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MRCOG PART 2 SBAs and EMQs

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ESSAY 208 - HEART DISEASE

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		Posted by neera B. Tue Aug 15, 2006 03:25 am
Heart disease in pregnancy is an important indirect cause of maternal mortality. Acertain from her history and previous notes the cardiac lesion, its severiy and if it has been surgically corrected and whether a prosthetic valve is present. Degree of breathlessness, palpitations and their effect on her quality of life are graded according to Newyork Heart Foundation Classification. Examination involves looking for pallor, fever, and blood pressure as these can precipitate cardiac failure.JVP, tender liver enlargement, pedal edema as signs of cardiac failure are looked for.Cardiac assessment is done.Echocardiography and ECG are performed. FBC to confirm baseline Hb is done. She is booked under consultant\'s care. A multidisciplinary team involving senior obstetrician, senior cardiologist, fetal medicine expert and senior neonatologist, experienced midwife should be involved in her care. If she has Eisenmenger\'s syndrome, 40% maternal mortality associated with it is explained and termination of pregnancy is recommended. Same is true of pulmonary hypertension. She is counselled in a sensitive manner about increased risk 1% of congenital heart disease in her offspring, and risk of IUGR, PTL, cardiac failure in pregnancy. Hence dating scan at 10-12 wks with nuchal thickness assessment, detailed anomaly scan at 22 wks and 2 wkly scans from 24 wks are recommended. Prosthetic valves are associated with risk of thromboembolism, warfarin is the effective agent but it is teratogenic between 6-12 wks. Hematologist should be involved and option of LMWH till 12 weeks followed by warfarin prophylaxis till one week before delivery is discussed. At each visit, BP, pallor, infection, urine microscopy is screened. Emphasis on regular antenatal care and report in case of fever is advised. If maternal and fetal condition remains stable , pregnancy can be allowed to proceed to term. Vaginal delivery is permissible, caesarian is only for obstetric reasons , prophylactic antibiotics are recommended for prosthetic valve due to risk of SABE . Second stage should be cut short with forceps or ventouse. Epidural is preferred. Methergine is avoided as it increases preload . Fluid overload is avoided as it can preciptate CHF.
		Posted by Srivas P. Tue Aug 15, 2006 06:47 am
Ideally pregnancy in a patient with congenital heart disease should have been a planned event. Since she has presented at 8 weeks she needs evaluation on her current cardiac status, nature of cardiac anomaly, associated pulmonary hypertension, arrthymias, anemia, any prior surgery and present medication to plan further management. She needs to be looked after in consultant led care with active inputs from senior cardiologist. Her NY heart association cardiac functional status needs to be assessed as 85% of maternal deaths occur in class III and IV. Her baseline echocardiography should be done. She may need to be offered TOP incase continuation of pregnancy endangers her life especially uncorrected Eisenmenger?s disease, uncorrected Tetrology fallot, coarctation aorta, uncorrected VSD, PDA or ASD especially when associated with pulmonary hypertension, primary pulm HT, marfan?s syndrome with aortic root involvement and these conditions maybe associated with 25-50% maternal mortality. With Marfan?s syndrome which is an autosomal dominant condition she should be told about 50% chances of her baby inheriting it. Since she has congenital heart disease there is 5-10%chance of her baby having a CHD. Any co-existing medical morbidities like hypertension, arrhythmia and anemia should be corrected and her anti HT medication should be reviewed and changed to safer drugs eg,ACE inhibitors can cause fetal renal side effects and should be stopped while atenolol can cause IUGR. Alternative medication should be started. If he has primary or sec pulmonary hypertension she may need early initiation of thrombo prophylaxis. Instructions on limiting stress and activity, early recognition of signs and symptoms of heart failure and reporting to hospital if has problems should be impressed on her. Serial echocardiography may be needed to assess ventricular function. Fetal complications include prematurity, IUGR and congenital anomaly especially cardiac. She should have dating scan and a detailed scan at 20 weeks to see cardiac anamoly. If she has Marfan?s syndrome she should have invasive tests to rule out the condition in baby(50% risks-Autosomal dominant). Fetal monitoring should be done in antenatal period to assess fetal growth. Labor is the most difficult period. Patient should be in left lateral position and propped up. Requires careful watch on volume status, avoiding sudden shifts in blood pressure and avoiding hypertension or hypotension. She should be sedated to decrease anxiety; pain relief should be given with epidural anesthesia. If she is in