METHODICAL INSTRUCTIONS



MINISTRY OF PUBLIC HEALTH OF UKRAINE

National Pirogov Memorial Medical University, Vinnytsya

CHAIR OF OBSTETRICS and Gynecology №1

METHODICAL INSTRUCTIONS

for practical lesson

« Pregnancy and labor with extragenital diseases »

MODULE 4: Obstetrics and gynecology

Topic 6

Aim: to learn how to diagnose and to prescribe special therapy for pregnant women with different medical illnesses.

Professional motivation: for most systemic illnesses, the physiologic and anatomic changes inherent in normal pregnancy influence the symptoms, signs and laboratory values to a considerable degree. Physicians providing obstetric care must have a thorough understanding of the effect of pregnancy on the natural course of a disorder on a pregnancy and the change in management of the pregnancy and /or disorder caused by their coincidence.

Basic level:

1. Medical conditions of pregnancy.

2. What specialist do consult pregnant women?

3. How often do medical conditions can complicate the course of a pregnancy.

STUDENTS' INDEPENDENT STUDY PROGRAM

I. Objectives for Students' Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

1- Pregnancy related changes of cardiovascular system during Pregnancy.

2- Classification of cardiovascular diseases in pregnant women.

3- Examination and urgency aid of pregnant cardiac patients.

4. Blood diseases in pregnancy.

5- Renal diseases in pregnancy.

6- Diabetes mellitus in pregnancy.

7- Indications to therapeutic abortion in extragenital disorders of pregnancy.

Key words and phrases: medical conditions of pregnancy.

Summary

Medical and surgical illnesses complicating pregnancy require interaction between obstetrician, internist, surgeon, anesthesiologist, and frequently other subspecialists. Because pregnancy does not make a woman immune to any disease, obstetricians must have a working knowledge of common medical and surgical diseases that may befall women during childbearing years.

Importantly, normal pregnancy-induced physiological changes of pregnancy must be interpreted in relation to their effects on underlying nonobstetrical disorders. Changes induced by pregnancy on many laboratory tests should also be considered.

Physiologic adaptation to pregnancy involves the cardiovascular, pulmonary, endocrine, hematologic, neurologic, renal and gastrointestinal systems. In a normal, healthy pregnant women, the adaptive responses a appropriate and well tolerated. When underlying pathology is present th responses of the different organ systems are less well tolerated, and organic failure may occur.

Heart disease complicates about 1 percent of pregnancies. Heart disease in pregnancy can be divided into two categories-rheumatic and congenital. The most common lesion associated with rheumatic heart disease is mitral stenosis. Regardless of the specific valvular lesion, patients are at higher risk of developing heart failure, subacute bacterial endocarditis, and thrornboembolic disease. Asymptomatic patients may develop symptoms of cardiac decompensation or pulmonary edema as pregnancy progresses.

As a general principle,all pregnant cardiac patients should be managed with the help of a cardiologist. During every prenatal visit, the patient should be carefully examined to exclude infection, cardiac decompensation, pulmonary congestion, and cardiac arrhythmia.

To minimize the increase in cardiac output, reassurance, sedation and epidural anesthesia are encouraged early in labor. Prophylactic antibiotics (arnpkiilin and gentamicin) against subacute bacterial endocarditis are started once labor is established, and they are continued for 48 hours postpartum.Rheumatic heart disease formerly accounted for the majority of cases. The marked hemodynamic changes stimulated by pregnancy have a profound effect on underlying heart disease in the pregnant woman. The most important consideration is that during pregnancy cardiac output is increased by as much as 30 to 50 percent.

Because significant hemodynamic alterations are apparent early in pregnancy, the woman with clinically significant cardiac dysfunction may experience worsening of heart failure before midpregnancy. Additional hemodynamic burdens are placed upon the heart in the immediate peripartum period when the physiological capability for rapid changes in cardiac output may be overwhelmed in the presence of structural cardiac disease.

The likelihood of a favorable outcome for the mother with heart disease depends upon the (1) functional cardiac capacity, (2) other complications that further increase cardiac load, and (3) quality of medical care provided.

Clinical Classification of Heart Disease

There is no clinically applicable test for accurately measuring functional cardiac capacity. The clinical classification of the New York Heart Association (NYHA) was first published in 1928, and it was revised for the eighth time in 1979. This classification is based on past and present disability and is uninfluenced by physical signs.

• Class I. Uncompromised—no limitation of physical activity:

These women do not have symptoms of cardiac insufficiency or experience anginal pain.

• Class II. Slight limitation of physical activity: These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort in the form of excessive fatigue, palpitation, dyspnea, or anginal pain results.

• Class III. Marked limitation of physical activity: These women are comfortable at rest, but less than ordinary activity causes excessive fatigue, palpitation, dyspnea, or anginal pain.

• Class IV. Severely compromised—inability to perform any physical activity without discomfort: Symptoms of cardiac insufficiency or angina may develop even at rest. If any physical activity is undertaken, discomfort is increased.

General management. In most instances, management involves a team approach with an obstetrician, cardiologist, anesthesiologist, and other specialists as needed. Cardiovascular changes likely to be poorly tolerated by an individual woman are identified, and a plan is formulated to minimize these. Four changes that affect management are emphasized by the American College of Obstetricians and Gynecologists (1992):

•The 50-percent increase in blood volume and cardiac output by the early third trimester

•Further fluctuations in volume and cardiac output in the peripartum period

•A decline in systemic vascular resistance, reaching a nadir in the second trimester, and then rising to 20 percent below normal by late pregnancy

•Hypercoagulability, which is of special importance in women requiring anticoagulation before pregnancy with coumarin derivatives.

