Which of the following is/are true about contraception in women with cardiac disease?

• a)
  

  As bosentan is a cytochrome P450 enzyme inhibitor, women with pulmonary arterial hypertension receiving bosentan need an increased dose of desogestrel.

  
  
• b)
  

  Levonorgestrel-containing contraceptives may carry a slightly lower risk of thromboembolic disease compared with combined hormonal contraceptives.

  
  
• c)
  

  Progestogen-only contraception is a suitable form of contraception for women taking long-term anticoagulation therapy (e.g. those with metallic prosthetic cardiac valves).

  
  
• d)
  

  After unprotected sexual intercourse, a copper intrauterine device can be placed up to 140 h after intercourse to be effective for emergency contraception.

  
  
• e)
  

  The Nexplanon® contraceptive implant needs replacing every year.

Which of the following is/are true about anticoagulation in pregnant women with prosthetic heart valves disease?

• a)
  

  Biosynthetic grafted-tissue heart valves do not need anticoagulation during pregnancy.

  
  
• b)
  

  A trough anti-Xa level measured 4 h after administering low molecular weight heparin should be between 0.8 and 1.2 IU/ml.

  
  
• c)
  

  3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins) are contraindicated in pregnancy.

  
  
• d)
  

  Warfarin is associated with a risk of embryopathy between 12 and 16 weeks of gestation.

  
  
• e)
  

  The risk of embryopathy seems to be low in women taking warfarin doses of 5 mg per day or less

Which of the following about heart disease in pregnancy is/are true?

• a)
  

  In young women, the main cause of aortic stenosis is congenital bicuspid aortic valves.

  
  
• b)
  

  Clopidogrel is contraindicated in pregnancy.

  
  
• c)
  

  Spontaneous coronary artery dissection is more common during late pregnancy or around the time of delivery.

  
  
• d)
  

  The most common cardiac abnormality in women with Marfan syndrome is tricuspid valve prolapse and regurgitation.

  
  
• e)
  

  Amiodarone is the preferred drug of choice to treat supraventricular tachycardias in pregnant women.

Which of the following is/are true about pregnancy-related risks?

• a)
  

  The number of women with acquired heart disease becoming pregnant has risen, but the number with congenital heart disease becoming pregnant has remained static, as these women are more aware of the pregnancy-related risks.

  
  
• b)
  

  Eisenmenger syndrome has a lower risk of perinatal mortality than transposition of the great arteries.

  
  
• c)
  

  Women with transposition of the great arteries who have had an arterial switch procedure are at risk of systemic ventricular failure during pregnancy.

  
  
• d)
  

  Failure to raise heart rate appropriately during cardiopulmonary exercise testing is associated with adverse cardiac events during pregnancy.

  
  
• e)
  

  Severe pulmonary regurgitation is a predictor of poor outcome in women with Tetralogy of Fallot.

Which of the following is/are features of the CARPREG score?

• a)
  

  Prior cardiac event (heart failure, transient ischemic attack, or stroke before pregnancy) or arrhythmia.

  
  
• b)
  

  Baseline NYHA class > III or cyanosis.

  
  
• c)
  

  Left heart obstruction (mitral valve area <2 cm ² , aortic valve area <1.5 cm ² , or peak left ventricular outflow tract gradient >30 mm Hg by echocardiography).

  
  
• d)
  

  Reduced systemic ventricular systolic function (ejection fraction ≤50%).

  
  
• e)
  

  A total score of over 1 indicates a 50% chance of a serious cardiac event in pregnancy.

Which women with the following conditions is/are at increased risk of aortic dissection in pregnancy?

• a)
  

  Marfan syndrome.

  
  
• b)
  

  Ehlers Danlos Syndrome type IV.

  
  
• c)
  

  Bicuspid aortic valve.

  
  
• d)
  

  Turner’s syndrome.

  
  
• e)
  

  Coarctation of aorta.

Which of the following is/are true about recurrence risk?

• a)
  

  The chance of a mother with congenital heart disease, having a fetus with congenital heart disease is about 20%.

  
  
• b)
  

  The chance of a mother with Marfan syndrome having a child with Marfan syndrome is 1:4 as it is autosomal recessively inherited.

  
  
• c)
  

  All daughters of mother’s with Turner’s syndrome (XO) will also have Turner’s syndrome.

  
  
• d)
  

  The chance of peripartum cardiomyopathy recurring in a subsequent pregnancy is 30–50%.

