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MRCOG PART 2 SBAs and EMQs

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Essay 217 - HEART DISEASE IN PREGNANCY

Posted by Zaharuddin R.
a)Nature of her heart disease need to be determined either it is acyanotic or cyanotic heart disease. Her functional status need to evaluated either she is asymptomatic or in heart failure. Her medications need to be reviewed especially if she is on warfarin or ACE-inhibitor. Her medical notes should be reviewed especially her latest investigation including echocardiogram. Advice from cardiologist is necessary either she is fit to conceive or is not advisable to conceive. Her condition and medications need to be optimized with combined management with cardiologist pre-pregnancy.

b)Risk to the fetus to have congenital heart disease is depending to the nature of the disease such as risk of isolated ventricular septal defect is 5-10%. If the patient is on warfarin, risk of congenital (teratogenic) defect is about 8% and an increased risk of fetal renal failure/agenesis if she is on ACE-inhibitors. Risk of teratogenic defect could be eliminated if changes with optimization of drugs made pre-conception.

c)During intrapartum, combined multidisciplines care is necessary with cardiologist and anaesthesist. The patient should be managed in dorsal position, with cardiac monitoring, oxygen supplementation with nasal prong and continuous cardiotocogram. Subacute bacterial endocarditis prophylaxis is needed if there is co-exist valve disease. Fluid restriction is compulsory with strict input/output , blood pressure and pulse rate monitoring. Resusucitation trolley should be at her bedside. Adequate analgesia in form of epidural type is recommended but discussion with anaesthesist is important if limited cardiac output lesion present such as coartation of aorta or mitral stenosis. Second stage of labour should be assisted to reduce patient?s effort with operative vaginal delivery. Ergometrine should be avoided in the third stage as it may precipitate hypertension and heart failure. The newborn should be examined by stand-by paediatrician for early detection of congenital heart disease.
Posted by Sreekala S.
a) The type of the congenital heart disease, haemodynamic significance of the lesion, presence of pulmonary hypertension, presence of cyanosis and the NYHA class are the important features that should be taken into account during counselling and subsequent management of this lady. In the presence of Pulmonary hypertension, Eisenmenger?s syndrome or severe aortic root dilation as in Marfarn?s syndrome the woman should be discouraged to become pregnant as it is associated with a very high mortality. History of any past corrective surgeries should be taken in to account. Use of any medications like beta blockers, anticoagulants like warfarin/heparin should be enquired as they may have to be modified prior to or in early pregnancy. Pre pregnancy counselling should involve a multidisciplinary team involving the cardiologist, obstetrician, GP and midwife.
b) The woman should be counselled that the fetus will be at an increased risk of congenital cardiac anomalies when compared to the general population. She should therefore be offered an anomaly scan at 20 weeks and a detailed fetal cardiac scan at 20-24 weeks.The fetus will be at an increased risk of embryopathy and intracranial haemorrhage if she is on warfarin. She should be told about the increased fetal risk of oligohydramnios, renal failure with ACE-inhibitors and increased risk of IUGR with beta blockers. She should be told that the fetus will be at an increased risk of miscarriage, IUGR and prematurity both iatrogenic and spontaneous in the presence of hemodynamic instability especially in the presence of maternal cyanotic heart disease. She should also be told that the outcome of most pregnancies is good especially ASD/VSD after corrective surgery. She should be reassured if her congenital heart disease is as a result of congenital rubella in which case the risk to her fetus is the same as in the general population.

c) Intrapartum care should involve a multidisciplinary team care with the Obstetrician, cardiologist, anaesthetist, midwife and the paediatrician with an agreed clearly documented plan of care. Caesarean section and IOL are indicated for obstetric reasons in most cases. An elective caesarean section is indicated in the presence of a severely dilated aortic root (>4.5cm). Infective endocarditis prophylaxis should be given at the onset of labour /SROM or prior to caesarean section and repeated after 6 hrs. Infective endocarditis prophylaxis is not recommended in the presence of isolated secondum ASD defects and following surgically corrected ASD/VSD. Thromboprophylaxis should be given. Continuous CTG monitoring is required during labour. Oxygen should be administered to the woman during labour. She should not be overloaded with fluids. If needed CVP must be used to monitor fluids in consultation with the anaesthetist. Adequate pain relief should be given in labour. Epidural analgesia should be considered and given in consultation with the anaesthetist. BP, PR, RR and oxygen saturation should be carefully monitored during labour and post partum. Second stage of labour should be cut short using forceps/ventouse. Syntometrine/Ergometrine should be avoided as they may cause a sudden increase BP. Postpartum haemorrhage should be avoided. Vital signs should be monitored carefully postpartum as there is a high risk of congestive cardiac failure in the immediate postpartum period . Paediatrician should be present at delivery. Breast feeding should be encouraged provided she is haemodynamically stable.
Posted by Badi A.
A 20 year old woman with congenital heart disease is planning a pregnancy. (a) Which features of her heart disease are relevant to your counselling and subsequent management? (6 marks) (b) What will you tell her about the risks to her fetus? (5 marks)(c ) Which principles will underlie your intra-partum care? (9 marks)

a) detailed history of type of cardiac problem, any corrective surgery or presence of heart valves and any medications being taken is essential to know before counselling.
detailed informations should be obtained about where, when was and with whom ( cardiologist ) the patient is having ger follow up.
regurgitant valvular disease such as mitral or aortic regurgitation is usually well toleated in pregnancy however stenotic lesions worsen in pregnancy.
pulmonary hypertension whether primary or secondary are at particular risk .
in esienmeger\'s syndrom pregnancy becomes risky with high maternal and fetal mortality rates.in such women she should be advised against pregnancy or offered termination.the risk of maternal mortlity in case of termination is 7% as compared to 50 % in case of continuing with th e pregnancy.
in case of prosthetic heart valves the patient should be on anticoagulation.
case specific mortality rate will be determined according to lesion she has.