Within this framework, both prognosis and management are influenced by the nature and severity of the specific lesion in addition to the functional classification.

Management of Class I – II. With rare exceptions, women in class I and most in class II go through pregnancy without morbidity. Throughout pregnancy and the puerperium, however, special attention should be directed toward both prevention and early recognition of heart failure.

Infection has proved to be an important factor in precipitating cardiac failure. Each woman should receive instructions to avoid contact with persons who have respiratory infections, including the common cold, and to report at once any evidence for infection.

Labor and Delivery. In general, delivery should be accomplished vaginally unless there are obstetrical indications for cesarean delivery. In spite of the physical effort inherent in labor and vaginal delivery, less morbidity and mortality are associated with this route.

Relief from pain and apprehension without undue depression is especially important. For many multiparous women, intravenous analgesics provide satisfactory pain relief. For others, especially nulliparas, continuous epidural analgesia often proves valuable. The major danger of conduction analgesia is maternal hypotension.

For vaginal delivery in women with only mild cardiovascular compromise, pudendal analgesia given along with intravenous sedation often suffices. However, when low- or mid-forceps use is contemplated, or in women with cardiac conditions who are unable to accommodate the marked changes in cardiac output often seen during labor and delivery, epidural analgesia is preferable.

Management of Class III-IV. Maternal mortality for classes III and IV has been reported to be 4 to 7 percent (McFaul and colleagues, 1988; Sullivan and Ramanathan, 1985). The important question is whether pregnancy should be undertaken or continued. If women choose to become pregnant, they must understand the risks and cooperate fully with planned care. If seen early enough, women with some types of severe cardiac disease should consider pregnancy interruption. If the pregnancy is continued, prolonged hospitalization or bed rest will often be necessary.

During pregnancy, there are a number of important adaptations of the respiratory system and changes in pulmonary function. Physiologically these changes are necessary so that the increased oxygen demands of the hyperdynamic circulation and the fetus can be satisfied.

Although the effect of pregnancy on bronchial asthma is variable, severe asthma is associated with an increased abortion rate and an increased incidence of intrauterine fetal death and fetal growth restriction, most probably as a result of intrauterine hypoxia. Pregnant asthmatics should be followed closely during pregnancy to ensure adequate maternal and fetal assessment. For outpatient treatment of occasional mild asthma attacks, inhaled b-agonists should be started on a regimen of inhaled corticosteroids or cromolyn.

If the patients has been taking oral steroids during pregnancy, the intravenous administration of glucorticoids is recommended during labor delivery and postpartum period. Vaginal delivery should be anticipated-Cesarean section is indicated only for obstetric reasons.

Mitral Stenosis

Rheumatic endocarditis causes three fourths of mitral stenosis cases. The normal mitral valve surface area is 4.0 cm2 . When stenosis narrows this to less than 2.5 cm2, symptoms usually develop. The contracted valve impedes blood flow from the left atrium to the ventricle. The most prominent complaint is dyspnea due to pulmonary venous hypertension and edema. Fatigue, palpitations, cough, and hemoptysis are also common. With tight stenosis, the left atrium is dilated, left atrial pressure is chronically elevated, and significant passive pulmonary hypertension can develop (Table 1-7). The increased preload of normal pregnancy, as well as other factors that increase cardiac output, may cause ventricular failure with pulmonary edema in these women who have a relatively fixed cardiac out-put. Indeed, a fourth of women with mitral stenosis have cardiac failure for the first time during pregnancy. Because the murmur may not be heard in some women, this clinical picture may be confused with idiopathic peripartum cardiomyopathy. With significant stenosis, tachycardia shortens ventricular diastolic filling time and increases the mitral gradient. This increase raises left atrial and pulmonary venous and capillary pressures and may result in pulmonary edema. Thus, sinus tachycardia is often treated prophylactically with -blocking agents. Atrial tachyarrhythmias, including fibrillation, are common in mitral stenosis and are treated aggressively. Atrial fibrillation also predisposes to mural thrombus formation and cerebrovascular embolization that can cause stroke. Hameed and associates (2005) described three pregnant women with tight mitral stenosis—valve area of 0.9 cm2 —who each developed an atrial thrombus despite a sinus rhythm. One suffered an embolic stroke, and another had pulmonary edema and maternal hypoxemia that caused fetal encephalopathy.

Mitral Insufficiency

When there is improper coaptation of mitral valve leaflets during systole, some degree of mitral regurgitation develops. eventually followed by left ventricular dilatation and eccentric hypertrophy. Chronic mitral regurgitation has a number of causes, including rheumatic fever, mitral valve prolapse, or left ventricular dilatation of any etiology—for example, dilated cardiomyopathy. Less common causes include a calcified mitral annulus, possibly some appetite suppressants, and in older women, ischemic heart disease. Mitral valve vegetations— Libman-Sacks endocarditis—arerelatively common in women with antiphospholipid antibodies. These sometimes coexist with systemic lupus erythematosus. Acute mitral insufficiency is caused by rupture of a chorda tendineae, infarction of papillary muscle, or leaflet perforation from infective endocarditis. In nonpregnant patients, symptoms from mitral valve incompetence are rare, and valve replacement is seldom indicated unless infective endocarditis develops. Likewise, mitral regurgitation is well tolerated during pregnancy, probably because decreased systemic vascular resistance results in less regurgitation. Heart failure only rarely develops during pregnancy, and occasionally tachyarrhythmias need to be treated. Intrapartum prophylaxis against bacterial endocarditis may be indicated.

