Both women with pre-existing yet undiagnosed heart disease and those with new (whether or not pregnancy-related) disease will present primarily to obstetricians or primary caregivers and not to a cardiologist. A timely diagnosis therefore depends on adequate awareness on the part of their GP or obstetrician. Main aims and objective of this study were to determine feto- maternal outcomes in pregnant patients with heart disease.
This prospective observational study was conducted in PGIMER and Dr. RML hospital, New Delhi, a Government hospital, in the Department of Obstetrics and Gynaecology in collaboration with Department of Cardiology, from November 2015 to March 2017. A total of thirty-five patients, pre-diagnosed or diagnosed with heart disease in current pregnancy were selected from antenatal clinic (ANC) in any trimester of reporting to hospital. Patients with associated chronic medical disorders, multiple gestation, LMP not known or any other complications which could adversely affect fetomaternal outcome were excluded from study. Four non-cardiac risk factors, four cardiac risk factors, NYHA (New York Heart Association) class (1994), CARPREG (cardiac disease in pregnancy) score (2001) and modified WHO class (2011) was assigned to the study population, at the time of enrolment. The Four non- cardiac risk factors taken were - age, parity, BMI and time of first antenatal visit. The four cardiac risk factors taken were: aetiology of heart disease, severity of lesion, associated cardiac complication (pulmonary artery hypertension (PAH), atrial fibrillation (AF), pulmonary edema) and prosthetic valve on anticoagulant therapy. The risk factors were co-related with adverse feto maternal outcome, which were defined as following. Adverse maternal outcomes were defined as occurrence of one or more of following events: development of congestive heart failure/pulmonary oedema, worsening of NYHA class, need for maternal intensive care unit admission and maternal mortality. Adverse fetal outcome was defined as occurrence of one or more of following- embryopathy, prematurity, LBW (Low birth weight), NICU (neonatal ICU) admission and fetal mortality: IUD (Intrauterine death), stillbirth or early neonatal death. On enrolment, a detailed history, prior cardiac event, prior cardiac surgery noted, and patients had 12 lead ECG, ECHO, Doppler for outflow measurement and pulmonary artery pressure recorded in cardiology department. Pulmonary oedema was confirmed by X-ray chest. Severe MS (mitral stenosis) was taken as valve <1 cm 2 and severe PAH (pulmonary artery hypertension)
Background. As a result of improved diagnostic and reparative techniques, congenital heart diseases are becoming a significant problem for women of childbearing age. Nowadays, more preg- nant women in the West are being diagnosed with an acquired heart disease because of the tendency to delay childbearing and increasing age-related risk of developing complications of hypertension, diabetes, obesity and other diseases. According to the Lithuanian Health Information Centre, the incidence of cardiovascular diseases in pregnancy is decreasing in Lithuania, from 1.4% in 2014 to 1% in 2016 (1). Heart diseases can aggra- vate maternal adaptive capabilities and complications that pose a threat to mother and foetus can occur. Management of such conditions presents a serious therapeutic challenge to multidis- ciplinary team. The aim of this article is to discuss the course of pregnancy and peculiarities of maternal and foetal care in a woman with hemodynamically significant heart disease.
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In general, vaginal delivery is a better option so the main principle in obstetric management was to wait for the spontaneous onset of labour. Patients were in semi recumbent position with lateral tilt. They were sedated in the first stage IV line was maintained. Prophylactic antibiotics were given routinely. If the patients were on drugs, the drugs were continued or else started as per cardiologist advice. Pulse rate, respiratory rate blood pressure and foetal heart rate were monitored. Instruments were used to cut short the second stage. Episiotomy and perineal lacerations were sutured under local anaesthesia. LSCS was done for obstetric indications only under epidural anaesthesia. After delivery the first 12-24 hours was carefully monitored for signs of failure & post partum hemorrhage and they were kept in intensive care unit for 48 hrs and were kept in postnatal ward for 14 days.
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This work represents the largest report to date of a co- hort of women, with 467 women with congenital cardiac disease who embarked on pregnancy in Cuba. Moreover, we have presented data from a middle-income health- care system as few comparable reports exist in the litera- ture [20–22]. However, owing to the study methodology, it was not possible to reconcile patient data for patients that had a subsequent pregnancy. As such, the analysis was based on individual pregnancy cases managed by the Service as opposed to outcomes based on inter-preg- nancy dependent variables. The implications of this are mainly that we have underestimated the deterioration in cardiovascular function with subsequent pregnancies. For example, a woman could have experienced a deteri- oration in cardiovascular function in her 1st pregnancy, which further decreased in a subsequent pregnancy. However, given that most women had an NYHA score of I at the start of pregnancy, this is unlikely to be the case. Improvements in data linkage systems would en- able more precise estimations of the impact of preg- nancy on cardiovascular disease and vice versa. The short follow-up time and retrospective nature of the study also restrict the conclusions that can be made, par- ticularly on long-term maternal cardiovascular outcomes following pregnancy for CHD patients.
and in cardiac clinic. Investigations were performed as per protocol. Characteristics of the patients were noted including their age (range and mean), obstetric history, time since diagnosis from pregnancy, associated medical problem, New York Heart Association classification of all patients was noted at beginning and in all subsequent visits. All patients were followed up for any obstetric, cardiac or medical complication and need of medication. The women were educated to report in the event of any complication or deterioration in their cardiac status or symptoms of cardiac failure. Obstetric events and any obstetric complications were noted in all women on every visit. Mode of delivery, any instrumental delivery or caesarean section were noted in all the women. Fetal outcome was also noted in all the patients as regard to mean birth weight, any growth restriction, APGAR score, any still birth, congenital anomalies and neonatal complications.