respiratory distress she may need intranasal oxygen and pulse oxymetry to avoid pulmonary edema. If she has pulmonary hypertension she may need invasive monitoring of pulmonary wedge pressure with pulmonary catheter though it is not routinely needed in all patients. Induction with oxytocin or PG can be given but fluid overload should be avoided.2nd stage should be cut short with instrument delivery and ergometrine should be avoided. It is better to control bleeding with oxytocin. Baby should be examined for congenital anomalies. Vaginal delivery is safer and C.S is done only for obstetric indications with senior most anesthetist and obstetric consultant. She should be ambulated early, TED stockings and thromboprophylaxis based on risk benefit ?especially if she is not mobile it should be considered. Prophylactic antibiotics should be given. Contraceptic advice should be given-- POPs are safer and COCs should be avoided .Woman for whom pregnancy is risky should be advised long term contraception-maybe permanent sterilization for pulmonary HT. If next pregnancy is allowed based on her present condition ?it should a planned event.
		Posted by Sarwat F. Tue Aug 15, 2006 07:48 am
Cardiac disease in pregnancy is a high risk pregnancy as it is one of the common causes of maternal death in recent confidential enquiry in maternal death. Management should be multidisciplinary involving consultant obstetrician preferably with an interest in maternal medicine, cardiologist, geneticist, paediatrician, anaesthetist, midwife, and GP. Close laision is necessary between people of multidisciplinary team to ensure continuity of care. History will be asked from the mother to find out the type of heart disease, any treatment she is taking, any history of surgery or valvular replacement. In case of valvular replacement anticoagulation is done as there is a risk of thromboembolic complications. Degree of cardiac decompensation is assessed by asking about any symptoms of breathlessness, chest pain, edema, palpitations. Examination will be done including blood pressure, pulse to check any coexisting hypertension or arrythmias. Cardiovascular system examination is done to check for any murmers or added heart sounds. Her medical record will be reviewed as management depends on the type of heart disease. In acyanotic heart disease, mitral and arotic regurgitation, cardiac output is maintained as peripheral resistance falls and condition is compensated. In acyanotic heart disease there is risk of decompensation especially with right to left shunts. There is also risk of intrauterine growth restriction and still birth. In pulmonary hypertension again there is a risk of decompensation and worsening of maternal condition. In eissenmingers syndrome the risk of maternal mortality is as high as 50 % so termination of pregnancy is offered which carries a much lower risk of 7% of maternal death. There is a risk of congenital cardiac disease in the offspring so appropriate counseling with cardiologist and geneticist is offered. She will be explained about various methods of prenatal diagnosis which include noninvasive like hormone measurements that is alpha feto protein, HCG, estriol, PAPP A and inhibin, detailed ultrasound examination, fetal echocardiography and invasive methods like amniocentesis and chorionic villous sampling with risk of miscarriage in the range of 1 to 2 %. Various factors that precipitate decompensation in woman with cardiac disease include dehydration, infection, anemia and immobilization. These factors should be avoided by steps like correcting anemia, prophylactic antibiotics and correct fluid balance. Patient should be seen by anaesthetist antenatally to discuss mode of analgesia and anaesthesia in labour. With stable hemodynamic condition, epidural can be given, however for specific cardiac conditions requiring caesarean section, general anaesthesia is recommended. Senior anaesthetist will assess the case antenatally and formulate plan for pain relief in the chart. Spontaneous labour can be awaited with anticipation of normal delivery in well compensated cardiac disease. However adequate pain relief is provided. Second stage is managed vigilantly with instrumental delivery if there is any maternal distress. There is a risk of post partum hemorrhage in women on anticoagulation so third stage is carefully managed. Syntocinon 5 units is given intramuscularly and ergometrine avoided. Baby is examined by neonatologist who should be present at the time of delivery as this is a high risk pregnancy. Examination done to find any congenital cardiac disease and investigations ordered if needed like echo. Thromboembolic risk assessment for patient is done antenatally and TED stockings and or enoxaprin given. Peripartum antibiotics are given to prevent any infection developing. Woman is given postnatal appointment for checking hemodynamic condition and appointment with cardiologist is made to adjust if any medications she is taking. Regarding contraception, barrier method is preferred as there is caution with pill use and IUD can lead to infection.