b)risks to the fetus will be divded into pregnancy related , cadiac related and tretment related .
pregnancy related complications inclued preterm labour which will lead to prematurity. slow growth of the fetus esp. if PIH exists
cardiac related include the risk to her baby to have a congenital heart disease and the importance to do detailed midtrimester scan along with an echocardiography.
treatment related esp. if taking warfarin or ACE-inhibtors.
serial u/s to monitor fetal growth rate.

c) principles of management intrpartum include effective analgesia, shortening second stage of labour ,minimizing blood loss, avoidance of fluid overload, antibiotic prophylaxis for endocarditis, safe anesthesia in case of c/s .
with adequate circulatory reserve epidural is well tolerated.
outlet foceps delivery indicated in 2nd stage. syntocinon will be given at the delivery ant. shoulder and ergometrin is contraindicated.C/S should be done if obstetric indication exist.
antibiotic prophylaxsis should be given to those with moderate and high risk group.
Posted by Srivas  P.
a) Type of lesion, severity of lesion, New York heart association heart status, coincident complications like heart failure, ventricular dysfunction, hypertension, arrthymias determine course of future pregnancy and should be assessed prepregnancy to optimize her condition and counsel if it is safe to plan a pregnancy.

For type of lesion-Primary or secondary pulmonary hypertension, Eisenmengers Syndrome, Marfan?s syndrome with significant aortic dilatation more than 55mm are associated with 25-50% mortality and she should be counseled against pregnancy. Severe heart valve dysfunction may need valve replacement pre pregnancy. She would need to be counseled about mechanical versus bio prosthetic valve replacements, complications, durability, need for anticoagulation throughout pregnancy with Mechanical valve and antibiotic prophylaxis with bioprosthetic valve. Uncorrected cyanotic congenital heart lesions should have surgery to correct it pre pregnancy and may need antibiotic prophylaxis during pregnancy if she gets pregnant without correction.

Mitral stenosis or mitral valve prolapse with atrial fibrillation may cause padadoxic emboli and she may need antenatal anticoagulation. Hypertension may complicate Marfan?s syndrome , coarctation of aorta, and she may need a beta blocker to control aortic dissection aortic rupture.

b)She is likely to have premature labour. IUGR and there is 3-10% likelihood of a congenital cardiac lesion in the baby depending on maternal lesion?50% have same anomaly like mother. The baby may be affected by anticoagulants like Warfarin if given to mother especially between 6-12 weeks pregnancy and defects include hypoplasia of the nose, stippling of bone, optic atrophy and mental retardation and baby also runs risk of intracranial haemorrhage when Warfarin given within 2 weeks of delivery. Marfan?s syndrome is an autosomal dominant condition and fetus has 50 % chance of having the syndrome but prenatal diagnosis may be possible only in some families with mutation detection and linkage analysis. Hence CVS and amniocentesis not offered. Preimplantation genetic diagnosis is possible but would need IVF.

c) Aim for vaginal delivery and caesarean section is done for obstetric indications only. She should have multi disciplinary care with obstetric consultant, senior anesthetist, cardiologist, critical care interventionist, Neonatologist, specialist nurse and in a unit with cardiac resuscitation facilities.

Maternal effort should be minimized. She should labor in left lateral position to avoid aortocaval compression and hypotension. Intranasal oxygen 5-6l/min may be given. Her pulse, B.P, Po2 should be monitored and she should have continuous electro cardiographic monitoring to detect arrhythmia. Volume status and maintenance of blood pressure is important and an intake output record should be kept. Watch for signs of heart failure. Epidural catheter is preferred to control pain and maternal apprehension with intrathecal narcotics to prevent tachycardia associated with pain.

If she is on anticoagulants, it is preferable to switch to thromboprophylactic dose prior to labor, unless Po2 is less than 80%, when full heparin dose maybe needed even in labor.

Invasive monitoring may be required in serious cardiac patients with pulmonary artery hypertension, if she is in cardiac failure and is deteriorating or if she is in incipient pulmonary edema. Pulmonary wedge pressure monitoring maybe needed in very critical cases and this should be decided by interventionist cardiologist after explaining the risks of the procedure like pulmonary artery rupture, arrthymia and thrombosis. CVP line is less risky and may be adequate.

Close fetal surveillance should be maintained throughout labor with continuous CTG. 2nd stage should be cut short with operative vaginal delivery. Ergometrine should be avoided. Prevent post partum haemorhage and volume shifts by immediate attention-bimanual massage and use of intravenous oxytocin and ensure completeness of placenta. Prostaglandins may be given. Neonatologist should be present at delivery and baby should be observed for congenital lesion.

Post partum volume status should be carefully monitored. Po2 decrease with possible pulmonary edema may need diuretic. Early mobilization should be encouraged. Prophylactic antibiotics needed in some conditions?Cyanotic heart diseases, prosthetic heart valves. Anticoagulation continued as required in some cases and may switch to warfarin postnatal and breast feeding may continue.

Previously discussed contraceptive plan should be reviewed. Sterilization for some conditions as discussed.

Posted by kiria O.
Congenital heart disease in woman planning pregnancy,need to identify risks which associated with maternal mortality and perinatal morbidity. certain feautures if present woman should be advised against pregnancy such as cyanotic heart disease, presence of pulmonary hypertension,esinnmenger syndrome.
Other condition such as presence of prosthtic valve need anticoagulation with warfarin and she must be counselled regarding risks associated with its use such as embryopathy in early pregnancy and CNS abnormality in late pregnancy. Also, detailed history regarding heart surgery, history of heart failure,and bacterial endocardites should be ascertained.
For appropriate counselling cardiologest must be involved and consultant obstetrician to a dvice woman for or against pregnancy

Woman with compansated congenital heart such as PDA,ASD OR VSD can be allowed for pregnancy but, need multidiciplinary care and frequant antenatal visits aiming for preventing or treating anaemia, infection and controlling hypertension as those factors may lead to heart failure.