Aortic Stenosis

This is a disease of aging, and in women younger than 30 years, it is most likely due to a congenital lesion. Aortic stenosis itself is less common since the decline in incidences of rheumatic diseases. In the United States, the most common lesion is a bicuspid valve. Stenosis reduces the normal 2- to 3-cm2aortic orifice and creates resistance to ejection. Reduction in the valve area to a fourth its normal size produces severe obstruction to flow and a progressive pressure overload on the left ventricle. Concentric left ventricular hypertrophy follows, and if severe, end-diastolic pressures become elevated, ejection fraction declines, and cardiac output is reduced. Characteristic clinical manifestations develop late and include chest pain, syncope, heart failure, and sudden death from arrhythmias. Life expectancy averages only 5 years after exertional chest pain develops, and valve replacement is indicated for symptomatic patients. Clinically significant aortic stenosis is uncommonly encountered during pregnancy. Although mild to moderate degrees of stenosis are well tolerated, severe disease is life threatening. The principal underlying hemodynamic problem is the fixed cardiac output associated with severe stenosis. During pregnancy, a number of factors commonly decrease preload further and thus aggravate the fixed cardiac output. These include regional analgesia, vena caval occlusion, and hemorrhage. Importantly, these also decrease cardiac, cerebral, and uterine perfusion. It follows that severe aortic stenosis may be extremely dangerous during pregnancy. From the large Canadian multicenter study by Siu and co-workers (2001) cited above, there were increased complications when aortic valve area was [?] 1.5 cm2. And in the report described earlier by Hameed and associates (2001), the maternal mortality rate with aortic stenosis was 8 percent. Women with valve gradients exceeding 100 mm Hg appear to be at greatest risk.

Hypertrophic Cardiomyopathy

Concentric left ventricular hypertrophy may be familial, and there also is a sporadic form not related to hypertension, termed idiopathic hypertrophic subaortic stenosis. Epidemiological studies suggest that the disorder is common, affecting approximately 1 in 500 adults. The condition—characterized by cardiac hypertrophy, myocyte disarray, and interstitial fibrosis—is caused by mutations in any one of more than a dozen genes that encode proteins of the cardiac sarcomere. Inheritance is autosomal dominant, and genetic screening is complex and not currently clinically available. The abnormality is in the myocardial muscle, and it is characterized by left ventricular myocardial hypertrophy with a pressure gradient to left ventricular outflow. Diagnosis is established by echocardiographic identification of a hypertrophied and nondilated left ventricle in the absence of other cardiovascular conditions. Most affected women are asymptomatic, but dyspnea, anginal or atypical chest pain, syncope, and arrhythmias may develop. Complex arrhythmias may progress to sudden death, which is the most common form of death. Asymptomatic patients with runs of ventricular tachycardia are especially prone to sudden death. Symptoms are usually worsened by exercise.

Pregnancy with Prior Ischemic Heart Disease

The advisability of pregnancy after a myocardial infarction is unclear. Ischemic heart disease is characteristically progressive, and because it is usually associated with hypertension or diabetes, pregnancy in most of these women seems inadvisable. Certainly, pregnancy increases cardiac workload, and all of these investigators concluded that ventricular performance should be assessed using ventriculography, radionuclide studies, echocardiography, or coronary angiography prior to conception. If there is no significant ventricular dysfunction, pregnancy will likely be tolerated. Exercise tolerance testing may be indicated, and radionuclide ventriculography results in minimal radiation exposure for the fetus.

Management of Chronic Asthma. The most recent management guidelines of the Working Group on Asthma and Pregnancy include:

1.Patient education—general asthma management and its effect on pregnancy.

2.Environmental precipitating factors—avoidance or control.

3.Objective assessment of pulmonary function and fetal well-being—monitor with PEFR or FEV1.

4.Pharmacological therapy—in appropriate combinations and doses to provide baseline control and treat exacerbations (National Heart, Lung and Blood Institute, 2004). Treatment of acute asthma during pregnancy is similar to that for the nonpregnant asthmatic. An exception is a significantly lowered threshold for hospitalization. Intravenous hydration may help clear pulmonary secretions, and supplemental oxygen is given by mask. The therapeutic aim is to maintain the pO2 greater than 60 mm Hg, and preferably normal, along with 95-percent oxygen saturation. Baseline pulmonary function testing includes FEV1 or PEFR. Continuous pulse oximetry and electronic fetal monitoring may provide useful information. First-line therapy for acute asthma includes a [?]-adrenergic agonist, such as terbutaline, albuterol, isoetharine, epinephrine, isoproterenol, or metaproterenol, which is given subcutaneously, taken orally, or inhaled. These drugs bind to specific cell-surface receptors and activate adenylyl cyclase to increase intracellular cyclic AMP and modulate bronchial smooth muscle relaxation. Long-acting preparations are used for outpatient therapy. If not previously given for maintenance, inhaled corticosteroids are commenced along with intensive -agonist therapy. For severe exacerbations, inhaled ipratropium bromide is given. Corticosteroids should be given early to all patients with severe acute asthma. Unless there is a timely response to treatment, oral or parenteral preparations are given. Intravenous methylprednisolone, 40 to 60 mg, every 6 hours is commonly used. Equipotent doses of hydrocortisone by infusion or prednisone orally can be given instead. Because their onset of action is several hours, corticosteroids are given initially along with -agonists for acute asthma.

