Epidemiology in Malaysia Accounts for 12% of maternal disease in 1996. Commonest cause of indirect maternal death in Malaysia In Sarawak there were a total of 9 maternal deaths from hearth diseases in the 3 years period between 2010-2012
How comman? Coronary artery disease is uncomman in pre- menopausal women of child-bearing age Most common; congenital heart disease or rheumatic valvular heart disease Cardiac complications result from hemodynamic changes that occur during pregnancy CVS adaptation in pregnancy Cardiac output: increased by 45% Stroke volume: increased Heart rate: increase by 10-20bpm Blood pressure: reduced in the 1 st and 2 nd
Chest examination : - shifted apex beat - loud diastolic murmur - cardiomegaly - basal crepitation Management 1. Precontraception counselling regarding : effect of hemodynamic changes and maternal risk Effect of fetal growth Effect of materanl drug and complicance Genetic transmission Need for frequent admission and long stay Encourage for complete family earlier and discourage from multiple pregnancy Contraception Barrier method: compliance issue Spermicides: high failure rate COCP: avoid in IHD, valvular heart disease and plmonary hypertension Implanon: very useful IUCD: contraindicated in prostatic valve, endocarditis Antenatal Management 1. Booking all mother should examine CVS properly if suspected, refer to cardiologist for ECHO 2. Antenatal Clinic History: look for any heart failure symptoms with access of NYHA PE :look any sign of heart failure Investigation: Hb,ECG, ECHO (if sx suggestive)
3. Factor aggravate heart failure identified and treat - Anemia - HPT - Infection(UTI or URTI) - Hyperthyroidism - Arrhythmias - Multiple gestation 4. Advice about : - Rest - Smoking cessation - Compliance of hematinic 5. Anticogulant - anticoagulant theraphy is indicated if patient had previous valve replacement and severe heart disease - 3 types regime can be used : - continue warfarin throughout preganancy, replace heparin for delivery ( 1-2 weeks prior for delivery) - replacement warfarin with heparin in 1 st trimester - use heparin throughout pregnancy 6. Time and mode of delivery: Mild and moderate heart disease : - aim for SVD, avoid induction of labour Severe heart disease /develop acute heart failure - admit patient early - prepare for preterm labour for sever heart disease patient
Intrapartum Management Aim for deliver within 6 hours Stop heparin before pregnancy Prop up left lateral Continue CTG, ECG and Sp02 Give 02 (3L/min) Give epidural anesthesia Antibiotics epidural given in severe cases: - IV ampicillin 2gr STAT and 8hr later (2 doses) - IV gentamicin 800mg and 8hr later ( 2doses) Avoid fluid overload Shortened 2 nd stage 3 good maternal push / by using instrumental delivery For 3 rd stage, give syntocinon (dont give ergometrine)