6. ==Normal cardiac signs and symptoms of pregnancy:
& Hyperventilation (as a result of increased minute ventilation)
& Edema (from volume retention and compressed inferior vena cava [IVC] by the
uterus)
& Dizziness/lightheadedness (from reduced SVR and venal caval compression)
& Palpitations (normal HR increases by 10–15 beats/min)
==Pathologic cardiac signs and symptoms of pregnancy:
& Anasarca, or generalized edema, and paroxysmal nocturnal dyspnea (PND) are
not components of normal pregnancy and warrant workup.
& Syncope should be evaluated for hypotension, obstructive valvular pathology
(aortic, mitral or pulmonic stenosis), pulmonary hypertension, pulmonary
embolism, or tachybradyarrhythmias.
& Chest pain may be due to aortic dissection, pulmonary embolism, angina, or even
myocardial infarction. Women are delaying their child-bearing years, with a higher
incidence of preexisting cardiac risk factors in the older pregnant woman.
& Hemoptysis may be a harbinger of occult mitral stenosis, although rheumatic heart
disease is becoming less common in developed countries.

7. ==Blood pressure (BP) will decline and HR will increase. The point of maximum impulse
(PMI) will be displaced laterally as the uterus enlarges. S3 is common because of increased
rapid filling of the left ventricle (LV) in early diastole. S4 is unusual and may reflect
underlying hypertension.
A physiologic pulmonic flow murmur is common because of elevated stroke volume passing
through a normal valve. Systolic murmurs of 1/6–2/6 can be explained by these physiologic
changes. A mammary souffle and venous hum are two continuous, superficial murmurs that
can be obliterated by compressing the site with the diaphragm of the stethoscope. If the
murmur does not change, consider patent ductus arteriosus or coronary atrioventricular (AV)
fistula.
==Abnormal cardiac findings during pregnancy:
& Clubbing and cyanosis are not a part of normal pregnancy; desatuaration for any reason is
abnormal and warrants investigation.
& Elevated jugular venous pressure is abnormal, reflecting elevated right atrial pressure; it is
important to evaluate neck veins in any pregnant woman who has peripheral edema.
& Pulmonary hypertension (right ventricular heave, loud P2, JVP elevation) evidence should
be investigated early. Women with pulmonary hypertension (pulmonary pressure greater
than 75% of systemic pressure) should be counseled in general as to the risks of pregnancy.
& Systolic murmur 3/6 or louder and any diastolic murmur audible in pregnancy are
considered abnormal and warrant evaluation.

8. --Obstruction to venous return by the enlarging
uterus causes stasis, and a further rise in risk of
thrombo-embolism.
--Increased intravascular blood volume partly explains
the higher dosages of drugs required to achieve
therapeutic plasma concentrations, and the dose
adaptations needed during treatment. Moreover,
the raised renal perfusion and the higher hepatic
metabolism increase drug clearance.
--BP, CO, and HR normalize over the next 5 to 6 weeks
as hormonal changes return to the pregravid state.

9. Genetic testing and counselling
† In cardiomyopathies and channelopathies, such as long
QT syndromes
† When other family members are affected
† When the patient has dysmorphic
features, developmental delay/ mental retardation, or
when other non-cardiac congenital abnormalities are
present, in syndromes such as in Marfan,
22q11 deletion, Williams–Beuren, Alagille, Noonan, and
Holt–Oram syndrome.
==If a pregnant woman suffers a cardiac arrest, the viable
baby should be delivered after 15 minutes if there is no
return of spontaneous maternal circulation.

12. --TEE safe but take care from sedation.
-- Dobutamine stress should be avoided.
-- Nuclear scintigraphy should be avoided during
pregnancy because of radiation exposure.
-- MRI is probably safe, especially after the first
trimester. Gadolinium can be assumed to cross the
fetal blood–placental barrier, but data are limited.