Labor and Delivery

Maintenance medications are continued through delivery. Stress-dose corticosteroids are administered to any woman given systemic steroid therapy within the preceding 4 weeks. The usual dose is 100 mg of hydrocortisone given intravenously every 8 hours during labor and for 24 hours after delivery. The PEFR or FEV1 should be determined on admission, and serial measurements are taken if symptoms develop. Oxytocin or prostaglandins E1 or E2 are used for cervical ripening and induction. A nonhistamine-releasing narcotic such as fentanyl may be preferable to meperidine for labor, and epidural analgesia is ideal. For surgical delivery, conduction analgesia is preferred because tracheal intubation can trigger severe bronchospasm. Postpartum hemorrhage is treated with oxytocin or prostaglandin E2. Prostaglandin F2 or ergotamine derivatives are contraindicated because they may cause significant bronchospasm.

Severe Acute Respiratory Syndrome (SARS)

This coronaviral respiratory infection was first identified in China in 2002. It causes atypical pneumonitis with a case-fatality rate of approximately 5 percent (Centers for Disease Control and Prevention, 2003b). Most cases were reported from Asia with an outbreak in Canada (Yudin and associates, 2005). Experience with SARS in pregnancy comes mostly from Wong (2004) and Lam (2004) and their colleagues from Hong Kong. From their review, Longman and Johnson (2007) reported a case-fatality rate in pregnancy of up to 25 percent. Ng and associates (2006) reported that the placentas from seven of 19 cases showed abnormal intervillous or subchorionic fibrin deposition in three, and extensive fetal thrombotic vasculopathy in two. One recent report noted improvement in maternal respiratory function when a pregnant woman with SARS underwent cesarean delivery (Oram and colleagues, 2007).

Renal diseases. Although some diseases of the kidney and urinary tract may be associated with pregnancy by chance, pregnancy often predisposes to the development of urinary tract disorders, an example being acute pyelonephritis. Infections of the urinary tract are the most common bacterial infections encountered during pregnancy. Although asymptomatic bacteriuria is more common, symptomatic infection may involve the lower tract to cause cystitis, or it may involve the renal calyces, pelvis, and parenchyma to cause pyelonephritis. Organisms that cause urinary infections are those from the normal perineal flora. There is now evidence that some strains of Escherichia coli have pili that enhance their virulence. In the early puerperium, bladder sensitivity to intravesical fluid tension is often decreased as the consequence of the trauma of labor as well as analgesia, especially epidural or spinal blockade. Sensations of bladder distension are also likely diminished by discomfort caused by a large episiotomy, periurethral lacerations, or vaginal wall hematomas. Asymptomatic bacteriuria refers to persistent actively multiplying bacteria within the urinary tract without symptoms and associated with preterm delivery and low-birthweight infants. Women with asymptomatic bacteriuria may be given treatment with any of several antimicrobial regimens. Selection can be chosen on the basis of in vitro susceptibilities, but most often is empirical. For example, treatment for 10 days with nitrofurantoin macrocrystals, 100 mg daily, has proved effective in most women. Other regimens include ampicillin, amoxicillin, a cephalosporin, nitrofurantoin, or a sulfonamide given four times daily for 3 day.

Acute pyelonephritis is the most common serious medical complication of pregnancy, occurring in 1 to 2 percent of pregnant women. The onset of pyelonephritis is usually rather abrupt. Symptoms include fever, shaking chills, and aching pain in one or both lumbar regions. There may be anorexia, nausea, and vomiting. The course of the disease may vary remarkably with fever to as high as 40°C or more and hypothermia to as low as 34°C. Tenderness usually can be elicited by percussion in one or both costovertebral angles. The urinary sediment frequently contains many leukocytes, frequently in clumps, and numerous bacteria. These serious urinary infections usually respond quickly to intravenous hydration and antimicrobial therapy. The choice of drug is empirical, and ampicillin, a cephalosporin, or an extended-spectrum penicillin is satisfactory. These serious urinary infections usually respond quickly to intravenous hydration and antimicrobial therapy. The choice of drug is empirical, and ampicillin, a cephalosporin, or an extended-spectrum penicillin is satisfactory.

Acute fatty liver failure. Acute liver failure may be caused by fulminant viral hepatitis, drug-induced hepatic toxicity, or acute fatty liver of pregnancy. The latter is also called acute fatty metamorphosis or acute yellow atrophy, and fortunately it is a rare complication of pregnancy that often has proved fatal for both mother and fetus. Typically, there is onset over several days to weeks of malaise, anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many women, vomiting is the major symptom. In perhaps half of these women, there is hypertension, proteinuria, and edema—signs suggestive of preeclampsia. Laboratory abnormalities include hypofibrinogenemia and prolonged clotting studies, hyperbilirubinemia of usually less than 10 mg/dL, and serum transaminase levels of 300 to 500 U/L. Peripheral blood shows hemoconcentration and leukocytosis, frequently mild thrombocytopenia, and evidence for hemolysis. In many woman, the syndrome worsens after diagnosis. Marked hypoglycemia is common, and obvious hepatic coma develops in 60 percent, severe coagulopathy in 55 percent, and there is evidence for renal failure in about half. Fetal death is common at this severe stage. Fortunately, either the disease is self-limited, or as generally accepted, delivery arrests rapid deterioration of liver function. During recovery, evidence for acute pancreatitis is common and ascites is almost universal. Recovery usually is complete and recurrence is rare.