		Posted by Kishor S. Tue Aug 15, 2006 09:09 am
Management will be multidisciplinary involving cardiologist and obstetrician, and dictated by the type of lesion and her functional status. Because of the increase in cardiac output, blood volume and haemodynamic changes in pregnancy, heart disease can deteriorate during pregnancy. The critical periods are: at the end of first trimester when cardiac output is increased maximally, around 32 ? 34 weeks when blood volume is increased maximally, during labour and just after delivery of the baby when extra blood is added to the circulation. Congenital heart disease is usually already diagnosed during childhood and it is expected in her case also. Details of the lesion and treatments given should be found out from the history and previous notes. The general behaviour of the different types are: Atrial septal defect generally performs well. So is small VSD. But large VSD will be associated with right ventricular dysfunction. Coarctation of aorta presents with hypertension in the upper half of the body. Eisenmenger syndrome or pulmonary hypertension carries high risk of mortality in pregnancy, hence TOP should be offered. Patent ductus arteriosus can be operated with consultation with the cardiologist during second trimester. Congenital vulvular lesion is extremely rare. At this visit, functional status should be assessed as per NYHA criteria and a detailed plan should be worked out. Risk assessment of VTE will be done and prophylaxis if needed. As mentioned earlier TOP is offered in Eisenmanger syndrome, even though there is still risk during TOP, but less than continuing the pregnancy. Routine antenatal investigations will be done and anaemia, if present should be treated as there is increased load on the heart. Dating scan is to be done in this visit. Anomaly scan along with fetal echography should be done at 22 weeks as there is an increased chance of fetal cardiac lesion. Close monitoring of hypertension is necessary as it can adversely affect the cardiac status. Fetal monitoring will be decided as per the progress in the antenatal care and findings. She needs a repeat thorough cardiac functional assessment at around 32 weeks that may necessitate admission. Use of diuretics should be reserved only for emergencies such as heart failure. Medical therapy should be always with consultation with cardiologist. Heart disease is not an indication for induction of labour, and in the absence of any obstetric indication she will be allowed to have a vaginal delivery. Pain relief is important as it may trigger heart failure and epidural analgesia is ideal. Second stage should be shortened with the help of instrumental vaginal delivery. Prophylactic ergometrine should not be given. Oxytocin drip is indicated instead. Postpartum endocarditis prophylaxis should be giver as per local protocol. But some studies do not recommend antibiotic prophylaxis as endocarditis is rare congenital heart disease. Breast feeding is not contraindicated. Contraceptive advice should be discussed and low dose COCP is safe, if there are no risk factors for VTE.
