagulant should be reinitiated post-partum?

IV UFH + warfarin

Once INR 2.5-3.0, stop UFH

What method of delivery is preferred in pregnant women with heart disease?

Vaginal delivery + forceps extraction

Which anesthesia is preferred in pregnant women with heart disease during delivery?

Epidural anesthesia

What are 3 signs of impending ventricular failure?

• HR >100

• RR >24

• Dyspnea

Cardiac surgery, if lifesaving, should be done under:

• Pump flow rate ___

• Normothermic perfusion pressure ___

• Hematocrit

• Pump flow rate >2.5 L/min/m2

• Normothermic perfusion pressure >70 mmHg

• Hematocrit >28%

Patients underwent cardiac transplantation should postpone pregnancy for at least ___

At least 1 year

• Risk of acute rejection ↓

• Intensity of immunosuppressants ↓

What is the timing for tubal resection in postpartum woman with heart disease?

Delayed up to days 2-3 to ensure stabilized hemodynamics

Symptoms of mitral stenosis will start to develop after valve area ___

<2.5 cm2 (normal 4 cm2)

Which valvular defect is associated with Lutembacher’s syndrome?

Congenital ASD + mitral stenosis

Atrial fibrillation results from mitral stenosis by ___

Elevated left atrial pressure

Therapeutic anticoagulants should be used in mitral stenosis in which cases?

• Persistent atrial fibrillation

• LA thrombus

• History of emboli

What is the surgery used to treat mitral stenosis?

Balloon vulvuloplasty

• Severe mitral stenosis

• Severe pulmonary hypertension

• Recurrent systemic embolization

What is the indications for balloon vulvuloplasty in mitral stenosis?

• Recurrent systemic emboli

• Severe mitral stenosis (A <1.5-2 cm2)

• Severe pulmonary hypertension

What is the recommended route of delivery in patients with mitral stenosis?

Vaginal delivery + epidural anesthesia

Severe obstruction occurs when aortic valve area ___

<1 cm2 (normal 3-4 cm2)

Aortic stenosis causes FGR and stillbirth by ___

Aortic stenosis —> cardiac output ↓ → uterine blood flow ↓

What is the recommended route of delivery in patients with aortic stenosis?

Vaginal delivery + epidural anesthesia + vasodilator

Which valvular disease is an absolute contraindication of pregnancy?

Eisenmenger syndrome

What is the criteria for the diagnosis of peripartum cardiomyopathy?

1. Heart failure occur last month of pregnancy - 5 months after delivery

2. Absence of prior heart disease

3. Absence of identifiable cause

4. LV systolic dysfunction

Which infection is a risk factor of peripartum cardiomyopathy?

Parvovirus B19, HHV 6, CMV, EBV

What is the antibiotic prophylaxis for infective endocarditis before vaginal & cesarean delivery?

Not recommended prophylaxis

Antibiotic prophylaxis regimen for infective endocarditis

• Ampicillin 2 g IV /

• Cefazolin 1 g IV /

• Ceftriaxone 1 g IV

Marfan syndrome is a cause of which valvular disease?

Aortic insufficiency

Aortic root repair should be done in Marfan syndrome if size of ascending aorta ___

>4 cm

What is the prophylaxis drug for Marfan syndrome?

β-blocker