Gestational diabetes. Gestational diabetes mellitus is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. This definition applies regardless of whether or not insulin is used for treatment. Undoubtedly, some women with gestational diabetes have previously unrecognized overt diabetes. Because gestational diabetes is typically a disorder of late gestation, hyperglycemia during the first trimester usually means overt diabetes. The most important perinatal concern was excessive fetal growth, which may result in birth trauma. Importantly, more than half of women with gestational diabetes ultimately develop overt diabetes in the ensuing 20 years, and there is mounting evidence for long-range complications that include obesity and diabetes in their offspring. Except for the brain, most fetal organs are affected by macrosomia that commonly (but not always) characterizes the fetus of a diabetic woman. fat infants of diabetic women more often required cesarean delivery for cephalopelvic disproportion. Advances in the management of the diabetic patient, such as tig"' metabolic control, availability of the fetal lung profile, and fetal biophysics profile determination, have obviated the need for early delivery. If ™e maternal state is stable, blood glucose is in the euglycemic range, and indicate continued growth of a healthy baby, delivery may be delayed to terrn and spontaneous onset of labor awaited.

Infections. Rubella, or German measles, a disease usually of minor import in the absence of pregnancy, has been directly responsible for inestimable pregnancy wastage, and even more importantly, for severe congenital malformations. Confirmation of rubella infection is often difficult. Not only are the clinical features of other illnesses quite similar, but about one fourth of rubella infections are subclinical despite viremia and infection of the embryo and fetus. Antibody signifies an immune response to rubella viremia. If maternal rubella antibody is demonstrated at the time of exposure to rubella or before, it is exceedingly unlikely that the fetus will be affected.

Congenital cytomegalovirus infection, termed cytomegalic inclusion disease, causes a syndrome that includes low birthweight, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, hemolytic anemia, and thrombocytopenic purpura.

➢ Management. There is no effective therapy for maternal infection Primary infection is diagnosed by fourfold increased IgG titers in paired acute and convalescent sera measured simultaneously, or preferentially by detecting IgM cytomegalovirus antibody in maternal serum. Recurrent infection usually is not accompanied by IgM antibody production. Unfortunately, neither of these methods is totally accurate to confirm maternal infection.

➢ Counseling regarding fetal outcome depends on the stage of gestation during which primary infection is documented. Even with a high infection rate with primary infection in the first half of pregnancy, the majority of infants develop normally.

Assignments for Self - assessment.

II. Multiple Choice.

Choose the correct answer / statement:

1-1. What is the incidence of cardiovascular disease complicating pregnancy?

a. 0.1%

b. 1%

c. 5%

d. 10%

1-2. During pregnancy cardiac output is increased by approximately what percentage?

a. 10

b. 33

c. 50

d. 67

1-3. Cardiac output reaches it's maximum at approximately which week of pregnancy?

a. 12

b. 20

c. 28

d. 36

1-4. In late pregnancy, which of the following contributes to the normal increase in cardiac output?

a. increased stroke volume

b. increased resting pulse rate

c. expanded blood volume

d. all of the above

1-5. When is heart failure and cardiac-related maternal death most common?

a. first trimester

b. second trimester

c. third trimester

d. peripartum

1-6. Which of the following symptoms or findings is the most likely indicator of heart disease in a pregnant patient?

a. nocturia

b. chest pain

c. tachycardia

d. peripheral edema

1-7. Which of the following cardiac signs is NOT a normal finding in pregnancy?

a. pericardial friction rub

b. 2/6 midsystolic murmur

c. brisk and diffuse cardiac apex pulsation

d. supraclavicular continuous venous hum

1-8. For which of the following procedures is pregnancy an absolute contraindication?

a. chest radiography b. 20lTl SPECT scintigraphy

c. 99Tc sestamibi perfusion imaging

d. none of the above

1-9. Which of the following is NOT an electrocardiographic change seen in normal pregnancy?

a. atrial premature beats

b. 15 degree left-axis deviation

c. P wave voltage increase of 50%

d. mild ST changes in the inferior leads

1-10. Using echocardiography which of the following is a common pregnancy-induced finding?

a. aortic insufficiency

b. mitral valve prolapse

c. tricuspid regurgitation

d. right atrial enlargement

1-11. Your patient states that she is comfortable at rest but that walking 40 yards to the mailbox causes shortness of breath and angina? What New York Heart Association classification would you assign to her?

a. I

b. II

c. III

d. IV

1-12. Which of the following conditions is categorized as a "Group 1-Minimal Risk" for maternal mortality by the New York Heart Association and the American College of Obstetricians and Gynecologists?

a. ventricular septal defect

b. pulmonary hypertension

c. prior myocardial infarction

d. Marfan syndrome with normal aorta

1-13. What is the approximate incidence of fetal congenital heart disease in the offspring of women born with cardiac anomalies?

a. 5%

b. 15%

c. 25%

d. 35%

1-14. Your patient has a cardiac lesion which places her at increased risk for heart failure during pregnancy. You counsel her that the most likely first symptom of early heart failure in pregnancy is which of the following?

a. heartburn

b. hemoptysis

c. palpitations

d. nocturnal cough

1-15. Your pregnant patient has mitral stenosis and is New York Heart Association functional class II. You plan all EXCEPT which of the following -during her pregnancy?

a. influenza vaccine

b. pneumococcal vaccine

c. intrapartum bacterial endocarditis prophylaxis

d. group B streptococcal vaginal and rectal -culture at 36 weeks

1-16. Which is the preferred intrapartum analgesia in most situations involving maternal heart disease?

a. paracervical block

b. intravenous analgesics

c. continuous epidural analgesia

d. spinal analgesia (saddle block)

1-3. Which of the following forms of analgesia is contraindicated in women with pulmonary hypertension?

a. spinal block

b. pudendal block

c. general anesthesia

d. intravenous analgesics

1-18. In general, which of the following is true of pregnancy complicated by a maternal mechanical valve prosthesis?

a. Fetal loss is rare.

b. Anticoagulation is mandatory

c. Cesarean delivery is recommended for most.

d. All of the above are true.