13. If an intervention is absolutely necessary:
--Best time to intervene is considered to be after the fourth
month in the second trimester. By this time organogenesis
is complete, the fetal thyroid is still inactive, and the
volume of the uterus is still small, so there is a greater
distance between the fetus and the chest than in later
months.
--Fluoroscopy and cineangiography times should be as
brief as possible and the gravid uterus should be shielded
from direct radiation.
--Heparin has to be given at 40–70 U/kg, targeting an
activated clotting time of at least 200 s, but not exceeding
300 s.

14. Cardiac surgery with cardiopulmonary bypass
-- Maternal mortality during cardiopulmonary bypass
is now similar to that in non-pregnant women.
-- significant morbidity including late neurological
impairment in 3–6% of children, and fetal mortality
remains high.
-- The best period for surgery is between the 13th and
28th week {first trimester  higher risk of fetal
malformations, third trimester  higher incidence
of pre-term delivery and maternal complications}.

15. Fetal cardiac anomaly is suspected
(1) A full fetal echocardiography to evaluate cardiac structure and
function, arterial and venous flow, and rhythm.
(2) Detailed scanning of the fetal anatomy to look for associated
anomalies (particularly the digits and bones).
(3) Family history to search for familial syndromes.
(4) Maternal medical history to identify chronic medical
disorders, viral illnesses, or teratogenic medications.
(5) Fetal karyotype (with screening for deletion in 22q11.2 when
conotruncal anomalies are present).
(6) Referral to a maternal–fetal medicine specialist, paediatric
cardiologist, geneticist, and/or neonatologist to discuss prognosis,
obstetric, and neonatal management, and options.
(7) Delivery at an institution that can provide neonatal cardiac
care, if needed.

17. *Antibiotics that can be given during all trimesters of
pregnancy:
--
penicillin, ampicillin, amoxicillin, erythromycin, mezlocilli
n, and cephalosporins. {group B}
--Vancomycin, imipenem, rifampicin, and teicoplanin
are all group C, which means risk cannot be excluded and
their risk–benefit ratio must be carefully considered.
--There is a definite risk to the fetus in all trimesters of
pregnancy with group D drugs
(aminoglycosides, quinolones, and tetracyclines) and they
should therefore only be used for vital indications

19. NB. Warfarin+ pregnancy
--Teratogenic effects:
-Potentially teratogenic (low MW, cross placenta) Embryopathy
, spontaneous abortion and stillbirth.
-The teratogenic effect appears to be dose related, with doses less than
5 mg/day providing the highest margin of safety {regardless of INR}
-most common bone and cartilage nasal and limb hypoplasia
--CNS abnormalities (including optic atrophy, microcephaly, mental
retardation, spasticity, and hypotonia)
-Immaturity of fetal enzyme systems and the relatively low
concentration of vitamin K-dependent clotting factors render the fetus
more sensitive than the mother to the anticoagulant effects of warfarin
 risk of hemorrhagic fetal death during vaginal delivery warfarin
should be discontinued after 34 to 36 weeks of gestation
-Preterm cesarean delivery may prevent hemorrhagic fetal
death, and fresh frozen plasma should be administered to the
neonate, mother

20. --UFH (c):
-Relative difficulty of maintaining a stable therapeutic response, the inconvenience of
parenteral administration, and the complications of heparin-induced
thrombocytopenia and bone demineralization in patients treated for more than seven
weeks
-Guided by APTT
--LMW heparin (B):
-Sustained, stable therapeutic response
-Reduce the inconvenience of parenteral administration
-Laboratory monitoring of the anticoagulant effect of LMW heparin is generally not
performed in nonpregnant patients, but some authors recommend measuring anti-
factor Xa levels four hours after injection in pregnant patients
-Less likely to precipitate heparin-associated thrombocytopenia, unclear whether bone
loss may be significantly reduced
-American College of Obstetricians and Gynecologists has stated that LMW heparin
can be considered in women who are candidates for prophylactic or therapeutic
anticoagulation during pregnancy
- Patients should be switched to subcutaneous unfractionated heparin about two weeks
prior to the expected delivery; this will permit regional anesthesia for labor {epidural
haematoma}