		Posted by adnan S. Tue Aug 15, 2006 05:06 pm
History is obtained regarding wheather her cardiac disease is cyanotic or acynotic as cyanotic congenital heart disease like Eisenmengers syndrome ,tetralogy of falllots ,and pulmonary hypertension are poorly tolerated in pregnancy.h/o previous corrective surgery is enquired .h/o previous pregnancy and any detoriation in her cardiac condition is enquired is also asked.For assessment of severity of cardiac condition history is obtained like shortness of breath ,palpitation.and restriction of physical activity on exertion,routine work and rest as NYHA class 1&2 do well compare to class 3&4.H/o medications she is taking is enquired . Examination is done to note any pallor,pulse and BP is checked , weight is checked to calculate BMI.Follwing investigations are requested likeFBC to note Hb ,MSU to r/o any infection,and echocardiography. Management by multidisciplinary team consist of obstetrician,cardiologist,and aneasthetist.In the presence of cyanotic congenital heart disease,pulmonary hypertension or Eisenmengers syndrome,maternal mortality is 50%,termination of pregnancy is recommended .Drugs she is taking to be reviewd,warfarin is associated with embryopathy ,heparin should be considerd,any modification in drugs should be modified in consultation with cardiologist.More frequent antenatal visits should be considerd in a joint clinic ,BP is checked regularly ,hypertension ,anaemia,UTI,should be recognized early and treated as they precipitate cardiac failure.Fetus is at the risk congenital cardiac defect along with anomaly scan detailed cardiac scan is done .There may be risk of IUGR serial growth scan is considerd with dopplers if required.Aneasthetic review with clear plan for intra-partum care should be documented. Vaginal delivery is the aim ,c-section is considered for obstetric indications.Early aneasthetic review is considered when present in early labour.Delivery should take place in a unit with facilities full resuscitation of mother as there is risk of pulmonary oedema,cardiac failure.Patient is put in left lateral position ,maternal monitoring is done with SO2,ECG,and strict fluid balance is maintained.continues fetal monitoring is done.Elective shortening of second stage of labour is considered .Ergometrine is avoided in third stage.antibiotic prophylaxis for bacterial endocarditis is given.Thromboprophylxis is considered .Women is moniterd in high dependency unit in the post-partum period for any signs of cardiac failure.Any change in medication or discontinuation during pregnancy is re-started.Future contraception is discussed.
		Posted by Ebeinheizer S. Tue Aug 15, 2006 08:34 pm
This patient is high risk pregnancy. The severity of her condition would be determined by the type of Congenital Heart Disease (CHD) and cardiac functional status according to classifications such as the New York Heart Association (NYHA). She might have a small asymptomatic VSD or a severe uncorrected Tetralogy of Fallot. A multidisplinary team comprising the Obstetrician, Cardiologist, Anaesthetist, Midwife and GP should be involved in her management due to her heart condition as cardiac disease is one of the common cause of maternal mortality in the UK. She should be seen in a combined clinic with the Cardiologist and Obstetrician. I would also organise a review by the Anaesthetist to address issues of pain relief and anaesthesia for any surgical intervention. Very rarely, especially amongst the asylum seekers or migrant community, pregnancy against medical advise despite very severe life threatening CHD might be seen. This would be an extremely difficult situation to handle and senior input with very careful documentation is important. Termination of pregnancy should be offered. Sterilization or reversible long acting contraception until her condition is corrected should be offered too. Similar approach need to be employed if this patient?s cardiac function is progressively deteriorating with pregnancy which poses extra burden on her CHD. I would obtain further history and physical examination in view of her cardiac status. Excessive dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, pitting oedema are signs/symptoms of cardiac failure which could be overlapping with conditions in pregnancy. I will review her cardiology notes as well. Further information about the type of CHD, cyanotic or acyanotic, surgical correction if any, artificial valve and prophylactic warfarin / antibiotic would dictate management. Prophylactic antibiotic, usually of penicillin group, are safe in pregnancy/breastfeeding and should be continued and converted to intra-venous in labour. Warfarin need to be changed to Low Molecular Weight Heparin (LMWH) due to potential teratogenicity and better safety and efficacy of LMWH. Antenatal and 6 weeks postnatal TED stockings and LMWH is necessary if she has 2 other risk factors in addition to CHD for thromboembolism. If she is on warfarin, warfarin embryopathy should be looked for at detailed anomaly ultrasound at 18-20 weeks. I will also organise fetal echocardiography at 22-24 weeks as her baby has higher risk of CHD. Subsequent antenatal care should be combined with the Obstetrician and GP/Community Midwife to detect any deterioration of her cardiac status. Patient should be advised to seek immediate medical attention if this develops. Induction of labour and caesarean section should be for obstetric indications and I would aim a spontaneous vaginal delivery for her. In certain cardiac condition or deterioration of function, early delivery by Caesarean Section after maternal steroids might be necessary. In albour, adequate analgesia, preferably epidural is necessary to avoid undue stress due to pain on the patient which can exacerbate cardiac failure. In some circumstances, instrumental delivery to shorten second stage to prevent excessive maternal bearing-down causing cardiac strain might be necessary. Thromboprophylaxis with LMWH and TED stockings for 3-5 days postnatally would be necessary according to the risk scoring. COCP should be avoided as it increases the risk of thrombotic events. Progestogen based contraception (DMPA,Implanon,POP) can be offered. I would give letter to GP/Community Midwife explaining her CHD.