1-19. Compared with heparin, warfarin use is associated with high rates of which of the following?

a. stillbirth

b. spontaneous abortion

c. congenital malformation

d. all of the above

1-20. Disadvantages associated with porcine heart valves include which of the following?

a. lower durability

b. mandatory anticoagulation

c. high rates of thromboembolism

d. none of the above

1-21. With respect to heparin anticoagulation during pregnancy, which of the following laboratory parameters should be maintained at a level of 1.5 to 2.5 times the baseline value?

a. bleeding time

b. thrombin time

c. prothrombin time

d. partial thromboplastin time

1-22. Your patient has a mechanical prosthetic heart valve and is receiving heparin anticoagulation therapy. She presents to labor and delivery at 36 weeks gestation with persistent, heavy vaginal bleeding. Her vital signs are stable. Hemoglobin is 12 g/dL, platelet count is 185,000/µL and PTT is within the recommended therapeutic range. Sonographic evaluation reveals no evidence of placenta previa or placental abruption. Her cervix is 4 cm dilated with evidence of ruptured membranes. FHTs are 140 bpm with accelerations and no decelerations. What is the most appropriate next step in her care?

a. platelet transfusion

b. prompt cesarean delivery

c. protamine sulfate administration d. hypogastric artery angiographic embolization

1-23. How many hours following vaginal delivery should anticoagulation therapy for a mechanical prosthetic valve be reinstated?

a. 6

b. 18

c. 24

d. 36

1-24. Which of the following surgical treatments for symptomatic mitral stenosis in pregnancy is associated with the lowest maternal and fetal morbidity?

a. open mitral valvotomy

b. closed mitral valvotomy

c. mitral valve replacement

d. percutaneous balloon mitral valvuloplasty

1-25. Which of the following is currently the most common cause of mitral stenosis in women in the United States?

a. Lyme disease

b. Graves disease

c. rheumatic fever

d. congenital malformation

1-26. What is the approximate surface area (cm2) of a normal adult mitral valve?

a. 1

b. 2

c. 3

d. 4

1-27. Symptoms typically develop when the surface area (cm2) of a stenotic mitral valve narrows to below what value?

a. 0.5

b. 1.5

c. 2.5

d. 3.5

1-28. Which of the following is NOT a common symptom of mitral stenosis?

a. dyspnea

b. syncope

c. palpitations

d. hemoptysis

1-29. Suggested management decisions regarding the labor and delivery of a woman with mitral stenosis and an otherwise uncomplicated pregnancy include which of the following?

a. epidural analgesia

b. mandatory cesarean delivery

c. aggressive hydration prior to epidural analgesia

d. mandatory antimicrobial bacterial endocarditis prophylaxis

1-30. What is the primary hemodynamic problem associated with severe aortic stenosis?

a. fixed cardiac output

b. fixed cardiac preload

c. ineffectual ventricular contractility

d. hyperdynamic ventricular contractility

1-31. Suggested management decisions regarding the labor and delivery of a woman with aortic stenosis and an otherwise uncomplicated pregnancy include which of the following?

a. epidural analgesia

b. mandatory cesarean delivery

c. no intravenous hydration prior to epidural analgesia

d. mandatory antimicrobial bacterial endocarditis prophylaxis

1-32. Which of the following pregnancy-related hemodynamic changes is thought responsible for the negligible effects of aortic and mitral insufficiency during pregnancy?

a. increased cardiac output

b. decreased resting heart rate

c. decreased vascular resistance

d. increased ventricular contractility

1-33. What is the approximate incidence of congenital heart disease in the United States?

a. 8 per 100 live births

b. 8 per 1000 live births

c. 8 per 10,000 live births

d. 8 per 100,000 live births

1-34. Which of the following is the most common form of atrial septal defect (ASD)?

a. ovale type

b. ostium primum

c. ostium secundum

d. sinus venosus

1-35. Which of the following factors most adversely affects the maternal cardiac risk related to atrial septal defect (ASD) and pregnancy?

a. childhood repair of lesion

b. concurrent pulmonary hypertension

c. presence of sinus venosus type ASD

d. presence of ostium secundum type ASD

1-36. Which of the following is a possible complication of unrepaired ventricular septal defect?

a. bacterial endocarditis

b. Eisenmenger syndrome

c. pulmonary hypertension

d. all of the above

1-37. What is the incidence of fetal atrial or ventricular septal defect if the mother has such a defect?

a. 5 to 15%

b. 15 to 30%

c. 30 to 2%

d. 2 to 60%

1-38. Which of the following maternal conditions would most likely prompt the recommendation for pregnancy termination?

a. atrial septal defect

b. aortic regurgitation

c. bacterial endocarditis

d. Eisenmenger syndrome

1-39. Which of the following cardiac lesions is NOT associated with cyanosis?

a. mitral stenosis

b. Fallot tetralogy

c. Ebstein anomaly

d. coarctation of the aorta

1-40. Which of the following is NOT an associated finding in Fallot tetralogy?

a. overriding aorta

b. pulmonary stenosis

c. bicuspid aortic valve

d. right ventricular hypertrophy

1-41. Which of the following is the preferred mode of delivery in a woman with a cyanotic heart lesion?

a. vaginal delivery with spinal analgesia

b. vaginal delivery with epidural analgesia

c. elective cesarean delivery with epidural analgesia

d. elective cesarean delivery with general anesthesia

1-42. Eisenmenger syndrome may result from which of the following lesions?

a. atrial septal defect

b. patent ductus arteriosus

c. ventricular septal defect

d. all of the above

1-43. Which of the following is the LEAST common underlying cause of pulmonary hypertension?