21. Mechanical prosthetic heart valves:
--FDA  LMWH is not recommended for
thromboprophylaxis in pregnant women with
prosthetic heart valves.
--However, other expert panels disagree, and the
American College of Chest Physicians recommended
that LMWH remain a therapeutic option in this setting

22. 2008 ACCP Guidelines
One of three approaches for anticoagulation during pregnancy:
--Aggressive adjusted-dose unfractionated heparin throughout the pregnancy;
heparin is administered subcutaneously every 12 hours in doses adjusted to
keep the mid-interval aPTT at least twice control or to attain an anti-Xa level
of 0.35 to 0.70 U/mL. After a stable dose is achieved, the aPTT should be
measured at least weekly.
--Adjusted-dose subcutaneous LMW heparin therapy throughout the
pregnancy in doses adjusted according to weight to achieve the
manufacturer's recommended anti-Xa level four hours after subcutaneous
injection.
--Unfractionated or LMW heparin therapy (as above) until the thirteenth
week, a change to warfarin until the middle of the third trimester, and then
restarting unfractionated or low molecular weight heparin until delivery
Heparin can be restarted 12 hours post-cesarean delivery and 6 hours post-
vaginal birth, if no significant bleeding has occurred replaced with warfarin
(stopping the heparin when the INR is therapeutic)

23. Other indications for AC in pregnancy
Venous thromboembolism
Atrial fibrillation associated with significant
underlying heart disease
Antiphospholipid antibody syndrome
Heart failure, particularly in the presence of a
ventricular thrombus
Eisenmenger syndrome
Paroxysmal nocturnal hemoglobinuria

29. --Monthly injectables that contain medroxyprogesterone acetate are
inappropriate for patients with heart failure because of the tendency
for fluid retention. Low dose oral contraceptives containing 20 mg of
ethinyl estradiol are safe in women with a low thrombogenic
potential, but not in women with complex valvular disease.
--Barrier methods (condom), the levonorgest relreleasing intrauterine
device is the safest and most effective contraceptive that can be used
in women with cyanotic congenital heart disease and pulmonary
vascular disease.
--IUD- Antibiotic prophylaxis is not recommended at the time of
insertion or removal since the risk of pelvic infection is not increased.
If excessive bleeding occurs at the time of menses, the device should
be removed. It is contraindicated in cyanotic women with haematocrit
levels >55% because intrinsic haemostatic defects increase the
risk of excessive menstrual bleeding.

30. --IVF Thrombo-embolism may complicate in vitro
fertilization when high oestradiol levels may
precipitate a prothrombotic state.

36. -Repaired atrial septal defects (ASD) and ventricular septal
defects (VSD) confer no increased cardiac risk.
-Unrepaired left-to-right intracardiac shunts (ASD and
VSD) are well tolerated because of the reduction in SVR,
which decreases left to-right shunting during pregnancy.
Patients are at an increased risk for paradoxical
embolization if they develop deep venous thrombosis.
-Right-to-left (cyanotic) shunting is poorly tolerated in
pregnancy because of reduction of SVR.
-Women with Eisenmenger’s syndrome risk a 30% to 50%
maternal mortality with pregnancy. Such high-risk women
are counseled to avoid pregnancy or undergo therapeutic
termination.

39. PAH, Eisenmenger syndrome
--Every effort should be made to maintain circulating volume, and to avoid
systemic hypotension, hypoxia, and acidosis which may precipitate refractory
heart failure. Supplemental oxygen therapy should be given if there is
hypoxaemia.
--I.v. prostacyclin or aerosolized iloprost have been occasionally used
antenatally and peripartum to improve haemodynamics during delivery in
PAH,,, in Eisenmenger  systemic vasodilatation increases the
right-to-left shunt and decreases pulmonary flow, leading to increased
cyanosis and eventually to a low output state.
--Teratogenic effects of some therapies, such as bosentan.
--In PAH associated with connective tissue disorders, anticoagulant
treatment should be considered on an individual basis. In PAH associated
with portal hypertension, anticoagulation is not recommended in patients
with increased risk of bleeding. In Eisenmenger with cyanosis, AC is
indicated.
--In patients with Eisenmenger syndrome+ heart failure, diuretics must be
used judiciously and at the lowest effective dose to avoid haemoconcentration
and intravascular volume depletion.

