Author
Information
Sachin Pardeshi*, Mayadeo NM**, Himangi Warke***
(*
Assistant Professor, ** Professor, *** Associate Professor. Department of Obstetrics and
Gynecology, Seth G.S.
Medical College
and K.E.M Hospital ,
Mumbai , India
Abstract
Though
incidence of cardiovascular diseases and pregnancy has decreased over the last
few decades, the incidence of heart disease in pregnant women has been reported
to range from 1 to 4% , mitral disease being the most common.[1,2] Cardiac
surgeries during pregnancy is a high risk procedure with respect to fetal
wellbeing, with fetal mortality ranging from 0 to 35%, averaging 19%.[3,4]
This
is a case report of 23 years old primigravida with rheumatic heart disease with
severe mitral stenosis. mitral regurgitation and severe pulmonary hypertension
diagnosed four months prior to admission at our institute. She presented to our
hospital in emergency with severe dyspnoea with hemoptysis at 36 weeks of
gestation. Initially she was stabilized medically in intensive care unit, but
required mitral valve replacement subsequently.
Introduction
The
incidence of heart disease during pregnancy ranges from 0.4 to 4.1%,[5] During
pregnancy cardiac output increases by 30-40% above normal. From 20th
to 32nd weeks of gestation there is also volume expansion by 30-50%
and oxygen consumption by 25-30% above non pregnant levels.
Mitral
stenosis is the most common valvular lesion and may require surgical
intervention when the lesion is severe enough to cause heart failure in spite
of medical therapy. Surgical intervention should be considered for pregnant
women with heart disease with decompensated state.
Case
report
A
23 years old primigravida admitted in emergency in view of cardiac failure. Patient was diagnosed to have rheumatic heart disease
with mitral stenosis 4 months back. She presented with dyspnoea grade III-IV for 15days,
hemoptysis for 10 days, and bilateral pedal edema for 1month. On physical
examination patient was orthopneic, pulse was 98 beats per minute, regular.
Blood pressure was 110/70mm of Hg. Jugular venous pressure was 8cms. Bilateral
ankle edema was present.
On
cardiac examination, there was a mid-diastolic murmur. On respiratory system
examination there were bilateral basal crepitations. Abdominal examination
revealed 36 weeks’ uterus with fetal heart sounds present. On per vaginal
examination the cervical os was closed. Her electrocardiogram revealed left
axis deviation and right ventricular hypertrophy. 2-D Echo was suggestive of
left atrial enlargement with severe mitral stenosis, severe mitral
regurgitation and severe pulmonary hypertension with an ejection fraction of
60%. The mitral valve area was 0.7-0.8 cm2. An urgent cardiology
opinion was taken and patient was transferred to intensive cardiac care unit. Patient
was initially stabilized with injection frusemide, digoxin, and oxygen by mask.
Infective endocarditis prophylaxis was given. But thereafter owing to her
declining health status, a decision of emergency surgical intervention was
taken and mitral valve replacement was performed on day 2 after
admission. Fetal heart sounds were monitored throughout the procedure. The
procedure was uneventful. The patient was monitored in intensive cardiac care
unit. Patient was peri-operatively on Inj. Heparin for anticoagulation. Daily
obstetric examination was done. The patient was transferred back to antenatal
ward on the 11th post operative day. The patient went into active
labour 15 days post procedure. She was
transferred back to cardiac ICU where she delivered vaginally a live male baby
2.480 kg. Injectable Heparin was withheld during labour. After delivery
anticoagulation therapy was restarted.
Discussion
Cardiac surgery in pregnancy has been reported
successfully by many authors. Fetal age
and timing of the surgical procedure should be taken into account when possible
on an ethical basis with regards to maternal and fetal outcome.
Surgical intervention in case of cardiac
diseases during pregnancy has 90% neonatal mortality at 25weeks of gestation
and decreases to below 15% at 30weeks.[6]. It is critically
important to observe the response of fetal heart rate to surgical and drug
therapy throughout the pregnancy. Uterine contraction, hypoxia, hypotension,
low blood flow, maternal positioning,
drugs crossing fetoplacental barrier are some of the factors responsible for
inducing fetal bradycardia. In individual settings, the maternofetal response
may vary according to the health status at the time of the procedure and the
timing of operation.
Clinical knowledge gained from such cases gives
immense insight in the management of these cases, especially considering the
inability to conduct clinical trials in pregnant women undergoing mitral valve
replacement.
References
1.
Mahli A, Izdes S, Coskun D. Cardiac operations
during pregnancy: review of factors influencing fetal outcome. Ann Thorac Surg
2000;69:1622-6
2.
Cardiac
diseases in pregnancy. ACOG technical bulletin number 168-June 1992. Int J
Gynaecol Obstet 1993;41:298-306.
3.
Parry AJ,
Westaby S. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg
1996;61:1865-69.
4.
Ueland K.
Cardiac surgery and pregnancy. Am J Obstet Gynecol 1965;92:148-62.
5.
McFaul PB, Dorman JC, Lamki H et al. Pregnancy
complicated by maternal heart disease. A review of 519 women. Br J Obstet
Gynaecol 1988;95:861-67.
6.
Cooper RL,
Goldenberg RL, Creasy RK et al. A multicenter study of preterm birth weight and
gestational age specific neonatal mortality. Am J Obstet Gynecol 1993;168:78-84
Citation
Pardeshi S, Mayadeo NM