<prompt> Which of the following is seen in pregnancy with heart disease, which is not seen in normal pregnancy?AIIMS November 2013, Nov 2012Distended neck veinsExertional dyspneaPedal edemaSupine hypotension  <response>: Ans. a. Distended neck veins Ref: Dutta 7e p50, 51, 52, 53, 55: Williams Obstetrics 22e p1019Distended neck veins are seen in pregnancy with heart disease, but not seen in normal pregnancy.Supine hypotension is found during late pregnancy, the gravid uterus produces the compression effect on the IVC, when the patient is supine. This, however, results in opening of the collateral circulation by means of paravertebral azygous vein. In some cases 10, when the collateral circulation fails to open up, the venous return of the heart may be seriously curtailed. This results in production of hypotension. - Dutta 7e p53A state of hyperventilation occurs during pregnancy leading to increase in tidal volume and therefore respiratory minute volume by 40. It is probably due to progesterone acting on the respiratory centre and also to increase in sensitivity of the centre to carbon dioxide. The woman feels shortness of breath.- Dutta 7e p55The increased accumulation of fluid in the tissue spaces mainly below the uterus is due to:1. Diminished colloid osmotic tension due to hemodilution driving the fluid out of the vessel2. Increased venous pressure of the inferior extremities. Thus slight edema of the legs is not uncommon, in otherwise normal pregnancy .- Dutta 7e p50.Clinical Indicators of Heart Disease During PregnancySymptomsSigns Severe progressive dyspnea MC symptomQ Syncope with exertionQ Progressive orthopneaQ Paroxysmal nocturnal dyspnea Persistent neck vein distentionQ Systolic murmur 36 gradeQ Diastolic murmurQ CardiomegalyQ Sustained arrhythmia Persistent split 2nd heart sound, low P2 Clubbing and cyanosisQAnatomical changes in CVS during PregnancyHeart is pushed upward and outward, with slight rotation to the left.Hemodynamic Changes during Pregnancy Non-PregnantPregnancy near TermChangeCardiac output litremin4.56.2640Stroke volume ml657527Heart rate per minute708517Blood pressureUnaffected or mid-pregnancy drop of diastolic pressure by 5-10 mm HgVenous pressure8-10 cm femoral20 cm water100 waterColloid oncotic pressure2018-14Systemic vascular resistance -21Pulmonary vascular resistance -34 