		Posted by Freha Z. Wed Aug 16, 2006 02:54 am
Cardiac disease is among the leading cause of maternal death in Confidential enquirie 97-99. History should be taken to evaluate her current cardiac status and needs to be classified according to New York Heart Association. History regarding any corrective surgery shoud be taken. Her care should be shared by senior obstetrician, cardiologist, neonatologist and senior midwife. She should be booked under consultant care. Sensitive counselling is needed if she has pulmonary hypertension either primary or secondary to Eisenmanger Syndrome. In this case maternal mortality is 40%. In the event of unplanned pregnancy she can be advised therapeutic termination. If such advice is declined multidisciplinary care, elective admission for bed rest , oxygen and thromboprophylaxis is recommended. She should know that she is at high risk of having a baby with congenital heart disease therefore a booking scan should be followed by detailed anomaly scan at 18-20 week. She is also at high risk of developing IUGR therefore serial scans from 24 weeks should be started for fetal growth and surveillance( left to right shunt). There should be early involvement of obstetric anaesthetist and carefully documented plan of delivery. Regular visits are required for early detection and treatment of aggaravating factors like anaemia and infection. In case of prosthetic valves she will need anticoagultion and should be discussed with her regarding risks and benefits of continuing warfarin therapy. Use of Warfarin in 6-9 weeks leads to Warfarin embryopathy, intravascular haemrrhage, increased risk of miscarriage and can also cause stillbirth. Warfarin needs to be stopped by 10 days of delivery and replaced by Heparin. Labour should be in left lateral position.Continuous fetal monitering and ECG monitering and full resuscitation facilities are required. The current Uk recommendations for endocarditis prophylaxis is amoxycillin 1g(i/v) and gentamicin 120mg(i/v) at onset of labour, at ruptured membranes or prior to caesarean section followed by Amoxycillin500mg orally/i/v/i/m 6hrs after delivery. Epidural is preferable to avoid physical and mental stress. Syntocinon if required can be given by infusion pump to limit fluid overload in order to prevent cardiac failure. Aim is vaginal delivery in absence of obstetric complications .To shorten second stage instrumental delivery is required. Ergotamine should be avoided. Neonatologist should be present at time of delivery. Continued intensive care is required postpartum. Safe contraception should be discussed.