Woman need to be counselled regarding increase risks of fetal congenital heart disease(3%), growth restriction,fetal hydrops and fetal death in utero. Also, the risk of spontanous and iatrogenic prematurity.

The principles of intrapartum care must include appropriate form for controlling pain which induce stress and increase blood pressure such as epidural analgesia and this option must be disscused with consultant anasthatist.
Maternal monitring during labour is essential including pulse,blood pressure. respiratory rate and best with pulse oximetry,ECG and blood pressure monitring.
containous fetal monitring is essential to detect fetal heart abnormalites which may neccitate fetal blood sampling.
Fluid input output is very essential to be recoreded with CVP line and hourly urine out put aim to prevent fluid over load and pulmonary odema.
Second stage of labour can be shortened by elective forceps if appropriate to prevent undue stress.
avoid use of ergometrin or syntometrin as this increase blood pressure and oxytocin used instead to minimise blood loss and reduce risk of post partum anaemia.
Prophylactic antibiotic such as amoxicillin and gentamycin is recommended to prevent bacterial endocardites.
As maternal mortality is mostly occure in labour and in post partum period ,woman need to be transffered to high dependancy unit and continous monitring with appropriate thromboprophylaxis must be ensured.
Posted by Freha Z.
(a) Outcome of pregnancy is related to several cardiac factors. Pulmonary hypertension is associated with maternal mortality of 30-50%. It may be due to Eisenmangers Syndrome where there is left to right shunt. Women with this condition should be advised against pregnancy and suitable contraception should be offered. Cyanosis is another factor carrying thromboembolic risk due to polycythemia and increased risk of fetal loss( if O2 saturation <80-85%) and increased risk of IUGR. Poor pregnancy outcome is likely if women has poor functional status(NYHA) which depends on level of exertion. Class I and II do well in pregnancy unlike class III and IV. Drugs taken should be optimised prepregnancy in consultation with cardiologist as certain drugs like ACE inhib. and warfarin are associated with fetal adverse effects.
(b) The risk of the fetus having a congenital heart defect is 2-5%. If fetus is effected it tends to have same leison as mother. Risk to fetus is 18-20% if mother has aortic stenosis. Marfans syndrome and hypertrophic cardiomyopathy have autosomal dominant inheritance. She should be referred for detailed fetal cardiac ultrasound. Serial ultrasound need to be done to detect growth restriction. There is also treatment related teratogenic risks to fetus associted with warfarin.mShe should be advised preconceptual folic acid to reduce the risk of congenital heart disease and neural tube defect.
(c) Her management should involve multidisciplinary team including cardiologist, obstetrician, anaesthetic and experienced midwife. An agreed documented plan of delivery should be followed. Women should be delivered in propped up position. Maternal oxygen saturation, pulse, BP, and ECG should be monitered during labour. Continuous electronic fetal monitering should be done but at times may not be useful in conditions like heart block. Stict fluid balance should be maintained to avoid cardiac failure due to fluid overload. Antibiotc prophylaxis giving amoxicillin 1g i/v plus gentacin 120mg i/v at onset of labour or ruptured membrane or prior to caesarean section, followed by amoxycillin 500mg orally/ i/m/ i/v after 6 hours as prophylaxis against endocarditis. Elective caesarean indicated in complex leisons and to optimise paediatric care. Vaginal delivery is safe in isolated cardiac leison. Epidural analgesia needs careful evaluation as may cause hypotension and decrease preload. Second stage should be shortened with help of instumental delivery to avoid straining. Ergometerine should be avoided in third stage. Thromboprophylaxis may be indicated and should be carefully balanced against the risk of bleeding. Neonatologist should be present at time of delivery.
Posted by Parveen  Q.
The severity of the defect, her haemodynamic status are the major deteminant features . The newyork heart association prognostic indicators, presence of pulmonary hypertension, and if the defect was corrected are the other features. Corrected ASD, VSD, PDA has good pregnancy outcome.Also the medication taken by her like warfarin, ACE inhibitors cause significant embryopathy and she should be advised to see the cardiologist before contemplating pregnancy for the change of medication. Conditions like pulmoary hypertension, tetralogy of fallot , carries significant mortality and she should be deferred from getting pregnant.Patient in heart failure is another fator to be considered.
2. There is increased risk of congenital heart disease . which varies between 3-10 %in ASD.Also increase risk of micarriage , prematurity, IUGR and intrauterine fetal death. when mother is on drugs like warfarin in first trimester, fetus suffers from chondrodysplasia puncta, intracranial haemorrhage, and ACE inhibitors cause renal failure, or fetal death, so they need to be changed. High resolution USS with fetal echocardiography done at 18-22 weeks to rule out structural anamailes, but has to be told that not all anamalies could be identified. Serial USS, to assess fetal growth , if there is evidence of chronic hypoxia in the mother.
3.The intrapartum care is provided by the obsetrician, cardiologist, pyhsician, anasthetist ,midwife.she should be kept in left lateral positon to avoid overload on heart . stress in labour avoided by adequate analgesia. B.P, pulse, oxgen saturation monitored. CVP line maintained .Epidural anaesthesia reduces the systemic resistence and reversal of shunt. care should be taken to aviod fluid overload, intake output maintained. continuous ECG montiring for detecting cardiac arrthmias, if occurs, should be treated immediately. Labour is short, and the outcome is good mostly,. sometimes second stage of labour has to be cut short by instrumental delivery. LSCS is done for only obstetric indication. Third stage of labour should be activley managed ,avoiding ergometrine , syntocinon can be given in infusion or intravenous. Ergometrime changes the hemodynamic status. prophylactic antibiotics given and early ambulation encouraged.
Posted by M M A.
a) Appropriate assessment of her condition is mandatory because of increase risk of maternal and perinatal morbidity and mortality.
Type or nature of cardiac disease is important, non-cyanotic congenital heart disease like (ASD,VSD, PDA) are usually simple defects with minimal haemodynamic significance and they often have good pregnancy outcome especially if there is mild or no pulmonary hypertension , they are managed as low risk category , maternal mortality are less than 1%.on the other hand if the patient has cyanotic heart disease like Eisenmenger\'s complex or tetrology of Fallot, pregnancy is not advices, maternal mortality are high , 25%-50%,with increase perinatal morbidity and mortality also.
Severity of disease is also important, it can be elicited by history of repeated syncopal attacks, cyanosis, chest pain, examination can reveil precordial thrill, pansystolic murmur all over the precordium that is not changed by position, or diastolic murmur that reflect functional or structural abnormality,
Elevated haematocrit, low Oxygen saturation, ECG& Echocardiography findings, all can give a hints about her disease, usually cardiac disease can be classified into four Grades, Grade 1&2 do well in pregnancy, but Grade 3&4 are in risk if pregnancy occur. All these done with assistance of a Multidisplinary Team that including Cardiologist, Cardiothoracic surgeon, Consultant Obstetrician, senior anesthetist and Neonatologist. The team can allow assessment of Cardiovascular reserve of the patient, if she is haemodynamically unstable, her drug regimen should be re-adjusted or she might need an intervention like surgery, the ideal time is pre-conceptional, PDA if not corrected in childhood may need ligation because pregnancy can increase Left to right shunt with subsequent development of pulmonary hypertension,
Drug History is important, some are contraindicated in pregnancy like Angiotensin converting enzyme inhibitor which causes fetal renal failure, Digoxin is safe in pregnancy, Diuretics is controversial, benefits should be weight against risks of these drugs.
If her disease necessitates the use of anticoagulant, consideration should be taken to use LMWH with good monitoring; warfarin can lead t embryopathy if used in first trimester and fetal or neonatal haemorrhage if used after 36 weeks gestation.
Features of heart failure like shortness of breath, ankle oedema, elevated JVP, shifting of apex beat, murmurs, load S3 and S4, can be dependant preconceptional for patient assessment but during pregnancy some of them can occur normally.

