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This is a draft cheat sheet. It is a work in progress and is not finished yet.


► Higher rates of obesity, hypert­ension, and diabetes
    o Half of adults aged 20 and older have at least one risk factor for cardio­vas­cular disease
► Another related reason is delayed childb­earing
► Cardiac output increases by 30-50, average of 40%
    o 20% of this total takes place by 8 weeks gestation and is maximal by mid-pr­egnancy (25-32 weeks)
    o Increase heart rate (approx. 10bpm)
        -12-16 weeks AOG
        - 32-36 weeks AOG
► Resting pulse and stroke volume are even higher later in pregnancy
► Increase venous pressure within lower extrem­ities comparing upper extrem­ities
► Multifetal pregna­ncies
► After 28 weeks' gestation
► Heart failure develops peripartum {nl}} nbsp;   - Preecl­ampsia, hemorrhage and anemia, and sepsis

►Hemod­ilution --> increased renin production
    -increased end-sy­stolic and end-di­astolic dimensions
► For given filling pressures, there is approp­riate cardiac output so that cardiac function during pregnancy is eudynamic
    - Spherical remode­lling ―> depressed longit­udinal deform­ation

Diagnostic Studies

▸ Electr­oca­rdi­ogram (ECG)
▸ Radiog­raphy
▸ Echoca­rdi­ography
▸ Cardio­vas­cular MR Imaging
▸ Cardiac cathet­eri­zation

Classi­fic­ation of Functional Heart Disease

▸ Class I. Uncomp­romised
▸ Class II. Slight limitation of physical activity
▸ Class III. Marked limitation of physical activity
▸ Class IV. Severely compro­mised

Risk Classi­fic­ation of CVD and Pregnancy

Risk Classi­fic­ation of CVD and Pregnancy (cont.)


▸Women in NYHA class I and most in class II- No morbidity
    - Avoid contact with persons who have respir­atory infections
    -Cigarette smoking and illicit drug use are prohibited
▸ Women in NYHA class III and IV
    Prolonged hospit­ali­zation and bedrest


▸ Vaginal delivery under epidural anesthesia
▸ Indication for Cesarean delivery
    - dilated aortic root >4 cm or aortic aneurysm;
    - acute severe congestive heart failure;
    - recent myocardial infarc­tion;
    - severe sympto­matic aortic stenosis;
    - warfarin admini­str­ation within 2 weeks of delivery;
   - need for emergency valve replac­ement immedi­ately after delivery


▸ IV analgesia - Continuous epidural analgesia
▸ Women with pulmonary arterial hypert­ension or aortic stenosis - narcotic regional or general anesthesia
▸ Signif­icant heart disease - Subara­chnoid block not generally recomm­ended
▸ Cesarean delivery - epidural analgesia


▸ Cardio­vas­cular decomp­ens­ation during labor may manifest as pulmonary edema with hypoxia or as hypote­nsion, or both.
 ­  -K-sparing diuretics B-blocking agents


▸ Decomp­ression —> Intrav­ascular compar­tment —> peripheral vascular resistance —> increased myocardial perfor­mance
▸ For puerperal tubal steril­ization after vaginal delivery, the procedure can be delayed up to several days to ensure that the mother has normalized hemody­nam­ically


Valve replac­ement before pregnancy
Porcine tissue valves


▸ Warfarin - dose given at <5mg/d
▸ Heparin
    - high maternal mortality
    - Overdose: Protamine Sulfate



1. Adjust­ed-dose LMWH (SC below umbilicus) is given twice daily, given until 13 weeks, and then warfarin is substi­tuted until near delivery and is replaced by Heparin again.
2. In women judged to carry a high risk of thromb­osis, warfarin is suggested throughout pregnancy, then Heparin is substi­tuted close to delivery. In addition, aspirin, 75 to 100 mg, is given daily. Heparin is discon­tinued 24 hrs before delivery. If delivery happens while the antico­agulant is still effective, and extensive bleeding is encoun­tered, then protamine sulfate is given intrav­eno­usly.
3. Antico­agulant therapy with warfarin or heparin may be restarted 6 hours following vaginal delivery. If CS delivery, full antico­agu­lation is withheld, resuming heparin 6 to 12 hours or after 24 hours