  
  
• e)
  

  The chance of a fetus inheriting the q22 gene from a parent with Di George syndrome is 50%.

A 30-year old woman with repaired Tetralogy of Fallot attends the pre-conception clinic for counselling. She is well and symptom free. Which of the following is/are true?

• a)
  

  A lack of symptoms means that this woman is at low risk.

  
  
• b)
  

  The woman should be offered genetic testing.

  
  
• c)
  

  The woman should have a pre-conception cardiac magnetic resonance scan if not carried out recently.

  
  
• d)
  

  The major risk for this woman is pulmonary hypertension.

  
  
• e)
  

  Delivery at 38 weeks is indicated.

Which of the following is/are true about planning delivery in a woman with congenital heart disease?

• a)
  

  Cardiac features are more important than obstetric features.

  
  
• b)
  

  Those at increased risk should be delivered by Caesarean section.

  
  
• c)
  

  Regional anaesthesia is contraindicated as it causes vasodilatation.

  
  
• d)
  

  Invasive monitoring with an arterial line is mandatory.

  
  
• e)
  

  All patients should be delivered in a regional specialist centre.

Intrauterine growth restriction is commonly seen in pregnancies associated with:

• a)
  

  An unrepaired maternal VSD.

  
  
• b)
  

  Arrhythmia treated with beta-blockade.

  
  
• c)
  

  Women who have undergone the Fontan procedure.

  
  
• d)
  

  Repaired coarctation and a normal blood pressure.

  
  
• e)
  

  Women with severe pulmonary regurgitation.

Which of the following statements is/are true about pregnancy and the aorta?

• a)
  

  Aortic wall compliance increases in pregnancy.

  
  
• b)
  

  Women with an aortic diameter below 40 mm have no need for follow up during pregnancy.

  
  
• c)
  

  The tunica media is thought to be more vulnerable during pregnancy owing to loss of structure of the elastic fibres.

  
  
• d)
  

  There is hypertrophy of smooth muscle fibres in the media layer.

  
  
• e)
  

  There is hyperplasia of smooth muscle fibres in the media layer.

Which of the following statements is/are true about Marfan syndrome in pregnancy?

• a)
  

  Women should be advised against pregnancy if the aortic diameter is larger than 40 mm.

  
  
• b)
  

  Other factors such as prior dissection and family history alter the risk.

  
  
• c)
  

  Pregnancy probably has an irreversible effect on the aortic diameter.

  
  
• d)
  

  An emergency operation is indicated when a type A dissection occurs.

  
  
• e)
  

  In women with Marfan syndrome, Caesarean section is preferred regardless of the aortic diameter.

In Turner syndrome, dissection has been shown to be related to:

• a)
  

  The second trimester.

  
  
• b)
  

  The postpartum period.

  
  
• c)
  

  Presence of a bicuspid aortic valve.

  
  
• d)
  

  Presence of coarctation.

  
  
• e)
  

  Altered course of the aortic arch.

Which of the following statements is/are true about delivery in women with aortic disease?

• a)
  

  Caesarean section is preferred in women with an aortic diameter exceeding 45 mm.

  
  
• b)
  

  Epidural anaesthesia is contra-indicated in women with Marfan syndrome.

  
  
• c)
  

  Epidural injection may be more difficult in women with Marfan syndrome.

  
  
• d)
  

  Vaginal delivery in women with an aortic diameter below 40 mm can be carried out in a similar manner to that in the normal population.

  
  
• e)
  

  In acute aortic dissection, use of nitroprusside should be avoided if the fetus is still in utero.

Which of the following is/are contraindications to regional anaesthesia for Caesarean section?

• a)
  

  Fontan circulation

  
  
• b)
  

  Severe pulmonary hypertension

  
  
• c)
  

  Severe aortic stenosis

  
  
• d)
  

  Decompensated heart failure

  
  
• e)
  

  Mechanical valve with full anti-coagulation

Which of the following is/are true about the use of oxytocin after a Caesarean delivery in women with cardiac disease?

• a)
  

  It causes a decrease in SVR of up to 50%.

  
  
• b)
  

  A bolus dose should always be given if possible.

  
  
• c)
  

  Ephedrine is the vasopressor of choice if hypotension occurs.

  
  
• d)
  

  It may cause ST changes on electrocardiography.

  
  
• e)
  

  It should be given in combination with ergometrine in women with pulmonary hypertension.

