Women with various medical conditions were seen in an antenatal clinic.
Which condition would pose the highest risk of serious maternal morbidity or maternal death?

An obese 39-year-old smoker is admitted with chest pain at 34 weeks' gestation. She had been
offered LMWH thromboprophylaxis but declined as she doesn’t want to self-inject. The pain came
on suddenly and has been present for 90 minutes so far. It radiates to her back, between her
shoulder blades. She also has some pins and needles in one arm. The midwife noticed that her
blood pressure is different in the two arms. On examination a harsh systolic murmur is heard.
What is the most likely diagnosis?

For how long is the cumulative risk of type 2 diabetes highest after a pregnancy complicated
by gestational diabetes?

The NICE guideline for gestational diabetes recommends that affected women with are
offered screening for type 2 diabetes after delivery. What is this recommendation?

A 30-year-old has had her third baby at 36 weeks of gestation following an induced labour on
account of pre-eclampsia. Her previous pregnancies were also complicated by pre-eclampsia.
What would be the effect of her recurrent pre-eclampsia on her risk of hypertension in later life?

You review a 38-year-old Black African woman in the labour suite who is currently 40 weeks
into her second pregnancy. She had an uncomplicated vaginal delivery at term 4 years ago.
She presents with worsening breathlessness and palpitations over the last few days. She also
mentions that she requires four pillows to sleep at night. She denies any chest pain, cough or
syncope. There is no past cardiac or respiratory history of note. On examination:

BMI = 35
• pulse = 134 bpm and regular
• blood pressure = 130/78 mmHg
• respiratory rate = 28 breaths per minute
• SpO2 on air = 94%
• chest clear
• normal first and second heart sounds with gallop rhythm
• mild-to-moderate peripheral oedema.
An ECG shows sinus tachycardia and a chest X-ray shows an enlarged heart with pulmonary
congestion. Her arterial blood gas is normal. She has been reviewed by the cardiologist and had an
urgent echocardiogram, which shows moderate left ventricular dysfunction.

6) Which of the following is not a risk factor for her clinical condition?

7) What is the most common non-benign arrhythmia in pregnancy?

A woman with mitral stenosis and atrial fibrillation asks your advice about contraception. She
is anticoagulated because of her atrial fibrillation. What would you advise?

A 29-year-old who presents with palpitations and mild chest pains is examined and following
an assessment is diagnosed to have supraventricular tachycardia (SVT). What would be the initial
treatment of this patient?

A woman presents to the antenatal clinic with palpitations. She describes these as episodes of
a fast heartbeat which last about 5–10 minutes and occur roughly once a week. They can come on
suddenly at any time. She hasn’t blacked out with them, but feels anxious when they happen. She
hasn’t had any heart problems before, but her father has had a heart attack aged 55. There is no
other family history of note.

A 20-year-old woman attends the obstetric cardiology clinic with her partner for prepregnancy counselling. She has a repaired tetralogy of Fallot (ToF) and is contemplating her first
pregnancy. She is asymptomatic and her recent echocardiogram showed mild pulmonary
regurgitation.

11) What advice would you give her regarding her likely pregnancy outcome?

You are asked to review a 25-year-old woman in the antenatal clinic who is known to have
Marfan syndrome. She is currently at 12 weeks of gestation in her first pregnancy. At 15 years of
age, she suffered from dislocation of the lens (right eye). She has never had any cardiac symptoms
and her aortic root diameter was 4.5 cm on her last echocardiogram (2 months ago). She has no
other medical or surgical history of note. Currently, she is not on any medications. Her father and
her uncle died of aortic dissection.
She is planning to have an elective caesarean section.
On examination:
• BMI = 22
• pulse = 60 bpm and regular
• blood pressure = 110/50 mmHg
• chest clear with normal heart sounds.

12) Which risk factor in her history increases her risk of aortic root dissection?

You are asked to review a 22-year-old woman who is known to have mitral stenosis. She is
currently at 12 weeks of gestation in her first pregnancy. She has had percutaneous mitral
commisurotomy in the past. Currently she is asymptomatic and is not on any medications. There is
no other medical or surgical history of note.
On examination:
• BMI = 22
• Pulse = 60 beats/minute and regular
• BP = 110/50 mm Hg
• Chest = clear; loud heart sounds with diastolic murmur over mitral area.
A recent echocardiogram showed moderate mitral stenosis with a large left atrium.

13) What plan would you put in place to optimally manage her pregnancy?

14) What is the ejection fraction likely to be during a normal pregnancy?

15) Five women come to a maternal medicine clinic. Alice has had a bioprosthetic aortic valve replacement; Bushra has mitral regurgitation; Camelia has aortic regurgitation; Della has mild aortic stenosis and Elaine has a mechanical prosthetic mitral valve. They are all primiparous, and have no other risk factors.

Which one are you most concerned about?

A 40-year-old woman presents to the emergency department with acute chest pain. She is 28
weeks pregnant with DCDA twins conceived through IVF. She has a BMI of 40.
Which ECG change will best support a diagnosis of myocardial infarction?

17) Which women presenting with palpitations are particularly at risk of arrhythmias?

18) Risk factors for ischaemic heart disease include all except;

19) What cardiovascular changes would you expect from 8 weeks of gestation?

20) ECG changes that are physiological, not pathological, during pregnancy are all except;