cardiology update: the breathless pregnant woman
TRANSCRIPT
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Cardiology Update:The Breathless Pregnant Woman
Sara ThorneSeptember 13th 2018
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There’s someone in A&E who’s breathless pregnant and
What should I do?
• Panic for 20 sec• Think, ‘what would I do if she wasn’t pregnant?’ – then (usually) – do it• Get help from someone who knows what they’re doing
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To consider the -
• Causes of breathlessness in pregnancy
• Causes of maternal mortality
• Cardiovascular demands of pregnancy
• Use of cardiac drugs in pregnancy
• Decision making processes in the acutely unwell pregnant woman
Objectives
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Heart disease
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• 77% of the women who died were not known to have heart disease before their pregnancy.
• Most of the women who died from heart disease did not get to see a cardiologist
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50% - improved care may have made a difference to outcome
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Case History 1
21 year old woman
28/40 weeks pregnant, twins.Admitted to local hospital with 3 days SOB & orthopnoea
O/EBreathless, sitting upP 123 SRBP 138/80HS normalChest wheezy, quiet bases
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The breathless pregnant woman: which statement is true?
1. All pregnant women get breathless
2. Wheeze may indicate pregnancy induced asthma
3. May be discharged from A&E after exclusion of PE
4. Orthopnoea is a common feature of normal pregnancy
5. CT thorax is contraindicated in pregnancy
6. Influenza vaccination is contraindicated in pregnancy
Question
✓
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✗
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Breathlessness in Pregnancy
• CardiacOrthopnoea…paroxysmal nocturnal dyspnoea…pulmonary oedema
Ventricular dysfunctionNative valve diseaseThrombosed mechanical valveTachyarrhythmia
• Pulmonary embolus
• RespiratoryDecompensated asthmaPneumonia / influenza
• Normal
Same DD as non pregnant, but different emphasis
Cardiology review, CXR & echo without delay
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Case History 1
What happened next…
DD PE or chest infection
Rx Enoxaparin 1.5mg/kg OxygenSteroids for fetal lung maturation (betamethasone)
CT scan Attempted, but would not lie flatScout film = congestion
Further RxIV antibiotics
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Cardiovascular changes in pregnancy:Which statement is true?
During pregnancy
1. Cardiac output rises most rapidly in the 3rd trimester
2. The rise in cardiac output is largely due to a rise in heart rate, typically to around 115bpm
3. Stroke volume increases by 10%
4. Cardiac output rises by 50%
5. Total peripheral vascular resistance rises
Question
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✓
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Hb
Karamermer et al ‘07
Who is most at risk?
• Unable to increase cardiac outputImpaired systolic ventricular functionSevere mitral stenosisSevere aortic stenosisCoronary artery diseasePulmonary arterial hypertension
• Mechanical valves
• Aortopathy
Cardiovascular Changes in Pregnancy
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Case History 1
Next morning…..
Worse: unable to sleep, sat in chair all nighttoo breathless to eat
Cardiology opinionEcho – impaired left ventricular function
mitral regurgitation
Tertiary centre phoned for advice
• Furosemide• Transfer• Baseline bloods:
U&E ‘normal’ Cr 48K 4.3
ABG on 5L O2: pH 7.43pCO2 4.2pO2 9.8HCO3 21.9Lact 1.76BE -3.6
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Which Drugs Can You Use?
Fetal effect Pregnancy Breast feeding
ACEI, ARB Renal (& cardiac) anomalies
✗ safe
Blockers Reduced fetal growth? ✓ safe
Digoxin nil ✓ safe
Nitrates nil ✓ safe
Hydralazine nil ✓ safe
Thiazides Nil (diabetogenic) ✓ safe
Furosemide Nil (plasma volume) ✓ safe
Spironolactone Antiandrogenic Caution, feminisation?
safe
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Case History 1
Arrives with CPAP, 20mg furosemide given pre transferSitting upright, unable to speak in sentencesP130 SRBP 100/85Gallop rhythmChest – widespread crackles and wheeze
• Furosemide 40mg IVGTN infusion
• CXR:
• Echo: Dilated LV, severe systolic dysfunction, EF 20%Torrential MR
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Case History 1
Good diuresis
Joint consultant obstetric, cardiology & obstetric anaesthetic reviewFetal heart beats presentDelivery pack and 2 resuscitaires on CCU
Feels much better, can speak in sentences and lie downBP148/85
BUT….. P120
-3.6
48
What is her metabolic state?Is she perfusing her kidneys?