b) We should inform the patient clearly about fetal risk; these include miscarriage and fetal loss as a result of mother hypoxia and consequent polycythemia and thromboembolism.
There is small incidence that the fetus will have congenital heart disease, but if there are two members of the family have CHD, the risk increase to 10%, and 50% if three members are affected, therefore; fetal cardiac scan is recommended at 20-22 weeks of gestation., also genetic councelling may be required.
Intrauterine growth restriction also can occur which need serial growth scan and Doppler monitoring of fetal and fetoplacental vessels .Also there is risk of preterm labour and prematurity whether spontaneous or iatrogenic, with subsequent increase in perinatal morbidity and mortality.
Risk of drug exposure also can be added.

c) Many principles should be followed for intrapartum care; the aim is to allow spontaneous vaginal delivery, however, induction of labour for obstetrical causes is not contraindicated, sometimes induction can be employed for patient when she has sever cardiac disease and labour is intended to to occur at day time
The patient will require a close monitoring of general condition, vital sings: pulse rate, blood pressure, temperature, oxygen saturation, some need invasive monitoring by Swan Ganz catheter if the delivery suite is familiar with its use to avoid fluid overloud.
The patient should be advised to lie on left lateral decubetus to avoid supine hypotension syndrome, or should lie with a pillow under her back in semi sitting position, adequate analgesia is required to reduce stress of labour, regional anesthesia should be discussed earlier with specialist anesthetist with clear documentation, patient usually can tolerate Epidural analgesia with adequate pre-loading IV fluid to avoid hypotension.
Antibiotic prophylaxis is administered routinely to minimize risk of bacterial endocarditis with attention to patient drug allergy, Continuous electronic fetal monitoring is required, caesarean section is done for obstetrical causes only, but some times when the cardiac disease is sever and necessitate early delivery and the cervix is unfavorable, CS can be done, General anesthesia can be a safe option with the presence of consultant anesthetist.
Short labour is desirable with shortening of the second stage by using forceps or ventose, however, if fetal decent is expected to progress easily by little maternal efforts, instrumental delivery can be withholded.
Oxytocin use in the third stage is preferred uterotonic because has little effect on maternal peripheral resistance, Ergometrin is contraindicated; although in some cases of sever PPH with lax uterus not responding to oxytocin, Ergometrin or syntometrin can be used with extreme precautions.
We should ensure that full resuscitation facilities are available in our delivery suite and Neonatologist should be present.