A woman presents in the first trimester with a history of a distal deep vein thrombosis (DVT) 2 years previously when she fractured her leg in a skiing accident. Which of the following is/are true?

• a)
  

  She has a 25% risk of developing a recurrent venous thromboembolism in her pregnancy and should be offered thromboprophylaxis.

  
  
• b)
  

  If she had also been taking the combined oral contraceptive pill (COC) at the time of her DVT, antenatal and postpartum thromboprophylaxis would usually be recommended.

  
  
• c)
  

  If indicated, antenatal thromboprophylaxis should be started by the third trimester.

  
  
• d)
  

  Regional analgesia or anaesthesia is considered safe in women taking prophylactic dose low molecular weight heparin (LMWH) as long as there is a 12 h gap between the last dose and placement of the neuraxial catheter.

  
  
• e)
  

  Postpartum prophylaxis with LMWH is preferable as warfarin crosses into the breast milk in clinically relevant amounts.

Women with mechanical prosthetic heart valves (MPHV) require therapeutic levels of anticoagulation throughout pregnancy. Which of the following is/are true?

• a)
  

  Warfarin is effective at preventing thrombo-embolic complications in over 99% of women with MPHV.

  
  
• b)
  

  Warfarin embryopathy occurs in 5–12% of infants exposed to warfarin between 12 and 14 weeks gestation.

  
  
• c)
  

  Late fetal loss and stillbirth occur more commonly with higher doses of warfarin.

  
  
• d)
  

  Women taking therapeutic doses of anticoagulation must be delivered by elective Caesarean section.

  
  
• e)
  

  Women who have received therapeutic doses of LMWH are unable to have an epidural for analgesia during labour.

In the presence of a maternal cardiac arrest, lateral tilt of the woman during active resuscitation is not advocated because:

• a)
  

  Lateral tilt has been shown to be of no value in pregnancy.

  
  
• b)
  

  It may be difficult to achieve adequate tilt for a pregnant woman during resuscitation.

  
  
• c)
  

  It may interfere with effective chest compressions.

  
  
• d)
  

  It may cause fetal trauma.

  
  
• e)
  

  It may delay other aspects of the resuscitation.

During maternal cardiac arrest, left uterine displacement is recommended because:

• a)
  

  The woman can remain supine.

  
  
• b)
  

  It is associated with a lower incidence of hypotension.

  
  
• c)
  

  It facilitates effective chest compressions.

  
  
• d)
  

  It facilitates fetal monitoring during the arrest.

  
  
• e)
  

  It moves the uterus to a more inferior position in the abdomen, facilitating adequate maternal resuscitation.

The American Heart Association guideline for resuscitation of maternal cardiac arrest is important because it:

• a)
  

  Provides guidance for the sequence of responders’ activities.

  
  
• b)
  

  Advises that the hands are placed lower on the sternum to improve compressions.

  
  
• c)
  

  Recommends delayed defibrillation if the woman is pregnant.

  
  
• d)
  

  Advocates re-bolusing with magnesium for women receiving intravenous magnesium.

  
  
• e)
  

  Provides the first published algorithm for cardiac arrest in pregnancy.

Peri-mortem Caesarean section has been shown to:

• a)
  

  Improve survival rates for babies, but not mothers.

  
  
• b)
  

  Be an appropriate step after 4 mins of unsuccessful resuscitation.

  
  
• c)
  

  Ideally occur in a sterile environment.

  
  
• d)
  

  Virtually never improve maternal haemodynamic parameters.

  
  
• e)
  

  Be more appropriately used after participation in training programmes.

Which of the following is/are true about adaptation to the physiological changes of pregnancy in women with pulmonary hypertension?

• a)
  

  In Eisenmenger syndrome an increase of left-to-right shunting is expected.

  
  
• b)
  

  In Eisenmenger syndrome, hypercoagulation occurs and bleeding risk decreases.

  
  
• c)
  

  In Eisenmenger syndrome, the fall in systemic vascular resistance causes a decrease in systemic oxygen saturation.

  
  
• d)
  

  Increase in blood volume and cardiac output causes right heart failure, whereas pulmonary pressures do not change significantly.

  
  
• e)
  

  Local vascular thrombosis is a typical risk in group 4 pulmonary hypertension (chronic thrombo-embolic pulmonary hypertension) but not in group 1 (pulmonary arterial hypertension).

Which of the following is/are true about mortality risk in pregnancy?