40. Cyanotic heart disease without pulmonary
hypertension
--Restriction of physical activity and supplemental
oxygen.
--Prevention of venous stasis (use of compression
stockings and avoiding the supine position) is
important. For prolonged bed rest, prophylactic
heparin administration should be considered.

41. --Risk of paradoxical embolism, in women with a
residual shunt {ASD, AVSD}, prevention of venous
stasis (use of compression stockings and avoiding the
supine position) is important, as is early ambulation
after delivery.

42. Coarctation of the aorta
--Hypertension should be treated, although aggressive
treatment in women with residual coarctation must be avoided
to prevent placental hypoperfusion.
--Percutaneous intervention for re-CoA is possible during
pregnancy, but it is associated with a higher risk of aortic
dissection than outside pregnancy and should only be
performed if severe hypertension persists despite maximal
medical therapy and there is maternal or fetal compromise.
--The use of covered stents may lower the risk of dissection.
--Severely symptomatic PS not responding to medical therapy
and bed rest, percutaneous valvuloplasty can be undertaken.

49. Short stature

51.  BB

52. -Type A dissection (involving the ascending aorta)
should be managed surgically, with delivery of the
viable fetus before repair. Type B dissection
(descending aortic involvement) can be managed
medically with labetalol or nitroprusside..

56. Medical management if symptomatic severe
--No endocarditis prophylaxis
--Severe mild physical activity {avoid syncope}
--Medical therapy for coronary artery disease, and atrial fibrillation
--HTN:
-Diuretics reduce preload, on which the patient may depend for maintenance of cardiac
outputcaution.
-Beta blockers reduce contractility which may pose a risk for the overloaded left
ventricleavoided in patients with symptomatic aortic stenosis and heart failure.
-Vasodilators (such as hydralazine, nitroglycerin, and nifedipine) in the presence of a
fixed valvular stenosis may reduce systemic blood pressure and reduce coronary artery
perfusion pressure caution
-ACEI small dose , gradual titration
--Prevention and treatment of concurrent conditions {eg.influenza, fever, volume
status}
--+ve inotropic agents such as dobutamine must be used with caution; tachycardia
(with reduced cardiac output) and myocardial ischemia(O2 demand)
--Nitruprusside: may be if no hypotension, critically ill
*Percutaneous valvuloplasty can be undertaken in non-calcified valves with
minimal regurgitation, AVR after CS

60. -Only patients with severe symptomatic regurgitation (New
York Heart Association [NYHA] class III–IV or greater)
should be considered for valve replacement before pregnancy,
and the only indication for valve replacement for regurgitation
in the gravid patient is infective endocarditis.
-IE prophylaxis is optional in vaginal delivery for patients with
prior IE, prosthetic valves, congenital heart disease (CHD)
within the first 6 months of repair or after 6 months if there is
residual shunting, surgically constructed systemic-pulmonary
shunts or conduits, and posttransplantation valvulopathy.
-It is not indicated in cesarean section per 2007 American Heart
Association (AHA) guidelines, although it is often given.

62. --Safety of drug-eluting stents in pregnant woman is
therefore still unknown.
--Data on emergency coronary artery bypass graft
surgery during pregnancy are rare.
--Safety data regarding glycoprotein IIb/IIIa
inhibitors, bivalirudin, clopidogrel, prasugrel, and
ticagrelor are lacking.
-- Heparin can be used safely; however, there is little
data on the use of stents because clopidrogel has not
been studied in pregnancy.