Posted by neera  B.
Relevant features include the type of lesion e.g in Eisenmenger\'s syndrome and pulmonary hypertension, termination of pregnancy is advised. Severity of lesion is important e.g if aortic root dilatation is more than 4cm termination of pregnancy is advised while if it is less than 4cm the prognosis is good; if mitral valve stenosis is severe,preconceptional corrective surgery is recommended.NYHA grading of heart disease is very relevant to councelling as higher grades have worse prognosis.Presence of arrythmias,hypertension are associated with worse outcome.Mechanical heart valves necessitate thromboprophylaxis with warfarin,so counselling about its side effects such as chondrodysplasia punctata,miscarriage,stillbirth and intracranial haemorrhage is important. If she has bacterial endocarditis or prosthetic valve, antibiotic prophylaxis is indicated. History of her present medication is relevant as ACE inhibiters or warfirin may need to be stopped preconceptionally. care by a multidisciplinary team gives better outcome.
I will reassure her that most fetuses have no problems. However, the risk of congenital heart disease is increased in the fetus, often the same lesion as the mother, so tertiary level anomaly scan ultrasound at 18 wks and fetal ECHO at 22 wks will be offered to her.There is higher rate of miscarriage, prematurity, fetal growth retardation and intra uterine death; so serial ultras ounds willbe needed during pregnancy. There is increased risk of obstetric injury due to increased instrumental delivery rate. Fetus may be at risk of side effects of medication like warfrin.
The unit protocol and management plan must be followed during intrapartum care. Multidisiplinary team involving consultant obstetrcian, cardiologist , consultant anaesthetist, neonatologist and senior midwife should be involved in her care. Antibiotic prophylaxis should be offered to women with prosthetic valves or becterial endocarditis. Thromboprophylaxis risk assessment should be done ;adequate pain relief should be provided, epidural should be offered. Maternal monitoring with pulse oximetry, pulse, blood pressure and respiratory rate should be done. Fluid balance chart must be kept as excessive fluids can cause pulmonary edema. Partogram should be maintained. Fetus should be monitored with continious CTG ;mobilisation should be encouraged and oral hydration should be maintained.
In the second stage of lobour, lithotomy position should be avoided as far as possible. Prolonged labour must not be allowed; Second stage may need to be cut short with intrumental delivery. Oxytocin should be given at delivery of anterior shoulder but methylergometrine should be withheld.Neonatlogist should be present.
Since cardiac output increases after delivery, cardiac faliure may occur ,so careful maternal monitoring after delivery for at least 24 hours is an important principle.. Severe cadiac disease should be monitored in HDU setting. Head end should be propped up.
Posted by Olubunmi O.
Heart disease in pregnancy is the leading cause of indirect maternal mortality and is associated with significant morbidity and poor perinatal outcome. The severity of her cardiac condition will determine her subsequent management. ASD,VSD, PDA or New york heart association classification classes 1 and 2 are usually low risk and may expect good outcomes. Complex cyanotic heart disease, Congestive heart failure,Eisenmenger syndrome, Pulmonary hypertension, right to left shunts or NYC classes 3 &4 are associated with high maternal mortality and poor perinatal outcome.
Her cardiology notes will be reviewed and a multidisciplinary team involving the anaesthestist and Cardiologist will be involved in her management. Further investigations may be required including ECG and echocardiogram as determined by the cardiologist.
If she falls into the high risk category, she should be advised against pregnancy and reliable and effective contraception provided. Other options like adoption may be discussed. If she is in the lower risk group her care will be based in a consultant led unit with multidisciplinary involvement including the consultant obstetrician, Cardiologist and Anaesthetist. Preconceptual folic acid should be started and the patient screened for rubella, TORCH and hepatitis at booking. Drugs modification should be done in conjunction with the cardiologist, warfarin should be changed to LMWH.
She will need frequent antenatal visits with a detailed anomaly and cardiac scan at 20-22 weeks to rule out cardiac malformations .
Regular growth scan in the 3rd trimester is essential as there is increased risk of IUGR with impaired maternal cardiac function .There should be regular checks for anaemia ,infection, cardiac arrythmias and raised blood pressure with correction as these may worsen cardiac function. Cardiac symptoms like Shortness of breath and pedal oedema may mimic pregnancy symptoms and should prompt further investigation. Corticosteroids should be administered if delivery before 36 weeks is anticipated .Anaesthetic review should be done to determine mode of analgesia in labour or should operative delivery be needed.
The fetus is at increased risk of Congenital heart disease. Risk is higher if there is positive family history, previous affected child or siblings. There is also increased risk of IUGR and poor perinatal outcome if impaired maternal cardiac reserve and function.
There is a significant risk of iatrogenic prematurity should cardiac function worsen and preterm delivery expedited. This is associated with neonatal morbidity and mortality and long term morbidity. Drugs like Warfarin and Ace inhibitors are associated with bleeding ,congenital anomalies, impaired foetal renal function and oligohydramnious. Intra-partum the foetus will be at higher risk of instrumental or assisted delivery.
The principle of intra-partum management includes anticipation of vaginal delivery and reservation of CS for obstetric indications.Multidisciplinary management in labour with close continuous monitoring of oxygen saturation, ECG and electronic foetal monitoring. The need for more invasive monitoring should be decided by the cardiologist.The patient should be nursed in the left lateral position to improve cardiac return. Involvement of the anaesthesist and Epidural analgesia for pain if cardiac output is not impaired is recommended. Endocarditis prophylaxis should be provided if there is history of endocarditis, cyanotic heart disease, valvular dysfunction or prosthetic valves. Strict monitoring of fluid input and output to prevent overload is essential.2nd stage should be shortened to keep cardiac load to a minimum .Ergometrine should be avoided in the 3rd stage, syntocinon my be used. Delivery should be attended by neonatologist and baby assessed for CHD. Continuous monitoring for 72 hours post partum in HDU if indicated as there is increased cardiac load post partum.
Posted by Sarwat F.
Features relevant to counselling and subsequent management include type of heart disease any corrective surgeries done, degree of cardiac decompensation present and any medication she is taking. For diseases like Eissenmingers syndrome and primary pulmonary hypertension pregnancy is not advisable. As maternal mortality is very high. She may need alteration of medicines as there is a risk of teratogenecity in first trimester. She will be explained the need for multidisciplinary care involving obstetrician, cardiologist, anaesthetist, neonatologist and geneticist. Proper counseling will be necessary to maintain adequate followup.
Risks to the fetus include risk of congenital heart disease in the fetus, IUGR and prematurity as cardiac condition in the mother may need elective preterm delivery. A fetal echocardiograph will be organized at 22 weeks of gestation. Detailed anomaly scan at 22 weeks will also help to exclude major structural abnormalities. As there is a risk of fetal hypoxia in certain cyanotic congenital heart diseases, serial growth scans are arranged to monitor fetal growth. Geneticist, neonatologist and cardiologist will be involved as a part of multidisciplinary team to give the accurate risk of transmission of the condition.
Principles underlying intrapartum care include maintaining adequate cardiac reserve, preventing cardiac decompensation, prevention of infection with antibiotics and to shorten the second stage of labour. in most cardiac conditions there is no contraindication to vaginal delivery and caesarean section is done only for obstetric indications. Epidural anesthesia can be provided if there is no coagulopathy and adequate cardiac reserves. In patients with reduced circulatory reserve epidural anaesthesia is contraindicated. For women who had therapeutic enoxaprin, epidural can be given 24 hrs after the last dose. Intravenous antibiotics are given to prevent subacute bacterial endocarditis. Labour is monitored on partogram. Second stage is shortened by instrumental delivery to prevent cardiac decompensation. Active management of third stage of labour is done by giving intravenous syntocinon at the time of delivery of anterior shoulder. Ergometrine is avoided as it causes severe peripheral vasoconstriction. Thromboembolic prophylaxis is given according to the hospital protocol.
Posted by Farzana N.
She should be counseled in a combined clinic in a multidisciplinary set up with involvement of obstetrician, cardiologist, or physician ,anesthetist and if necessary a cardiothoracic surgeon. Prepregnancy counseling will allow an accurate assessment of the severity and nature of the cardiac lesion and her cardiovascular reserves .
Pregnancy in woman with condition like with ASD, VSD, PDA are low risk with favourable maternal and fetal outcome.
Pregnancy is contraindicated in Eisenmenger syndrome,Pulmonary hypertension,Marfans syndrome with aortic root involvement all of which are associated with high risk therefore advised against pregnancy and appropriate contraception should be discussed.
Her drug needs to be reviewed and optimized .Most of the drug can be used safely but some drug such as Angiotensin-converting enzyme inhibitors and B-blockers Atenolol should be avoided because of the fetal risk of intrauterine growth retardation ,renal failure and death . She will be counseled regarding thromboprophlaxis and different options shoud be discussed.
Warfarin is associated with embryopathy in early pregnancy and has adverse fetal effects if used late in pregnancy .It is preferable to be changed with heparin prepregnancy .Any modification of the drug should be with consultation of cardiologist .She should be counseled in case she need surgical correction of cardiac lesion to be performed pre pregnancy.
She has fetal risk of congenital heart disease which is over above general population Her pregnancy will be high risk therefore she should be advised for early booking in multidisciplinary care frequent antenatal visit ,avoidance of factors contributing to cardiac decompensation such as aneamia ,infection and hypertension .
She will need detailed ultrasound at 18-20 weeks and fetal echocardiography to detect cardiac anomalies.Serial growth scan for detection of fetal growth retardation especial important with severe cardiac disease and cyanotic congenital heart disease .
Decisions regarding timing ,mode of delivery , type of anaesthesia ,cardiac momitoring antibiotic prophylaxis ,thromboprophlylaxis and site of delivery will need to be planned in advance and clearly documented.
Patient with CHD has 2-5 % fetal risk of congenital heart disease which is increased in cardiac lesion with outflow obstruction .She has increase risk of miscarriage which is 45% with cyanotic heart disease .She has risk of fetal growth retardation ,preterm labour and fetal death .Prenatal diagnosis can be performed by high resolution ultrsond and echocardiogram but all lesion cannot be detected.
Regarding her intrapartum care vaginal delivery is preferred as there is no evidence of elective ceaseraen section confers any benefit to mother or fetus. Caesearean section for obstetrics indication .A short labour and effective analgesia will minimize the stress of labor to mother and risk of hypoxia to fetus. During labour care must be taken to avoid supine hypotension due to aortocaval compression by gravid uterus lying in left lateral position or supported by pillows or wedge . Choice of anaesthesia depands on circumstances of delivery and maternal cardiac status . With good cardiac reserve early epidural anaesthesia is well tolerated and provide effective analgesia minimizing heart rate and blood pressure changes but should be used with extreme caution in patient with restricted cardiac output or right to left shunts .