• a)
  

  Pulmonary hypertension has been identified as a predictor of mortality in the European Registry on Pregnancy and Cardiac Disease.

  
  
• b)
  

  Women with idiopathic pulmonary arterial hypertension have a higher mortality risk than women with pulmonary arterial hypertension associated with congenital heart disease.

  
  
• c)
  

  Mortality is significantly lower in pregnant women with mild pulmonary hypertension compared with women with severe pulmonary hypertension.

  
  
• d)
  

  Death occurs mainly during the postpartum period in women with pulmonary hypertension.

  
  
• e)
  

  New York Heart Association functional class and the use of advanced pulmonary hypertension therapies have been identified as predictors of mortality in two previously published reviews.

Which of the following is/are true about the medical treatment of pregnant women with pulmonary hypertension?

• a)
  

  Tadalafil is contra-indicated because of fetotoxicity.

  
  
• b)
  

  Calcium channel blockers are advised in women with Eisenmenger syndrome.

  
  
• c)
  

  Advanced pulmonary hypertension therapies have proven efficacy in all groups of pulmonary hypertensions except in group 3 (pulmonary hypertension due to lung diseases, hypoxia, or both).

  
  
• d)
  

  Because hypoxia leads to erythrocytosis with hyperviscosity, all women with Eisenmenger syndrome should be treated with anticoagulants throughout pregnancy.

  
  
• e)
  

  Research suggests that women in which advanced therapy is started at delivery or postpartum have higher mortality than women in whom this therapy is started more than 1 week before delivery.

Which of the following is/are true about the management of contraception and pregnancy in pregnant women with pulmonary hypertension?

• a)
  

  Endothelin receptor blockers reduce the efficacy of oral contraceptives.

  
  
• b)
  

  As prostacyclin derivates and phosphodiesterase inhibitors are the main contributors to the improved prognosis of pregnant women with pulmonary arterial hypertension, they should be given routinely.

  
  
• c)
  

  When a woman with pulmonary hypertension presents with pregnancy, termination is advisable and can be carried out with low risk.

  
  
• d)
  

  Caesarean section with general anaesthesia is the preferred mode of delivery.

  
  
• e)
  

  As barrier methods of contraception pose no health risk for the woman, they are the preferred mode of contraception.

In pregnant woman with mitral stenosis, which of the following statements is/are true?

• a)
  

  Mitral valve intervention is recommended before pregnancy in women with severe mitral stenosis.

  
  
• b)
  

  In women with mitral stenosis, the most common cardiac complications during pregnancy are atrial arrhythmias (i.e. atrial fibrillation) and pulmonary oedema.

  
  
• c)
  

  Beta-blockers are recommended for the treatment of mitral stenosis during pregnancy.

  
  
• d)
  

  In women who remain symptomatic despite medical treatment, percutaneous balloon valvuloplasty should be considered.

  
  
• e)
  

  Women who develop atrial fibrillation during pregnancy should be treated with aspirin.

Which of the following statements is/are true about the management of women with mechanical heart valves during pregnancy?

• a)
  

  Thromboembolic complications are increased during pregnancy.

  
  
• b)
  

  Anticoagulation with low molecular weight heparin is not recommended for women with mechanical valves during pregnancy.

  
  
• c)
  

  Women with mechanical valves who are anticoagulated with low molecular weight heparin should have regular peak anti-Xa levels measured.

  
  
• d)
  

  Maternal INR measurements are a good guide to fetal INR effects.

  
  
• e)
  

  If labour begins while a woman is taking warfarin, a Caesarean delivery is indicated.

You are asked to review a patient’s ECG on the delivery unit. The following ECG changes are normal during pregnancy:

• a)
  

  Sinus tachycardia

  
  
• b)
  

  Right bundle branch block

  
  
• c)
  

  Left axis deviation

  
  
• d)
  

  ST segment depression

  
  
• e)
  

  Left bundle branch block

Regarding Acute Coronary Syndromes in Pregnancy:

• a)
  

  Ischaemic Heart Disease is the biggest cause of maternal mortality in the UK

  
  
• b)
  

  Atherosclerotic risk factors are less important than outside of pregnancy

  
  
• c)
  

  Coronary artery dissection is the biggest cause of ACS during pregnancy

  
  
• d)
  

  Troponin levels during pre-eclampsia are often elevated above the threshold usually considered for a diagnosis of ACS

  
  
• e)
  

  Coronary atherosclerosis is the biggest cause of ACS during pregnancy