		Posted by Ismatara B. Wed Aug 16, 2006 10:15 am
Cardiac disease is one of the important indirect causes of maternal mortality in UK with increased morbidity and adverse perinatal outcome. A multidisciplinary team approach is required involving the senior obstetrician, cardiologist, anaesthetist, physician and cardiothoracic surgeon to manage successfully and timely if any complication occur. A through history including type of cardiac problem (e.g. cyanotic/acyanotic), any corrective surgery or presence of heart valves and any drugs should be under taken. Severity of disease should be assessed by the New York Heart Association functional classification jointly with cardiologist, grade I-II do well, but III-IV is in risk to continue pregnancy. Examination to look for pulse, temperature, blood pressure, pallor, leg oedema, as these will indicate cardiac failure (CHF). Blood for FBC to look for anaemia, ECG and echocardigraphy for cardiac assessment should be done. Prognosis for acyanotic heart disease is good. In cyanotic heart disease, Eisenmenger?s syndrome, pulmonary hypertension, whether primary or secondary, pregnancy becomes risky with high fetal and maternal mortality rates. Maternal deaths usually occur during labour or in the postpartum period. Such women should be offered for termination, as maternal mortality is 7% in termination, as compared to 50% if pregnancy is continued. As this a high risk pregnancy, should be booked under consultant led care and frequent antenatal visit is recommended preferably in a joint clinic. During pregnancy screening for anaemia, infections, dysarrythmias and hypertensions should be done and corrected timely and aggressively, because these may cause cardiac decompensation and worsen prognosis.It should be born in mind that ankle oedema, shortness of breath may be due to cardiac compromise and difficult to differentiate from normal late pregnancy symptoms. If she is on warfarin should be avoided during pregnancy due to embryopathy and haemorrhagic disorder of the mother and newborn. LMWH should be considered during this period. This should be given with the advice of cardiologist. She should be counseled about, increased risk of IUGR, preterm labour and 1% risk of congenital heart disease of offspring in a sensitive and sympathetic manner. So an early scan at 10-12 wks for dating, detailed anomaly scan at 20-22 wks and fetal echocardiography to rule out CHD is recommended. Serial ultrasounds scans from 24wks to monitor fetal growth are important with Doppler if necessary. Antibiotic prophylaxis should be given to women at high risk for previous endocarditis or complex cyanotic heart disease to avoid infection. A discussion with anaeshetic should be arranged and plan for adequate analgesia during labour should be ensured with clear documentation A vaginal delivery with effective analgesia and a short second stage is usually preferred to avoid maternal exhaustion with the reservation of caesarean for obstetric indications. Patient should be in left lateral position, so venous return is not compromised. The choice of anaesthesia depends upon maternal cardiac status. With adequate circulatory reserve, epidural anaesthesia is well tolerated. It should be used with extreme caution in patients with restricted cardiac output or right to left shunts. In these, general anaesthesia is the safer option. Continuos fetal monitoring and maternal monitoring with SO2, ECG should be done and fluid balance is strictly maintained to avoid maternal and perinatal morbidity and mortality. Neonatologist should present with full resuscitation facilities and the baby should be looked for any cardiac abnormality. Antibiotic prophylaxis is given for bacterial endocarditis, Amoxicillin 1g IV and gentamycin 1.5mg/kg not more than 120mg, then amoxicillin 500mg IM QID (PO, IV or IM) 6 hrly until baby born. Vancomycin, if allergic to penicillin.Ergometrine is avoided in third stage of labour and Fluid overload is avoided as these can cause CHF. Syntocinone is to be given to avoid blood loss. Thromboembolic complications increase in patients with prosthetic heart valves and should be anticoagulated for the whole of the pregnancy and thromboprophylaxis during puerperium as per protocol. She should be monitored in HDU to be vigilant about sign and symptom of CHF, as there is significant maternal mortality in postpartum period. Drugs that were changed or discontinued during pregnancy should be restarted. Discussion about future contraception should be done.
		Posted by neera B. Thu Aug 17, 2006 01:37 pm
Dear Dr.Paul, In one of the courses I attended, I was instructed that if ques is justify mgmt of her PREGNANCY, then discuss till mode and time of delivery and not labour,postnatal etc. But here more than half the marks are for delivery, postpartum,contraception,neonatal examn after delivery. I am thoroughly confused.PLease advise. thanx,neera
		Posted by Ebeinheizer S. Thu Aug 17, 2006 05:54 pm
Please correct my essay. Thank you.