Fluid balance should be strictly monitored because of risk of pulmonary oedema .In high risk cases pulmonary wedge pressure monitoring may be needed. maternal monitoring with Ecg and oxygen is requred.Continouse electronic fetal monitorin is recommended .Antiboitic prophylaxis from the start of labour for bacterial endocardits shoud be considered.Elective shortening of the second stage to minimize the rise in blood pressure caused by maternal pushing. Ergometerine should be avoided in third stage .syntocinon is preferred over ergometrine Neonate should need assessment for congenital cardiac anomaly.Blood loss should be minimized and replaced promptly . Cardiac load increased following delivery and woman should be monitored closely at least for 72 hours after delivery .
Posted by SWATI M.
a)The nature of the heart disease whether cyanotic/ acyanotic is important as women with cyanotic heart disease is likely to have more complications.The current NYHA class to which patient belongs determines her ability to cope up with increased work load on heart.Type of heart lesion influence counselling and management ,for instance morbidity and mortality is higher in Eisenmenger?s syndrome.In presence of pulmonary hypertension ,prognosis is worse and pregnancy should be discouraged.Use of anticoagulants ,antihypertensives such as ACE inhibitors influence pregnancy outcome.Previous corrective cardiac surgery if successful will have better prognosis.

b)There is increased risk of miscarriage ,IUGR,Preterm delivery and LBW if mother has cyanotic heart disease.The anticoagulant warfarin can lead to embryopathy especially if the fetus is exposed to the drug between 6-12 weeks and it can be minimized by use of alternative drug -heparin.The risk of having congenital heart disease is increased upto 5-10% which is 1% for general population.She will be offered the cardiac scan at 22-24 weeks at fetomaternal unit but only 50-60 % of cardiac anomalies are diagnosed antenatally. Prognosis is usually good if mother is asymptomatic ,NHYA class I/II , had successful corrective cardiac surgery.