a. atrial septal defect

b. patent ductus arteriosus

c. ventricular septal defect

d. idiopathic primary pulmonary hypertension

1-1. Which drug used for long-term therapy of pulmonary hypertension dilates and lower, pulmonary vascular resistance?

a. minoxidil

b. hydralazine

c. epoprostenol

d. nitroglycerin

1-2. Mitral valve prolapse most commonly presents with which of the following?

a. syncope

b. chest pain

c. palpitations

d. no symptoms

1-3. Which of the following statements is true of mitral valve prolapse?

a. It has a general population incidence of 12 to

15%.

b. It is commonly associated with other cardiac lesions.

c. It typically presents with palpitations and syncope.

d. None of the above are true

1-47. Which of the following etiological factors has been identified in women with peripartum cardiomyopathy?

a. mitral stenosis

b. viral myocarditis

c. chronic hypertension

d. all of the above

1-48. Myocardial biopsy in women with presumed idiopathic cardiomyopathy most commonly reveals which of the following?

a. gummas

b. myocarditis

c. caseating granulomas

d. myxomatous degeneration

1-49. Which of the following conditions carries the highest risk for bacterial endocarditis?

a. mitral valve prolapse without valvar regurgitation

b. cardiac pacemaker in place

c. prior coronary bypass graft surgery

d. porcine prosthetic cardiac valve in place

1-50. Which of the following is the most common cause of bacterial endocarditis, both acute and subacute forms?

a. Streptococcus viridans

b. Streptococcus aureus

c. Neisseria gonorrhoeae

d. Streptococcus pneumoniae

1—51. Which of the following is a nearly universal characteristic of endocarditis?

a. fever

b. syncope

c. headache

d. scleral petechias

1-52. Which of the following antimicrobial combinations is recommended for bacterial endocarditis prophylaxis?

a. ampicillin plus gentamicin

b. ampicillin plus doxycycline

c. penicillin G plus doxycycline

d. vancomycin plus clindamycin

1-53. Which of the following is contraindicated for the treatment of arrhythmias in pregnancy?

a. digoxin

b. cardiac pacemaker

c. electrical cardioversion

d. none of the above

1-54. Which of the following is the most commonly seen cardiac arrhythmia?

a. atrial fibrillation

b. complete heart block

c. ventricular tachycardia

d. paroxysmal supraventricular tachycardia

1-55. Which of the following, if chronic during pregnancy, requires heparin anticoagulation therapy?

a. atrial fibrillation

b. ventricular tachycardia

c. first-degree heart block

d. paroxysmal supraventricular tachycardia

1-56. A pregnant patient at 32 weeks' gestation is brought to the emergency room following a syncopal episode. She complains of a sudden onset of chest pain that she describes as constant and "ripping" in nature and states that it radiates to her back (pointing to her interscapular area). Her BP is 150/98, pulse is 90, temperature is 98.8°F. and respiratory rate is 14. Neurological examination reveals no abnormalities. Her cardiac examination reveals weak peripheral pulses and a murmur consistent with aortic regurgitation. Your initial questioning should include a search for which of the following possible underlying etiologies?

a. Turner syndrome

b. Marfan syndrome

c. Noonan syndrome

d. all of the above

1-57. The patient in Question 56 is found to have nonspecific ST changes on ECG. Her chest radiograph shows a widened mediastinum and abnormal aortic arch contour. Which of the following tests is considered definitive for identification of this disorder?

a. echocardiography

b. aortic angiography

c. computed tomography of head

d. magnetic resonance imaging of chest

1-58. Women are at increased risk for cardiovascular complications during pregnancy with an aortic root diameter greater than which of the following?

a. 20 mm

b. 30 mm

c. 40 mm

d. 50mm

1-59. Of the following, which is the most commonly associated complication of aortic coarctation?

a. aortic rupture

b. atrial fibrillation

c. tricuspid regurgitation

d. pulmonary hypertension

1-60. Women are at greatest mortality risk if a myocardial infarction occurs during which of the following periods?

a. early first trimester

b. early second trimester

c. late second trimester

d. late third trimester

1-61. The most common cause of nonfamilial left ventricular hypertrophy is which of the following?

a. diabetes

b. mitral stenosis

c. pulmonic stenosis

d. chronic systemic hypertension

1-62. What is the most common cause of death in women with hypertrophic cardiomyopathy?

a. stroke

b. arrhythmia

c. aortic dissection

d. vascular occlusion

Chapter 2. Chronic Hypertension

2-1. Risk factors for the development of chronic hypertension include which of the following?

a. heredity

b. smoking

c. parity >3

d. prior molar pregnancy

2-2. In nonpregnant women, antihypertensive therapy for mild to moderate hypertension has been shown to decrease the incidence of which of the following?

a. infertility

b. mortality

c. diabetes

d. endometrial cancer

2-3. Nonpharmacological interventions to treat hypertension include all EXCEPT which of the following?

a. weight loss

b. high-fat diet

c. physical activity

d. smoking cessation

2-4. Your nonpregnant patient's blood pressure measures 13/94 on several visits and persists despite lifestyle changes. The first-line treatment agent for her should come from which of the following antihypertensive medication groups?

a. thiazide-type diuretics

b. calcium-channel blockers

c. β-adrenergi.c receptor blocker

d. angiotensin-converting enzyme inhibitors

2-5. Your nonpregnant patient's blood pressure measures 164/98 on two separate visits. The most effective treatment for this patient typically requires which of the following?

a. sodium-lowering diet plus thiazide-type diuretic

b. sodium-lowering diet plus β-adrenergic receptor blocker

c. thiazide-type diuretic plus angiotensin-converting enzyme inhibitor

d. angiotensin-converting enzyme inhibitor plus angiotensin-receptor blocker

2-6. Evaluation of uncomplicated, long-standing, chronic hypertension early in pregnancy includes all EXCEPT which of the following?

