1. Mitral Stenosis in Pregnancy
25 year old Mitral Stenosis in Pregnancy having Class II symptoms. All the following are done for managing her delivery EXCEPT
a) Application of outlet forceps to cut short the 2nd stage
b) After delivery of the placenta, intravenous frusemide to be given
c) Methergine is to be administered after delivery of the anterior shoulder
d) Higher Antibiotic is to be given
e) Propped up position throughout 1st stage of labour with nasal Oxygen
Correct Answer: c)
Methergine is contraindicated in heart disease in pregnancy as these patients are more susceptible to developing myocardial ischemia and infarction associated with methylergonovine-induced vasospasm. Also it can cause volume overload induced heart failure.
2. NYHA class in Pregnancy
Regarding cardiac disease in pregnancy, according to the New York Heart Association classification, a patient with cardiac disease & slight limitation of physical activity would be
a) Class O.
b) Class I.
c) Class II.
d) Class III.
e) Class IV.
Correct Answer: c) Class II.
Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain (Class II). Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain (Class I).
3. Infective endocarditis prophylaxis
Infective endocarditis prophylaxis is not recommended during vaginal or cesarean delivery except for patients at highest risk of acquiring endocarditis.
Correct Answer: a) True. Ref: ECS/AHA Guidelines.
Infective endocarditis during pregnancy is rare, with an estimated overall incidence of 0.006% (1 per 100000 pregnancies). Endocarditis prophylaxis is now only recommended for patients at highest risk of aquiring endocarditis during high risk procedures, e.g. dental procedures. During delivery the indication for prophylaxis has been controversial and, given the lack of convincing evidence that infective endocarditis is related to either vaginal or caesarean delivery, antibiotic prophylaxis is not recommended during vaginal or cesarean delivery.
Patients with the highest risk for infective endocarditis are those with a prosthetic valve or prosthetic material used for cardiac valve repair, a history of previous infective endocarditis, and some special patients with congenital heart disease.
4. IE Prophylaxis
Primi at term cephalic presentation with labor pains and cx dilatation of 4cm. Her prenatal course was unremarkable. She has a past medical history significant for mitral valve prolapse with regurgitation demonstrated on echocardiography.
a) Administer intravenous antibiotics throughout labor.
b) Administer intravenous antibiotics 30 minutes prior to the delivery.
c) Administer intravenous antibiotics after the cord is clamped.
d) Administer intravenous antibiotics six hours after the delivery.
e) Antibiotic prophylaxis is not necessary
Correct Answer: e) Antibiotic prophylaxis is not necessary.
The risk of developing endocarditis depends upon both the cardiac condition and the nature of the procedure. According to the American Heart Association guidelines, antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery.
5. Anticoagulants for Heart Disease in Pregnancy
Oral anticoagulants cross the placenta and can produce a characteristic embryopathy with first-trimester exposure and, less commonly, central nervous system abnormalities and fetal bleeding with exposure after the first trimester.For this reason, it has been recommended that warfarin therapy be avoided during the first trimester of heart disease pregnancy and, except in special circumstances, avoided entirely throughout pregnancy. Because heparin does not cross the placenta, it is the preferred anticoagulant in pregnant women.
6. Heparin or Warfarin in Pregnancy
What should be given to woman with mechanical prosthetic valve in Pregnancy ?
Heparin or LMWH in the first trimester of pregnancy, switching to warfarin in the second trimester, continuing it until ≈38 weeks’ gestation, and then changing to heparin or LMWH at 38 weeks with planned labor induction at ≈40 weeks. (American Heart Association Guidelines)
7. Congenital Anomaly with Warfarin
A 34-year-old woman attends her obstetrics ultrasound appointment. Her medical history noted mechanical prosthetic valves. The scan reveals the presence of depressed nasal bridge, stippling of non-calcified epiphyses and microcephaly. No other neural tube defect, cardiac problem or orofacial defect was noted. A history of taking which drug is likely to explain the aetiology ?
d) Sodium valproate
Correct Answer: e) Warfarin.
Both sodium valproate and warfarin can cause depressed nasal bridge and microcephaly. Sodium valproate is commonly associated with neural tube defects, cardiac defects and other dysmorphic features.
Stippling of non-calcified epiphyses is commonly associated with warfarin. Neurological abnormalities may be seen with warfarin usage in the second or third trimester. Teratogenic risk with warfarin is overestimated and should always be balanced with the risk versus the benefit profile. In women with a prosthetic heart valve replacement, there is are an undisputed indication for warfarin usage.