c) Patient should be managed by the multidisciplinary team involving consultant obstetrician,cardiologist,consultant anaesthetist,neonatologist and senior midwife.Unit protocol/guidelines and management plan formulated antenatally should be followed.Caesarean section is done for obstetric indication .Nurse patient in propped up / left lateral position.Monitor P,BP,O2 saturation,ECG and RR.Invasive monitoring in severe cases with involvement of intencivist and management in HDU.Oxygen supplementation given if needed.Fetus should be monitored by continuose CTG .Keep emergency trolley ready.Observe aseptic precautions at all times with institution of antibiotic prophylaxis against bacterial endocarditis.Optimal number of vaginal examination to avoid risk of infection .Adequate analgesia should be given with maintainence of BP.Adjust doses of heparin in consultation with cardiologist.Offer appropriate thromboprophylaxis after risk calculation with early mobilisation and maintaining adequate hydration.Avoid fluid overload with judiciouse use of IV fluids.Shorten second stage by prophylactic use of ventouse / forceps.Neonatalogist should be present at delivery with the appropriate resuscitation trolley. Manage third stage by use of syntocinon and syntomerine/ergometrine is contraindicated.Keep woman and her family informed about her condition at all times.Communication between the staff is important for consistency in her care.Proper documentation about condition,complications,care provided is important.
Posted by sailaja devi K.
The features of heart disease that are relevant are (a) the type of heart disesase 1 left to right shunt 2 right to left shunt.3 out flow obstruction.(b) Pulmonary hypertension- increase the risk for death & morbidity (c) Eisenmenger syndrome. Eisenmenger syndrome has 40% mortality in pregnancy,no definitive treatment available so pregnancy is absolutely contraindicated.(d) cyanotic or acyanotic heart disease.Simple acanotic defect ,uncomplicated left to right shunt do well in pregnancy, women with minimum hemodynamic changes do well in pregnancy.

Look for the predictors .Predictors for risk of maternal cardiac complicaions during pregnancy help in counselling the women.They are NYHA classification greater than 2,left ventricular obstruction,cardiac dysfunction,previous arrthymia,previous cardiac complication. Left ventricular ouflow abstuction is aortic valve stenosis less than 1.5 cm2 . Myocardial dysfunction defined as ejection fraction less than 40 % or complex congenital heart disease.History of arrthymia that required treament.If there are no risk factors only 3% had complications, if one risk factor present 30% had complications ,if 2 risk factors were present 66 % had complications.

I will tell the women that the risk to fetus are miscarriage,growth restriction,prematurity. Fetus is at increased risk of congenital heart disease.Risk is 2-5% ,double that in general population. 50% cases lesion is concordant.Risk is more if mother had congenital heart disease compared with if father had.


Principles which underlie intrapartum care in first stage of labour are - 1 manage in intensive care unit with cardiologist anaesthetist ,obstetrician.2. avoid aortocaval compression ,supine hypotension - left lateral position /upright position is advised.3.Avoid hypovolemia ,maintain preload - monitor the intravascular fluid balance .4.continous electrocardiographic monitor for women to detect arrythmia.5.supplement oxygen to redcuce pulmonary vascular resistance 6.monitor oxygen saturation ,central venous pressure,blood pressure.7.Avoid thromboembolism using prophylaxis.8. avoid endocarditis if women is at risk.9 .avoid systemic hypotension - caution with epidural ,syntocinon.10.consider selective pulmonary vasodilators - inhaled nitric oxide , prostacyclin.11.consider caesarean section for obstetric indication.12.fetus is at risk because of hypoxia ,hypotension - continues electronic fetal monitoring is needed.

Principles in second stage of labour - operative vaginal delivery to cut short second stage . This avoids the blood pressure changes associated with pushing.

Principles in third stage of labour - avoid ergometrine ,syntocinon infusion preferred. Postpartum haemorrhage lead to decreased preload, hypotension .Maintain preload with intravenous crystalloids.
Posted by Randa E.
The features important to counselling and subsequent management are the type of the cardiac disease e.g. cyanotic/ acyanotic. Acyanotic conitions like ASD,VSD, PDA are low risk conditions associated with good pregnancy outcomes.
Pregnancy in women with Eisenmenger Syndrome, Pulmonary hypertention , Marfans syndrome with aortic root involvement or in women with complex cyanotic disease carry a risk of maternal mortality and poor perinatal outcome, and women with these conditions should be advised against pregnancy and adequate contraception given.
Another feature would be the severity of the disease which is assessed by the NYHA jointly with Cardiologist. Grade I-II do well during pregnancy, but grade III-IV would be at risk to get pregnant and should be advised accordingly. Any history of corrective surgery or the presence of prosthetic heart valves is also important.
Types of medication the woman is taking should be known , for certain types like anticoagulants e.g. warfarin or drugs like B-blockers have tetatogenic effects on the pregnancy and need to be modified prior to or during early pregnancy in alliance with cardiologist.
She should be told that there is an increased risk of congenital heart disease in the infant and there is also an increased risk of IUGR esp. if the mother is on (B-blockers) ,and an increased risk of preterm labour . There is also an increased risk of embryobathies and intracranial haemorrhage if she is on warfarin. Also she should know that there is an increased risk of oligohydramnios and renal failure especially if she is on ace inhibitors. An early scan at 10-12 wks for dating and a detailed anomally scan at 20-22wks and fetal echocardiography to rule out CHD should be offered. Serial u/s scans from 24wks to monitor fetal growth are important with Doppler if necessary.
She should be told that the outcome of pregnancy with acyanotic heart disease like ASD/VSD is usually good especially after corrective surgery. All that is discussed should be written down and documented clearly and all her wishes taken into consideration. She should also be given written information about her condition to take home and read carefully.
The intrapatum stage must be managed by a multidisciplinary team involving the senior obstetrician, cardiologist, anaesethist, physician, cardiothoracic surgeon, and an experienced midwife. A vaginal delivery should be anticipated in the majority of cases with effective analgesia and a shortened 2nd stage (ventouse/forceps) of labour with the reservation of c/s for obstetric indications. Effective anaesthesia in the form of an early epidural is usually well tolerated and provides effective analgesia and should be offered by a senior anasthesist. She should be nursed in the left lateral position during labour as not to compromise venous return. Labour is associated with increased cardiac load and so continuous maternal monitoring with SO2, ECG and invasive monitoring depending on advise from cardiologist/anathesist and continuous fetal monitoring should be undertaken.
Fliud overload should be avoided and fluid input/output restricted.
Antibiotic propholaxis should be given for bacterial endocarditis and ergometrine should be avoided in 3rd stage of labour. Syntocinon is adminsterd to avoid blood loss.