a. echocardiography

b. serum creatinine level

c. ophthalmological evaluation

d. serum thyroid-stimulating hormone level

2-7. In hypertensive women, adverse pregnancy outcomes most commonly occur when which of the following is also present?

a. parity >3

b. renal dysfunction

c. prior molar pregnancy

d. prior deep venous thrombosis

2-8. Pregnant women with chronic hypertension are at greatest risk compared with nonhypertensive controls for which of the following adverse events?

a. placental abruption

b. deep venous thrombosis

c. first-trimester abortion

d. postpartum cardiomyopathy

2-9. The development of superimposed preeclampsia in a chronic hypertensive patieritis increased proportionately with which of the following?

a. severity of baseline obesity

b. severity of baseline hypertension

c. number of family members with hypertension

d. number of family members with prior preeclampsia

2-10. Low-dose aspirin therapy during pregnancy in women with chronic hypertension has been shown in some studies to decrease the incidence of which of the following?

a. eclampsia

b. preterm labor

c. oligohydramnios

d. cesarean delivery

2-11. Which adverse pregnancy outcome is NOT increased in pregnancies completed by chronic hypertension?

a. preterm birth

b. perinatal death

c. fetal-growth restriction

d. spontaneous preterm rupture of membranes

2-12. In chronically hypertensive women, which of the following is most commonly associated with fetal-growth restriction?

a. maternal obesity

b. increased maternal age

c. increased maternal parity

d. maternal hyperthyroidism

2-13. What is the mechanism of action of alphamethyklopa?

a. relaxes arterial smooth muscles

b. increased sodium and water diuresis

c. increased peripheral vascular resistance

d. acts centrally to decrease vascular tone

2-14. Your pregnant patient persistently displays blood pressure readings of 150/104. The most appropriate first-line therapy for this patient includes which of the following?

a. thiazide-type diuretics

b. calcium-channel blocker

c. central-acting anti-adrenergic agents

d. angiotensin-converting enzyme inhibitors

2-15. Angiotensin-converting enzyme inhibitors are contraindicated in pregnancy due to what fetal effects?

a. cardiac defects

b. fetal renal defects

c. thrombocytopenia

d. patent ductus arteriosus

2-16. Beta-blockers, in particular atenolol, are associated with which of the following perinatal morbidities?

a. preterm birth

b. hyperglycemia

c. fetal-growth restriction

d. respiratory distress syndrome

2-3. The criteria that support the diagnosis of superimposed preeclampsia in women with underlying chronic hypertension include all of the following EXCEPT

a. severe headache

b. thrombocytopenia

c. new-onset proteinuria

d. iron-deficiency anemia

2-18. What is the risk of superimposed pregnancy-induced hypertension in women with chronic hypertension?

a. 30 per min

3-11. What is first-line therapy in a pregnant woman with uncomplicated community-acquired pneumonia?

a. dicloxicillin

b. clindamycin

c. ampicillin

d. erythromycin

3-12. What is the approximate percentage of penicillin-resistant pneumococcus?

a. 2

b. 5

c. 10

d. 20

3-13. Which of the following perinatal complications is associated with bacterial pneumonia?

a. fetal growth retardation

b. preterm labor

c. persistent fetal circulation

d. cerebral palsy

3-14. Pneumococcal vaccine should be given for which of the following conditions?

a. sickle-cell disease

b. gestational diabetes

c. pregnancy-induced hypertension

d. all pregnancies

3-15. Pregnant women with which condition should be vaccinated against influenza no matter what stage of pregnancy?

a. allergic rhinitis

b. hyperthyroidism

c. insulin-dependent diabetes

d. all pregnancies

3-16. What are the current Centers for Disease Control and Prevention recommendations for influenza vaccine (not Flumist) in pregnancy?

a. vaccinate only high-risk women

b. vaccinate only if epidemic is expected

c. vaccinate only if a new virus is expected

d. ail should be vaccinated

3-3. What is the treatment of choice for chemopro-phylaxis and treatment of influenza in pregnancy?

a. oseltamivir

b. amantadine

c. acyclovir

d. ganciclovir

3-18. Which of the following may be associated with in utero exposure to influenza A infection at mid-pregnancy?

a. hallucinations

b. bipolar disorder

c. schizophrenia

d. depression

3-19. Primary infection with varicella leads to pneumonia in what percentage of adults?

a. 10

b. 20

c. 30

d. 40

3-20. In a seronegative individual who is exposed to active infection, what is the attack rate of varicella?

a. 30%

b. 50%

c. 70%

d. 90%

3-21. What is a risk factor for varicella pneumonia in pregnancy?

a. >100 skin lesions

b. smoking

c. no prior infection

d. all of the above

3-22. Which of the following agents lowers the incidence-land severity of varicella pneumonia?

a. amantadine

b. varicella-zoster immunoglobulin

c. gamma-globulin

d. all of the above

3-23. What was the mortality rate of varicella pneumonia during pregnancy reported by the NIH Maternal-Fetal Medicine Units Network?

a. 300 mg/d and hypolipidemia

4-31. Of the following which is the most common cause of nephrotic syndrome?

a. membranous glomerulopathy

b. minimal change disease

c. poststreptococcal glomerulonephritis

d. amyloidosis

4-32. Successful pregnancy outcome can be anticipated despite maternal nephrosis in which of the following circumstances?

a. The patient is normotensive. b. Renal insufficiency is moderate. c. Proteinuria is ................
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