▸ Valve replac­ement - lifesaving
▸ Elective surgery
    - Pump flow rate should remain >2.5 L/min/m2
    - Normot­hermic perfusion pressure should exceed 70 mm Hg
    - Hematocrit should be kept >28 volumes percent


▸ Major compli­cations
    - Rejections during the early puerperium
    - Renal failure
    - Sponta­neous abortions


Atrial Septal Defects
▸ Atrial septal defects (ASDS) - asympt­omatic until the third or fourth decade
▸ Secund­um-type (70%)
▸ Pregnant woman with ADS - managed with compre­ssion stockings and prophy­lactic heparin

Ventri­cular Septal Defects
▸ Parame­mbr­anous
▸ Pregnancy is well tolerated with small-to- moderate sized shunts
▸ Eisenm­enger syndrome - pregnancy not advisable
▸ 10-16% - can be inherited

Atriov­ent­ricular Septal Defects
▸ 3% of all congenital cardiac malfor­mations Compli­cations include
▸ Compli­cations include
    - 23% persistent deteri­oration of NYHA class
    - 9% signif­icant arrhyt­hmias
    - 2% heart failure
▸ Seen in 15% of the offspring

Persistent (Patent) Ductus Arteriosus
▸ The ductus connects the proximal left pulmonary artery to the descending aorta just distal to the left subclavian artery
▸ Prophy­laxis for bacterial endoca­rditis is indicated at deliver
▸ For unrepaired defects the incidence of inheri­tance is 4%

Cyanotic Heart Disease
▸ Producing right-­to-left shunting of blood past the pulmonary capillary bed and developing cyanosis
▸ Most common is Tetralogy of Fallot - maternal mortality rate approaches 10%
▸ Ebstein anomaly

Pregnancy after Surgical Repair
▸ Transp­osition of the Great Vessels
    - Prior Mustard and Senning procedure
▸ Single Functional Ventricle
    - Fontan repair - high risk for compli­cat­ions.
▸ Eisenm­enger Syndrome
    - Considered to be an absolute contra­ind­ication to pregnancy


Mitral Stenosis secondary to Rheumatic Endoca­rditis
▸ Normal mitral valve - 4.0 cm2; stenosis <2.5 cm2
▸ Conseq­uences:
    - passive pulmonary HTN
    - 25% of women with mitral stenosis have heart failure for the first time during pregnancy
    - pulmonary edema
▸ Management
    - Limited physical activity
    - B-blocker drug therapy
    - If new-onset atrial fibril­lation develops
        ■ Intrav­enous verapamil, 5 to 10 mg
        ■ Electr­oca­rdi­ove­rsion is performed.
    - If Chronic fibril­lation
        ■ Digoxin, a B-blocker, or a calciu­m-c­hannel blocker can slow ventri­cular response
▸ Surgical interv­ention is considered for women with sympto­matic severe mitral stenosis: Balloon valvul­oplasty

Mitral Insuff­iciency
▸ Acute mitral insuff­iciency
▸ Chronic mitral regurg­itation

Mitral valve prolapse
▸ Myxomatous degene­ration
▸ B-blockers

Aortic Stenosis
▸ Congenital lesion: bicuspid valve
▸ During pregnancy, several common events acutely lower preload further
▸ Compli­cation rates were higher if the aortic valve area measured
▸ Asympt­omatic - observ­ation
▸ Sympto­matic:
    - Strict limitation of activity and treatment of infections
    - Critical aortic stenosis - intensive monitoring during labor is essential
▸ During labor and delivery, narcotic epidural analgesia seems ideal and avoids potent­ially hazardous hypote­nsion