Posted by Yasser S.
The important features to consider are the type of heart disease either cyanotic or acyanotic, the severity of symptoms determined by NYHA classification, the drug therapies she is on and any specific conditions like pulmonary hypertension.
Other important features that predict the outcome of pregnancy are history of transient ischemic attacks or arrythmias, heart failure, myocardial dysfunction and left heart obstruction. History of any corrective surgery done in her childhood is important. Most of the congenital heart diseases with corrective surgeries are tolerated well in pregnancy. The presence of cyanosis and/or pulmonary hypertension are poor predictors and carries significant risk to the mother and fetus. In the presence of which she needs to be advised against pregnancy.The medications that she is on is another factor that could expose her to an increased risk of teratogenicity and other adverse effects on fetus.

Regarding to the risks to her fetus, she should be told that the risk of her baby having the disease is higher when she has the disease as compared to a baby whose father has the disease. Usually the baby tends to have the same leision like the mother. She would need a detailed ultrasound scan for her baby to know the extent of the disease at 20-24 wks. Her baby is at an increased risk of premature birth & less birthweight. If she is using medication like warfarin and ACE inhibitors, then her baby may develop adverse effects from these medications in the form of physical abnormalities. She is also at an increased risk of miscarriage either spontaneous or induced due to medical reasons. She needs to have her pregnancy care in a hospital that has all the facilities of cardiologists and pediatric surgery available. She should be provided with written information leaflet regarding all these facts.

The intrapartum care should be in a multidisciplinary hospital with the availability of cardiologist, intensivist, anesthetist and obstetrician. Patient needs to be on continuos monitoring for blood pressure, pulse oximetry, input and output charting and echocardio monitor.During labor patient should be kept on supplemental oxygen in order to reduce pulmonary vascular resistance. She should be adequately hydrated to avoid hypovolemia. Fluid overload should also be avoided as it can cause pulmonary edema. Thromboprophylaxis is very important to avoid thromboembolism. Epidurals and drugs causing vasodilatation should be used with caution. Patient should receive adequate analgesia. She should be nursed in the lateral postion to avoid caval compression. Second stage of labor should be shortened to avoid extra stress. Ergometrine should be avoided in the third stage.
Posted by Abi T.
a) Counselling and subsequent management of this patient would depend on the specific heart condition that she has. The type of lesion precludes the outcome of pregnancy, eg, congenital heart defects are the commonest lesions and are usually hemodynamically insignificant. Most patients would also have had corrective surgery with minimal or no residual problems, hence will have good pregnancy outcomes. Valvular heart lesions such as mitral stenosis usually deteriorate in pregnancy and close monitoring is needed with cardiologist input to detect symptoms and signs of deterioration. Patients with moderate to severe mitral stenosis should defer pregnancy until corrective surgery has taken place.
The severity of the lesion is another feature that impacts on the woman\'s tolerance of pregnancy and subsequent outcome. This is determined by its impact on her functional status as defined by the NYHA classification. Patients in Class 1 and 2 have lower mortality and morbidity rates than those in Class 3 or 4. In fact pregnancy in women in the latter group should be discouraged.
The presence of cyanosis is equally important as this feature carries the highest maternal and perinatal mortality risk. Women with eisenmenger\'s syndrome , pulmonary hypertension and complex cyanotic congenital defects should avoid pregnancy.
Any medication taken eg, warfarin, ACE-inhibitors and beta blockers would need to be stopped or altered to a safer choice as these have teratogenic and fetal risks.
b) There is an increased risk of cardiac defects in the fetus, over and above that for the general population. The defect is usually concordant with the mother\'s and in Marfan\'s syndrome, which is of autosomal dominant inheritance, the fetus will have a 50% risk of being affected. There is also a risk or preterm delivery which is either spontaneous or iatrogenic. Certain drugs carry a risk of anomalies. Warfarin is associated with increased risk of miscarriages, skeletal defects and intracranial hemorrhages. Ace-inhibitors cause IUGR and oligohydramnios as they affect fetal renal function. Beta blockers are also associated with IUGR. A detailed anomaly scan should be offered together with fetal echocardiography with written information on its indication and limitations.
c) The initial principle of of intrapartum management is involvement of a multidisciplinary team comprising obstetrician, anaesthetist, cardiologist and an experienced midwife. Vaginal delivery should be anticipated and Caesarean sections only done for usual obstetric reasons. Ideally the patient should labour in an obstetric HDU setting or in a setting with full adult and neonatal resuscitation facilities. The patient should be nursed in the left lateral position to avoid aorto-caval compression and frequent maternal monitoring should include pulse, blood pressure, respiratory rate and oxygen saturation and ECG. Continous fetal electrocardiotocography is also indicated as maternal hypoxia and hypotension causes fetal distress.
There should be strict fluid management avoiding fluid overload as this will precipitate pulmonary edema and subsequently cardiac failure. Invasive monitoring is not compulsory unless there are signs of hemodynamic deterioration.
Effort should be made to reduce maternal stress and anxiety by offering effective analgesia and this is according to maternal choice. Elective shortening of second stage is recommended by use of instrumental vaginal delivery.
Endocarditis prophylaxis should be given at the onset of labour following recommended protocols.
Ergometrine should be avoided as it increases heart rate and vascular resistance and can precipitate cardiac failure. Oxytocin, instead should be used for the third stage.