		Posted by QWER Q. Fri Aug 18, 2006 06:50 pm
management involves multidisciplinary care with liason and advice from cardiology, anaesthesia, obstetricians, paediatrecians the GP and midwive. The patient needs assessment for prognosis to be determined. Signs of cardiac compromise in the history (ie breathlessness on miniminal exertion), palpitations and chest pain; and the examination (ie crepitations consitent with pulmonary oedema, raised JVP, irregular pulse compatible with AF) should be sought. The old notes reviewed. Relevant investigations include ECG which is cheap and informative, ECHO which is non invasive; O2 sats. Adverse prognostic features are the presence of cyanosis, pulmonary hypertension, NYHA with poor exercise tolerance and poor cardiac function reflected in ECHO. A cardiologist would assist in patient guidance which may include TOP recommendation( ie Eisenmengers). They would also guide medication alteration (ie discontinuation of ace inibibitors) The patient is informed of possible teratogenic effects of medications - ie warfarin and embryo-opathy. A joint decision between cardiologist and patient should be made between continuing warfarin, or changing to heparin in early pregnancy. The cardiologist and haemotologist should write a plan regarding anticoagulation from 37 weeks, usually this means going onto heparin from warfarin from 37 weeks and stopping anticoagulation as soon as labour begins. A detailed plan of delivery is formulated in advance with input from anaesthesia as well. In the antenatal period, regular review is required (eg fortnightly reviews), looking for evidence of cardiac deterioration - ie breathlessness. A detailed cardiac anatomy scan for congenital heart disease and serial us scans for fetal growth are important. The patient is educated on symptoms of worsening cardiac disease and given written information on who and how to seek help. Labour is dangerous as heart rate increases, and either vasoconstriction due to pain, hypervolaemia due to fluids/auto transfusion or hypovolaemia; vasodilation due to epidural can have significant haemodynamic effects. So freqent maternal monitering is needed - ie 15 minute BP, pulse, o2sats, respiratory rate. The fetal heart needs CTG monitering. The left lateral position promotes venous return to the heart. O2 may be needed; there may be a role for invasive monitering (ie CVP) or PCWP depending on extent of cardiac anomaly. Strict fluid balance decreases risk of fluid overload. 2nd stage may need shortening because of maternal exhaustion or potential cardiac compromise. In general ; cardiac lesions such as aortic stenosis; the main concern is hypovolaemia, impaired left venricular filling - so PPH/ epidurals are potentially problematic; whereas with mitral stenosis; the main risk is fluid overload; epidurals are beneficial and oxytocinon; auto transfusion post 3rd stage is a potential problem At delivery the baby needs review for cardiac anomaly by paediatricians. The mother needs close observation 48 hrs post partum, breast feeding is encouraged; counselling given on risks of next pregnancy and contraception that is appropriate given.
		Posted by Samir A. Sat Aug 19, 2006 06:25 am
Pregnancy in a cardiac patient is a high risk pregnancy. I\'ll take history for cyanosis with or without exertion, shortness of breath. palpitation, orthopnoea and easy fatigability, since cyanotic heart disease or/and heart failure with pregnancy carries high risk of maternal morbidity (such as preterm delivery, subacute infective endocarditis, aggravation of anaemia and frequent chest infection) and mortality (up to 50% in Eisenminger syndrome) and fetal complications such as prematurity, risk of congenital cardiac anomalies (2-3 times normal), other congenital anomalies and IUGR .I\'ll ask about drugs taken, since some drugs should be changed in pregnancy, for instance beta blockers causes IUGR, warfarin causes embryopathy, folic acid (FA)when was started since preconceptual FA for 3 months signinficantly reduces neural tube defects as proven by RCTs. I\'ll ask if she had prosthetic valve replacement since in such case warfarin has to be continued throughout pregnancy except from 6-9 weeks since there is evidence that this is reduces the risk of embryopathy if avoided at that period. I\'ll examine for heart rate (tachycardia is a sign of heart failure, anaemie, infection),take blood pressure(BP) since hypotension is a sign of low cardiac output condition or high BP in Coarctation of aorta, check JVP (jugular venous pulse) since high JVP is a sign of congestive heart failure which might be a sequle of pulmonary hypertensio/ Eiseminger syndrome. I\'ll examine the chest for crepitations and the heart for accentuated heart sounds especially the pulmonary component, murmers, rhythm and rate. I\'ll do FBC (anaemia), MSU (protein, luekocytes, red blood cells), ECG, and arrange for Echocardiograghy, because anaemia and chest infection should be treated agrrisvely, as well as heart failure in liaiason with the cardiologist. Antenatal care (ANC) will be done in cojoined care with cardiologist and anaesthetist. If she has Eiseminger syndtrome I\'ll counsel her for the choice of TOP (termination of pregnancy) since the maternal mortality rate with prenanmcy is about 50%. I\'ll start FA if was not srarted, Iron if anaemic + continue ANC as usual. In addition I\'ll do anomaly scan at 20 weeks to exclude congenital heart disease and other structural anomalies because of her higher risk of congenital heart disease. I\'ll do growth scan 2-4 weeks since she has the risk of IUGR. For delivery the aim is vaginal delivery. I\'ll consult a senior anaesthetist befor delivery since epidural anaesthesia may aggravate low cardiac output symptoms. I\'ll put in the plan that elective shortening of the 2nd stage is to be conducted as well as prophylactic antibiotic cover to mimimise the risk of suacute infective endocarditis. I\'ll manage the third satge actively without methergin to reduce the risk of bleeding and also low cardiac output symptoms.I\'ll advise for prophylaxis against thrombo-embolism (hydration, mobilisation with/without stocking, heparin). I\'ll discuss with the patient contyraception and the risk of recurrence (1:10) before discharge.