Aortic Insuff­iciency
▸ Aortic valve regurg­itation or insuff­iciency allows diastolic flow of blood from the aorta back into the left ventricle.
▸ If symptoms of heart failure develop, diuretics are given and bed rest is encouraged

Pulmonic Stenosis
▸ Usually congenital
▸ May be associated with Fallot tetralogy or Noonan syndrome
▸ Surgical correction done before pregnancy; if symptoms progress - balloon valvul­oplasty



▸ Symptoms may be vague
▸ Chest radiog­raphy often shows enlarged pulmonary hilar arteries and attenuated peripheral markings
▸ Final common pathway of pulmonary hypert­ension - right heart failure and death
▸ The maternal mortality rate increased - idiopathic pulmonary hypert­ension

▸ Activity limitation
▸ Diuretics, supple­mental oxygen, and pulmonary vasodi­lator drugs are standard therapy
▸ Prosta­cyclin analogues
▸ Inhaled nitric oxide
▸ Phosph­odi­est­erase-5 inhibitors
▸ Bosentan - contra­ind­icated in pregnancy


▸ Risk Factors:
    - Congenital heart lesions Intrac­ardiac devices
    - Intrav­enous drug users
    - Degene­rative valve disease
    - Intrac­ardiac devices
▸ Diagnosis and Manage­ment:
    - Fever - 80%
    - Murmur
    - Consti­tut­ional symptoms
▸ Duke's criteria:
    - Positive blood cultures for typical organisms and evidence of endoca­rdial involv­ement
▸ Pregnancy
▸ The American Heart Associ­ation recommends prophy­laxis for dental procedures in those with:
    - A prosthetic valve used in a valve repair
    - Prior endoca­rditis
    - Unrepaired cyanotic hear defect or repaired lesion with residual defect at prosthetic sites
    - Valvul­opathy after heart transp­lan­tation



▸ Risk factors include
    - Preecl­ampsia
    - Hemorrhage
    - Infection
    - Dyspnea
    - Orthopnea, palpit­ations,
    - substernal chest pain
▸ Clinical findings include:
    - Persistent basilar rales, hemoptysis
    - Cardio­megaly and pulmonary edema
    - Acute flash edema
    - Onset: at the end of the second­/be­ginning of the third trimester and peripartum
▸ Manage­ment:
    -Diuretic admini­str­ation
    - Hypert­ension - hydral­azine
    - Chronic heart failure - Heparin


▸ Primary Cardio­myo­pathy
▸ Secondary Cardio­myo­pathy

Hypert­rophic Cardio­myo­pathy
▸ Hypert­rophied and nondilated left ventricle (echoc­ard­iog­raphy)
▸ Most women are asympt­omatic
▸ Sudden death - most frequent cause of death
▸ Manage­ment:
    - Strenuous exercise is prohibited during pregnancy.
    - Drugs that evoke diuresis or diminish vascular resistance are generally not used

Dilated Cardio­myo­pathy
▸ Charac­terized by left and/or right ventri­cular enlarg­ement and reduced systolic function

Peripartum Cardio­myo­pathy
▸ Diagnostic criteria:
    1. Develo­pment of cardiac failure in the last month of pregnancy or within 5 months after delivery
    2. Absence of a cause for the cardiac failure
    3. Absence of recogn­izable heart disease prior to the last month of pregnancy
    4. Left ventri­cular systolic dysfun­ction demons­trated by classic echoca­rdi­ogr­aphic criteria
▸ Preecl­ampsia with cardio­myo­pathy
    - Began postpartum
    - 50% recover within 6 months of delivery
▸ Preecl­ampsia with hypert­ensive heart failure
    - Symptoms start antepartum
    - Mortality rate approaches 85%

Other Cardio­myo­pathy Types
▸ Arrhyt­hmo­genic right ventri­cular dysplasia
    - Progre­ssive replac­ement of right ventri­cular myocardium with adipose and fibrous tissue.
▸ Restri­ctive cardio­myo­pathy is probably the least common type
    -Inherited cardio­myo­pathy
    - Pregnancy is not advised
▸ Takotsubo cardio­myo­pathy
    - Rare form of acute reversible left ventri­cular apical wall ballooning


