Book of Medical Disorders in Pregnancy - Tintash

determine whether she will be safe in an
area where monitoring will be less
intensive.
Prognosis - Heart disease in pregnancy
carries an over all maternal mortality
rate of 0.8 to 5 per cent. In patients with
Class IV disease, the mortality is
markedly increased and may become as
high as 50 per cent. It is further
increased where inadequate medical
advice is obtained and the patient
received no treatment. The prime factor
in seriousness of the disease is the
presence or absence of cardiac decompensation.
Class I and II, as a rule, do
well with pregnancy. Prognosis is worse
in women over the age of 35 years.
Congestive heart failure may predispose
to premature labour because of
congestion of the uterus with blood
which has less than normal oxygen
content.
Fetal mortality –
Fetal mortality in Class I is 7 per cent
while in Class II it is 13 per cent. In
Class III it is 35 per cent and in Class IV
it is 54 per cent.
Quick Review
Management Options:
Cardiac Disease: general
Pre pregnancy:
Obstetrician and cardiologist in
collaboration, Discussion of maternal or
fetal risks, Discussion of effective/safe
contraception, Obtain update on cardiac
status, Optimize medical and surgical
management, advise against pregnancy
with certain conditions.
Prenatal:
83
Assess functional class of heart disease
(see Table 39.2) Termination is an
option with a few conditions S joint
management with cardiologist Optimize
medical management Avoid/minimize
aggravating factors An coagulation for
certain conditions (? Stop warfarin and
change to subcutaneous heparin: see
Chapter 50) Prophylactic antibiotics with
certain conditions (see Table 39.4 and
39.5) Fetal sur veil lance: Growth and
umbilical artery Doppler (especially if
left to right shunt) Detailed fetal cardiac
ultrasonography if maternal congenital
heart disease.
Labor/delivery: Elective induction may
be necessary for maternal and fetal
indications. Pro-phylactic antibiotics
with certain conditions (see Tables 39.4
and 39.5) Avoid mental and physical
stress (?epidural) Labor in left lateral or
upright position, Monitor electrocardiogram:
more invasive monitoring
with certain conditions Administer extra
oxygen with certain conditions, Full
resuscitation facilities available,
Continuous fetal heart rate monitoring,
Assisted second stage with certain
689
conditions, Avoid ergometrine for third
stage.
Postnatal:
Vigilance for cardiac failure, Avoid fluid
overload, Continued high dependency
care and discuss effective/safe
contraception.
Management options: Cardiac murmur,
Echocardiography for significant history
or pathological, murmur (late systolic,
pansystolic, diastolic), Cardiological
referral if abnormal echocardiography.