		Posted by afroz S. Sun Aug 20, 2006 06:40 am
This patient\'s management should have a multi- disciplinary approach involving senior obstetrician, cardiologist, senior anesthetist & pediatrician so as to improve the maternal and fetal outcome. The detailed history is taken so as to determine the severity of the cardiac illness . History of any corrective cardiac surgery including prosthetic valve replacement is taken. Drug history is taken including thromboprophylaxis and prophylactic antibiotics. This will guide towards the plan of management. Detailed examination of the patient should be done including vitals, cardiovascular ,respiratory are examined to detect the severity of the disease. Investigations include FBC, U & E, LFT ,co-agulation profile, EKG, echocardiography are the investigations to be done. The acyanotic heart disease has a good prognosis. Anemia should be corrected if present with iron supplementation. Infections should be promptly treated. Hypertension and arrhythmias should be taken care of as all these lead to the cardiac compromise.The patient with mechanical prosthetic heart valves who are on long term thromboprophylaxis with warfarin should be changed to heparin because warfarin causes embryopathy if used between 6 to 12 weeks which includes stipple epiphysis, nasal hypoplasia.It also increases the risk of fetal hemorrhage. Unfractionated heparin is associated with thrombocytopenia & osteopenia.Also warfarin should be replaced with heparin in the first trimester and then warfarin is continued till 36 weeks gestation to be followed by heparin prophylaxis as heparin can be reversed if required with protamine sulfate in case of bleeding.LMWH is once a day and has less side effects.Monitoring with APTT for heparin maintained between 2 to 2.5. Woman with Eisenmenger syndrome or pulmonary hypertension have a high mortality rate of around 50 % if the pregnancy is continued and they may be counseled about the termination of pregnancy which carries a mortality rate of 7 % . The risk to the fetus is explained to the patient including risk of congenital heart disease. Hence the anomaly scan including cardiac scan is advised. There is a risk of IUGR due to cyanotic heart disease. Hence close fetal monitoring with growth scans, CTG ,BPP & Doppler should be done. Antibiotic prophylaxis during labour is required to reduce the risk of endocarditis.Vaginal delivery is preferred.The patient is monitored closely in labour including vitals, pulse-oxymetry ,strict fluid intake output chart to avoid fluid overload.She should be laboured in left lateral position to avoid venacaval compression. Oxygen supplementation may be required. Continous CTG monitoring is done. The second stage may be shortened using forceps if required to avoid the effect of valsalva and in presence of maternal exhaustion. Epidural analgesia should be adjusted as per the last dose of heparin and in consultation with anesthetist. Ergometrine should not be given in 3rd stage of labour as it causes sudden increase in preload of heart and cardiac failure. The neonatologist should investigate the baby for CHD. Breast feeding is not contra indicated and advice about contraception is given. Pre-pregnancy counseling is required.