▸ Compatible with a successful pregnancy
▸ Some women with complete heart block have syncope during labor and delivery, and occasi­onally temporary cardiac pacing is necessary
▸ Women with permanent artificial pacemakers usually tolerate pregnancy well

Suprav­ent­ricular Tachyc­ardias
▸ Paroxysmal suprav­ent­ricular tachyc­ardia
 ­  - Twofold greater risk of septal defects
 ­  - Embolic stroke
▸ For acute treatment, raising vagal tone and blocking the atriov­ent­ricular node is done by:
 ­  -Vagal maneuvers, which include Valsalva maneuver
 ­  - Carotid sinus massage, bearing down
 ­  - Immersion of the face in ice water
 ­  - Intrav­enous adenosine is a short-­acting endogenous nucleotide that also blocks atriov­ent­ricular nodal conduc­tion.
▸ Synchr­onize cardio­version - recomm­ended
▸ Long term antico­agu­lation
 ­  - Intrav­enous metoprolol or propra­nolol
 ­  - Intrav­enous verapamil
 ­  - Intrav­enous procai­namide
 ­  - Intrav­enous amiodarone
▸ Pregnancy may predispose otherwise asympt­omatic women with Wolff-­Par­kin­son­-White (WPW) syndrome to exhibit arrhyt­hmias

Ventri­cular Tachyc­ardia
▸ Uncommon in healthy young women without underlying heart disease pregnancy
▸ Emergency cardio­version

Prolonged QT-Int­erval
▸ Torsades de pointes
▸ B-blocking agents­-pr­opr­anolol
▸ Many medica­tions may predispose to QT prolon­gation


Aortic Dissection
▸ Marfan syndrome and coarct­ation
▸ Bicuspid aortic valve, Turner or Noonan syndrome and Ehlers- Danlos syndrome
▸ Initial medical treatment - lower blood pressure
▸ Proximal dissec­tions - resected and the aortic valve replaced if necessary
▸ Distal dissec­tions - may be treated medically

Marfan Syndrome
▸ Autosomal dominant connective tissue disorder
▸ 2 to 3 cases per 10,000 indivi­duals
▸ Charac­terized by genera­lized tissue weakness that can result in dangerous cardio­vas­cular compli­cations
▸ Prophy­lactic aortic repair Prophy­lactic ẞ-blocking agents
▸ Vaginal delivery with regional analgesia - <4cm
▸ Elective CS - 4-5cm

Aortic Coarct­ation
▸ Relatively rare lesion
▸ The aorta is abnormally narrowed and is often accomp­anied by abnorm­alities of other large arteries
▸ Typical findings include hypert­ension in the upper extrem­ities but normal or reduced pressures in the lower extrem­ities.
▸ Major compli­cations with aortic coarct­ation include:
    - Congestive heart failure , and aortic rupture
    - Bacterial endoca­rditis of the bicuspid aortic valve
▸ B-blocking drugs


Myocardial Infarction During Pregnancy
▸ Mortality rate in pregnancy is higher compared with age- matched nonpre­gnant women
▸ Coronary angiog­raphy - diagnostic gold standard
▸ Myocardial ischemia is also associated with prosta­glandin E1 vaginal suppos­itories given for labor induction
▸ Treatment
    - Percut­aneous transl­uminal coronary angiop­lasty and stent placement during pregnancy is successful
    - If the infarct has healed suffic­iently, cesarean delivery is reserved for obstet­rical indica­tions, and epidural analgesia is ideal for labor

Pregnancy with Prior Ischemic Heart Disease
▸ Pregnancy in most of these women seems inadvi­sable
    - Ventri­cular perfor­mance should be assessed
    - For those who become pregnant before these studies are performed, echoca­rdi­ography is done.
    - Exercise tolerance testing may be indicated, and radion­uclide ventri­cul­ography exposes the fetus to minimal radiation