Question of the Week # 260

260 )  A 30 year old woman is evaluated  in your office during a routine antenatal visit. Her previous pregnancy 2 years was uneventful. She is now presenting at 12 week gestation. The patient has been compliant with antenatal vitamin supplements. She reports mild early morning nausea and vomiting. On physical examination, her vitals are with in normal limits. Cardiovascular examination reveal exaggerated heart sounds ( S1 and S2) and  a new systolic ejection murmur across the lower left sternal border. An S3 gallop is present.  A grade 1 diastolic murmur is heard at the left ventricular apex that increases in the left lateral decubitus position. Which of the following cardiovascular abnormalities would be best tolerated during an otherwise normal pregnancy?

A)     Mitral Stenosis with pulmonary hypertension

B)     Marfan syndrome with aortic valve involvement

C)     Peri-partum cardiomyopathy in prior pregnancy

D)     Atrial Septal Defect, Secundum type

E)    Bicuspid aortic valve with mean gradient 55mmHg.

5 Responses

  1. d

  2. dddd

  3. Can you please explain why d?
    Why does the last line ask something that is completely unrelated to information presented?

  4. D…….Diagnosis of an atrial septal defect by auscultation requires identification of the characteristic diastolic murmur. A medium frequency mid diastolic murmur at the lower left sternal edge occurs with rapid ventricular filling of the right ventricle after the tricuspid valve opens. The murmur is never more than grade 1-2/6, and identifying it usually takes effort. If the shunt is large enough to cause wide, seemingly fixed, splitting of S2, this murmur should be audible.

    Because of an increase in plasma volume during pregnancy, shunt volume can increase, leading to symptoms. Pulmonary artery pressure usually remains normal. So the cardiovascular abnormalities would be best tolerated during an otherwise normal pregnancy is Atrial Septal Defect, Secundum type

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