Re-Updated Heart Disease In Pregnancy

I had the oppurtunity to learn this case twice...
Yesterday :Teaching With Dr Bahiyah =)
Today (22nd Oct) : Teaching with Dr Rozihan (She's new HOD for O&G department)

Summary

27yo, Malay Housewife, G2P1 @ 37 w +4days POA with hx of corrected VSD at the age of 13 yo & 4years ago dx to have Valvular HD, NYHA class 2 under f/up & medications
admitted for further mx of her Heart Disease & plan mode of delivery. She remain asymptomatic throughout her pregnancy & her baby was found to be SGA with good fetal movement. Currently had irregular contraction with no other signs of labour.

On examination:

presence of well healed sternotomy scar, collapsing pulse, apex beat was displaced Left 6th IC space midclavicular line with MR & AR & she's not in failure

abdomen: only correspond to 34 weeks size (smaller than date), singleton fetus, longitudinal lie, fetal back at R maternal side, cephalic presentation, 5/5 palpable, not engaged yet, EFW about 2- 2.2, adequate liquor

Discussion:
She had no pre pregnancy counselling b4 (need to be highlighted in hx)

She was initially f/up at JB. Why now admitted to Kuantan??? (need to ask this Qs)
Following her husband or due to inadequate facilities?? for this pt its the former one

ECHO done twice in this patient. Why twice???
Patient becoming more severe??or become more symptomatic??
Doctor in HTAA just want to confirm otherwise no other indication as the patient was well

Did she attend any combine clinic??
Yes at 16 weeks

Was an detailed scan was done to her?? No.
Do u think she should have one???Yes because she has Congenital HD
VSD- 5% risk for her fetus

How to ask wether pt had done detailed scan??
Scan that need longer time to do (>30minutes) & doc mentioned to look at the fetus's fingers, face, etc

Why she was on Penicillin since her childhood??who prescribed to her??Does she need the abtc?
Pt corrected VSD no need to take life long Penicillin. This patient was given penicillin for 10 years & already stopped for 4 years ago. She was not under IJN f/up

Lasix...Y in this current pregnancy she 's on lasix???
Actually there was once during her pregnancy she developed SOB, palpitation & reduced effort tolerance. So she was started on this

Why patient was admitted??

To monitor any risk of failure (anemia, any infection-UTI/resp infxn & hypertension)

Anemia - monitor Hb. Gives pt hematinic

Iron tablets was given to all pregnant mummies. Iron tablet has prophylaxis dose & treatment dose. This patient need to be given treatment dose. Not prophylaxis dose which given to normal pregnant mummy. Tapi dose nya...saya xcek lagi...muahahaha (HELP...HELP...)

Regarding infection: each antenatal check up all pregnant mummies need to do urinalysis in order to catch mummies with asymptomatic bacteriuria. If this problem is not detected&treated, about 20%-25% mummies can get pyelonephritis. Kesian kan. (Dr Rozihan-HOD O&G)

How do you manage this patient if u see her for the 1st time???
I would like to confirmed her history 1st
Would like to ask any symptoms of heart failure & any risk factors that could precipitate heart failure such as anemia & any infection (UTI, respiratory infection) or any symptoms of hypertension

Do physical examination (PE)
Abdomen: (like what mentioned earlier)
VE: because patient complained of irregular contraction. Look at vulva vagina,etc2. Do bishop score, if favourable, sent pt to labour room
CVS: check wether patient in failure or not, any evidence of pulmonary hypertension & Infective endocarditis
Fetus: check for fetal well being - do CTG - check reactive or not

Do investigation such as
FBC - to check her HB level. Anemia can precipitate / worsen her heart dz & she might go for CS
US - confirm the fetal well being, AFI, continue plot the graph either baby IUGR/SGA (pt was on f/up b4, there must be graph plotted to check for this)

Refer to cardiologist for ECHO (to check for EF, severity of regurge & any evidence of pulm hypertension) & to optimise her condition & consult regarding her mode of delivery (wether she can withstand the stress of labour or plan for elective CS)

What is your mode of delivery???I would choose SVD if there is no obstetric indication or heart complication. Wait for spontaneous labour. Not allow post date & can induce her but with precaution. Prostin is only relative contraindication to heart disease. Why?? cause vasoconstriction & can cause increase venous return & overload the heart

If there is obstetric complication or she has severe heart disease - LSCS

If allow SVD what should you do??
1st phase of labour:
Patient was prop up, given oxygen, analgesia - epidural (inform anaest), if infused patient, avoid fluid overload
what is standard heart dz regime given to patient?? (yang nie tak jumpa lagi. Hoho =( )
SBE antibiotic prophylaxis - ampicillin & gentamycin

Regarding epidural analgesia.

Contraindication-patient on anticoagulant & aortic stenosis

advantage - can top up & heart disease pt is high risk case, so they have high chance to go for operative delivery (either ceaser@assissted delivery). so if she were put on epidural, no need to give extra analgesia & epidural also do not have effect on the baby

But Im query, pt heart disease in labour, kite put her on cardiac monitor ke???xpenah nampak ponggg~ ( need help regarding this)

2nd phase of labour:
Shortened the 2nd stage, assisst the delivery - vacuum

3rd phase of labour:
Avoid Ergometrine

Postpartum

Observed patient for 5 days
w/o fr PPH, anemia, thromboembolism
Adviced patient for contraception, how many children patient wants, adviced good spacing & what type suits the patient.
If patient compliance can give pills, if not injection or implanon, if patient already completed family @ fatal for her to get pregnant - BTL should be done but consult cardiologist first

OCP is not suitable for heart disease - estrogen can cause thrombosis in patient with heart dz

IUCD & barrier method also can be given to the patient. Books saying that IUCD can cause infection to the patient is an old school taught. Skang tidak lagi, dgn teknologi yg ada.Hehe

Barrier method is an option if both patient & husband are highly motivated & educated. Cannot say, due to less effectiveness ( low pearl index) is not suitable for the couple to opt this method

If she allows to get pregnant later, adviced for prepregnancy counselling & plan her pregnancy well

Last but not least, refer her to cardiologist for her heart disease follow up