63. 30-50%

66. --When ACE inhibitors are needed during breastfeeding,
benazepril, captopril, or enalapril should be preferred.
--Metoprolol, propranolol, or labetalol should be used
instead of atenolol.
Newborns should be supervised for 24–48 h after delivery
to exclude hypoglycaemia, bradycardia, and respiratory
depression.
--Aldactone is avoided.
--Hydralazine with nitrates should replace ACE
inhibitors/ARBs in patients with heart failure.
--B-type natriuretic peptide (BNP) levels do not rise with
normal pregnancy; levels increase in women with
myopathy, preeclampsia, eclampsia, and diabetes.

68. --Outflow obstruction may improve if the LV can dilate.
--Cardioversion should be considered for persistent
arrhythmia because AF is poorly tolerated.
--Epidural anaesthesia causes systemic vasodilation and
hypotension, and therefore must be used with caution in
patients with severe LVOTO.
-- I.v. fluids must be given judiciously and volume overload
must be avoided as it is poorly tolerated in the presence of
diastolic dysfunction.
--Syntocinon may cause hypotension, arrhythmias, and
tachycardia, and should only be given as a slow infusion.

70. --Symptomatic tachyarrhythmia is treated by catheter
ablation prior to pregnancy where possible.
--All antiarrhythmic drugs should be regarded as
potentially toxic to the fetus.
--Bradyarrhythmias and conduction disturbances are
rare during pregnancy temporary or permanent
pacing according to indication is safe.

74. --Doppler ultrasound of uterine arteries, performed during the second trimester (>16
weeks), is useful to detect uteroplacental hypoperfusion, which is associated with a
higher risk of pre-eclampsia and intrauterine growth retardation.
--Gestational hypertension develops after 20 weeks gestation and resolves in most
cases within 42 days post-partum.
--Pre-eclampsia =de novo appearance of hypertension+ new-onset of significant
proteinuria >0.3 g/24 h. Oedema is no longer considered part of the diagnostic criteria.
--Pre-eclampsia occurs more frequently during the first pregnancy, in multiple fetuses,
hydatidiform mole, or diabetes. It is associated with placental insufficiency, often
resulting in fetal growth restriction.
--Symptoms and signs of severe pre-eclampsia include:
† right upper quadrant/epigastric pain due to liver oedema+ hepatic haemorrhage
† headache+visual disturbance (cerebral oedema)
† occipital lobe blindness
† hyperreflexia+clonus
† convulsions (cerebral oedema)
† HELLP syndrome: haemolysis, elevated liver enzymes, low platelet count.
--Management  delivery of the placenta, which is curative. As proteinuria may be a
late manifestation of pre-eclampsia, it should be suspected when de novo hypertension
is accompanied by headache, visual disturbances, abdominal pain, or abnormal
laboratory tests, specifically low platelet count and abnormal liver enzymes; it is
recommended to treat such patients as having pre-eclampsia.

75. --i.v. labetalol, drug of choice in hypertensive crises is
sodium nitroprusside given as an i.v. infusion at 0.25–
5.0 mic/kg/min.
Prolonged treatment with sodium nitroprusside is
associated with an increased risk of fetal cyanide
poisoning.
--Drug of choice in pre-eclampsia associated with
pulmonary oedema is nitroglycerine (glyceryl
trinitrate), given as an i.v. infusion of 5 mic/min, and
gradually increased every 3–5 min to a maximum dose
of 100 mic/min

79.  0.5 IU/kg twice/d

82. --Thrombolytics are considered to be relatively contraindicated during
pregnancy and peripartum and should only be used in high risk
patients with severe hypotension or shock.
--Risk of haemorrhage, fetal loss and pre-term delivery
--Mostly streptokinase was used and, more recently, recombinant
tissue plasminogen activator. Both thrombolytics do not cross the
placenta in significant amounts.
--When thrombolysis has been given, the loading dose of UFH should
be omitted and an infusion started at a rate of 18 U/kg/h. After
stabilization of the patient, UFH can be switched to LMWH for the
residual duration of pregnancy.
--Vena cava filters indicated as nonpregnant.
--Vitamin K antagonists do not enter the breast milk in active forms
and are safe for nursing mothers.
--Mothers taking warfarin may nurse after delivery.