8. ABSOLUTE indications of Cesarean section in Heart disease
There is no consensus regarding ABSOLUTE indication Cesarean section in Heart disease or contraindication to vaginal delivery; as this is very much dependent on maternal status at the time of delivery and the anticipated cardiopulmonary tolerance of the patient.
ESC / European Society of Cardiology Guidelines (2011) for Cesarean section in Heart disease
Cesarean section in Heart disease should be considered for
1) patient on oral anticoagulants in pre-term labour,
2) patients with Marfan syndrome and an aortic diameter >45 mm,
3) patients with acute or chronic aortic dissection, and
4) those in acute intractable heart failure.
5) severe aortic stenosis (AS)
6) severe forms of pulmonary hypertension (including Eisenmenger syndrome)
9. Indications for Cesarean section in Heart disease are ALL EXCEPT
a) Eisenmenger’s syndrome
f) Pulmonary Stenosis
g) Coarctation of the Aorta
h) Ebstein’s anomaly
Correct Answer: None.
Poorly framed Question. Following are ESC / European Society of Cardiology Guidelines (2011) for each conditions.
a) Eisenmenger’s syndrome: They need special consideration because of the association of pulmonary hypertension with cyanosis due to the right-to-left shunt. Systemic vasodilatation increases the right-to-left shunt and decreases pulmonary flow, leading to increased cyanosis and eventually to a low output state. The literature reports a high maternal mortality of 20 – 50%.
If the maternal or fetal condition deteriorates, an early caesarean delivery should be planned. In others, timely hospital admission, planned elective delivery, and incremental regional anaesthesia may improve maternal outcome.
b&c) MR and AR: Maternal cardiovascular risk depends on regurgitation severity, symptoms, and LV function. Women with severe regurgitation and symptoms or compromised LV function are at high risk of heart failure. Usually well tolerated in pregnancy due to decrease in systemic vascular resistance.
Vaginal delivery is preferable; in symptomatic patients epidural anaesthesia and shortened second stage is advisable.
d) AS: Congenital AS is most often caused by a bicuspid aortic valve. The rate of progression of stenosis in these young patients is lower than in older patients.
Because bicuspid aortic valve is associated with aortic dilatation and aortic dissection, aortic dimensions should be measured pre-pregnancy and during pregnancy.
In severe AS, particularly with symptoms during the second half of the pregnancy, cesarean delivery should be preferred with endotracheal intubation and general anaesthesia. In nonsevere AS, vaginal delivery is favoured, avoiding a decrease in peripheral vascular resistance during regional anaesthesia and analgesia.
e) MS: Moderate or severe mitral stenosis (MS) is poorly tolerated during pregnancy. MS is responsible for most of the morbidity and mortality of rheumatic heart disease during pregnancy.
Vaginal delivery should be considered in patients with mild MS, and in patients with moderate or severe MS in NYHA class I/II without pulmonary hypertension. Caesarean section is considered in patients with moderate or severe MS who are in NYHA class III/IV or have pulmonary hypertension despite medical therapy, in whom percutaneous mitral commissurotomy cannot be performed or has failed.
f) Pulmonary Stenosis: Generally well tolerated during pregnancy. However, severe stenosis may result in complications including right ventricular (RV) failure and arrhythmias. Vaginal delivery is favored in patients with non-severe PS, or severe PS in NYHA class I/II. Caesarean section is considered in patients with severe PS and in NYHA class III/IV despite medical therapy and bed rest, in whom percutaneous pulmonary valvotomy cannot be performed or has failed.
g) Coarctation of the Aorta: Pregnancy is often well tolerated in women after repair of coarctation of the aorta (CoA) (WHO risk class II). Aortic aneurysms have an increased risk of aortic rupture and rupture of a cerebral aneurysm during pregnancy and delivery. Other risk factors for this complication include aortic dilatation and bicuspid aortic valve.
Spontaneous vaginal delivery is preferred with use of epidural anaesthesia particularly in hypertensive patients.
Elective caesarean section may be desirable in the occasional patient with coarctation and uncontrollable systemic hypertension, marked aortic root dilatation and/or severe residual or native coarctation.
h) Ebstein’s anomaly: In women with Ebstein’s anomaly without cyanosis and heart failure, pregnancy is often tolerated well (WHO risk classII). Symptomatic patients with cyanosis and/or heart failure should be treated before pregnancy or counseled against pregnancy. The preferred mode of delivery is vaginal in almost all cases.Prev Next
"Authored By Dr.Niraj Mahajan"
MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.Read more [+]