BAD, getting worseNO
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Question
Which one of these is false?
1. She should be delivered by section in cardiac theatres
2. A cardiac surgeon and perfusion team should be present
3. She should be taken to labour ward HDU post delivery
4. Both consultant obstetric and cardiac anaesthetist should be present
5. The consultant cardiologist should be present
✓
✓
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✓
✓
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Case History 1
Needs delivery…. now…in cardiac theatres… intra-aortic balloon pump placed en route to theatre
Who needs to be in theatre?
Consultant obstetrician & senior colleagueObstetric & cardiac anaesthetistObstetric scrub teamMidwife2 neonatal resuscitation teamsPerfusionistCardiac surgeonCardiologist
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Case History 1
Uneventful CS under GATwins in good condition, electively intubated
TOE on table post delivery: MR now mild, LV unchanged, LVEF 20%
Post op cardiac ITUExtubated quicklyRemained tachycardicAcidosis & renal dysfunction resolved
Babies extubated and transferred to local NNU at 1 weekMother discharged home same dayCardiology follow up - asymptomatic
-no improvement in LV at 3 months, mod MR• Final diagnosis
Pre-existing cardiomyopathy unmasked by pregnancy?Peripartum cardiomyopathy?
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24 year old Somalian, 17/40 1st pregnancyPresents to A&E with breathlessness and orthopnoea
• Increasing breathlessness from early pregnancy• 3 pillow orthopnea, sleeps badly, dry cough
On examination• Breathless, sitting up• Coughs++ lying flat• P120 sinus rhythm• BP 105/60• HS I___II___I• Chest widespread wheeze
Case History 2
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Case History 2
What happened next……
Differential diagnosis?AsthmaChest infection
Investigations?No, because pregnant
Initial management?OxygenSalbutamol nebuliserAntibiotics
Initial response? dyspnoea and distress Heart rate 130
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Case History 2
Cardiology review
RV heaveTapping apexHeart sounds …loud S1… tricky, HR 130Bases quiet, fine crackles and wheeze
Salbutamol nebuliser removedFurosemide 40mg IV given
CXR – LA dilatation, pulmonary oedemaECG – SR, p mitrale, p pulmonale, RV+Echo – oxygen & diuretics given whilst waiting
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Case History 2
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Case History 2
Echo: isolated severe rheumatic mitral stenosis, valve area 0.8cm2
Good diuresisAble to lie flatCautious blockadeHeart rate 90
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1. Continue medical therapy and intervene if decompensates
2. Termination of pregnancy on medical grounds
3. Mitral valve replacement
4. Balloon mitral valvuloplasty at 36/40
5. Balloon mitral valvuloplasty at 19/40
Question
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✓
What next?
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Case History 2
Pre balloonGradient 11mmHgValve area 0.8cm2
Post balloonGradient 3.5mmHgValve area 2.2 cm2
19/40 Balloon mitral valvotomyMVA 2.2cm2, no MR
Asymptomatic39/40Spontaneous normal delivery
5 years later…..
No further interventionJust completed 3rd pregnancy uneventfully
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The Breathless Pregnant Woman
Red flag symptoms• Orthopnoea…
…refuses to lie down in CT scanner• Paroxysmal nocturnal dyspnoea• Unable to speak in sentences
Red flag signs• Tachycardia >100• Hypotension• Tachypnoea & accessory muscles• Sitting upright• Frothy sputum• Wheeze or crackles
Red flag tests • ‘Normal’ but deteriorating renal function• Metabolic acidosis