• Obstetric cardiac disease
    • Patients may present before 28wks as the maximal pre-delivery co is achieved
    • Physiological changes
      • Peripheral vasodilatation leads to reduction in SVR
      • Co increases by 40-50% mainly by increased SV
      • There is auto transfusion of 300-500ml during contractions. This combined with SNS stimulation and reduced colloid osmotic pressure make women susceptible to p.o.
    • General management
      • Pre delivery
        • Ideally under shared care of cardiologists, obstetricians and anaesthetists
        • Clear plan established in advance
        • Optimise mothers condition pre-conceptually and during pregnancy
        • Consider tertiary referral and place of delivery
      • Mode of delivery
        • Usually vaginal unless there is a deterioration in cardiac status
        • Aim for spontaneous onset of labour, low dose epidural and assisted vaginal delivery with forceps/ventouse
        • General anaesthesia is also an option
        • Maintenance of haemodynamic stability is more important than the technique chosen
        • Oxytocin bolus should be omitted
        • Ergometrine and carboprost are not recommended
      • Postpartum
        • High levels of maternal surveillance up to 2 weeks
        • Development of peripartum cardiomyopathy can occur up to 5 months post delivery
    • Specific disease
      • MI
        • Most have identifiable risk factors
        • The treatment of choice is PCI
        • Aim for haemodynamic stability with GA, CSE or epidural
      • Aortic dissection
        • Commoner in Marfans
        • Risk near full term and immediate postpartum
        • If aortic root diameter >4cm the risk of rupture is higher
        • Consider root replacement pre-conception
        • Monitor every 4-8wks
      • Valvular heart disease
        • MS commoner in immigrant populations
        • High risk of pulmonary oedema esp with pre-eclampsia
        • Use slow epidural if SVD is to be tried
        • MR and AR are generally well tolerated due to vasodilatation of pregnancy
        • AS carries high risk - avoid sudden vasodilatation
      • PAH
        • Very high risk
        • Mortality 30-50%
        • Use PA vasodilators (eg sildenafil)
        • Delivery under 'cardiac' anaesthetic
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/9/2/44.full.pdf