All relevant investigations were done including ECG and echocardiography and they were evaluated clinically by both obstetrician and cardiologist. Management was planned by cardiologist and obstetrician according to the condition of patient, NYHA functional status, and type of cardiac lesion, cardiovascular stability, and duration of pregnancy and viability of foetus. Patients were managed as per advice of cardiologist and obstetrician as joint approach.
All women who were registered in the study center were called at least once a month in the first two trimesters, twice weekly up to 32 weeks and weekly from 36 weeks. Echocardiography was done for all women on confirmation of pregnancy and repeated if any symptoms of worsening heart disease were noticed. Co morbidities like anemia, infections, diabetes and pre-eclampsia were all screened for and treated promptly if identified. Pregnant women were evaluated by both obstetricians and cardiologists regularly. Mode of delivery was planned in a multi-disciplinary approach by cardiologists, obstetricians and anesthesiologists together. Caesarean section was planned only for obstetric indications, the only exception being a case of Takayasu arteritis which was scheduled for an elective caesarean section. Close monitoring was done as soon as labor commenced, extending into the immediate postpartum period. Fluid monitoring was of utmost importance and was done depending on the type of cardiac lesion. Infective endocarditis prophylaxis was given where indicated.. RESULTS
Peripartum cardiomyopathy 49 is a idiopathic cardiomyopathy that is defined as deterioration in cardiac function presenting typically between the last month of pregnancy and up to five months postpartum. PPCM is a form of dilated cardiomyopathy. Fatkin and associates (1999), reported that inheritance of idiopathic cardiomyopathy occurs in nearly one third of the cases. The patient is considered to have PPCM when all the causes of heart failure are excluded according to Broan and Bertelet (1998) 50 and Hibhaw and co-workers (1999) 51 . Ford and associates reported good prognosis in women with idiopathic cardiomyopathy i.e., PPCM. According to Lampert and colleagues (1997) 52,53 , 50% of women diagnosed to have peripartum cardiomyopathy regained their normal left ventricular function within 6 months of diagnosis.
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The interval between birth and participating in the in- terviews did not exceed 6 months, in order to minimize the influence of parenting after birth on the mothers’ recollection of the pregnancy experience. The timing of interviews was carefully selected to avoid adding stress/ anxiety to participating mothers, which could influence their recall. The issue of time frame (intervals ranging from 1 to 6 months), from birth to time of interview, depended on when the participant wished to be inter- viewed. Many interviews (n = 6) were done in the out-patient department, following the infant’s surgery, upon individual contact and setting a time. The remaining half (n = 6) were done in the hospital when the infant’s condition was stable (e.g., the day before ex- pected discharge). Of the total of 12 mothers who partic- ipated in in-depth interviews, five mothers participated within 3 months and seven mothers between 4 and 6 months postpartum. The gestational age of the fetus at prenatal screening differed between mothers, ranging from the 21st to 33rd week of pregnancy.
Based on this assumption and with the purpose of reducing the gestational risks, interventional treatment (balloon mitral valvuloplasty or surgery) prior to conception has been recommended to patients with severe mitral stenosis who wish to get pregnant. However, like in the present study, usually women with mitral stenosis are referred for cardiological follow-up only after the beginning of pregnancy.
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Diagnosis and management of heart disease in pregnancy poses a strict challenge to the obstetrician in the backdrop of worsening haemodynamics by the physiological circulatory changes of pregnancy. Superimposed on that, cardioactive drugs, cardiac interventions and use of anticoagulants in pregnant females with prosthetic heart valves may also cause adverse feto-maternal outcome . Thus, risk stratification becomes imperative for women with heart disease for optimal pre-pregnancy counselling and obstetric management. Various predictors for adverse maternal cardiac and neonatal events have been identified in the past; based on these predictors, different risk scores have been designed to predict cardiac complications, of which CARPREG risk score is the most widely accepted, and used and validated by previous researchers [5-8].
For women with a pre-transplant diagnosis of an inher- ited cardiomyopathy, genetic counselling can be consid- ered and offered if appropriate. Offspring from couples with a pre-transplant diagnosis of congenital heart disease have a varying degree of inheritance risk dependent upon the underlying lesion. Two larger series have demonstrated that for cardiac lesions such as Tetralogy of Fallot inheri- tance risk is in the region of 2.5%, however for some left sided lesions, such as aortic stenosis, this risk may be as high as 13 – 18%. 11,12 For congenital heart disease that arises de-novo the risk of recurrence in off-spring is between 3 – 5%. 13 Dedicated foetal echocardiography at 19 – 22 weeks ’ gestation is recommended if the original maternal diagnosis was congenital heart disease, but not generally performed for cardiomyopathies with postnatal onset. 14,15 If peripartum cardiomyopathy was the maternal pathology there is data to suggest that this group of women are at a higher risk of rejection in the ﬁ rst 12 months following transplantation, and that they have a higher risk of re-transplantation. This has led some transplant centres to advise against pregnancy given the potential adverse outcomes. 16,17
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Abstract: Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy of unclear etiology affecting women without preexisting heart disease during the last month of pregnancy or during the first 5 months postpartum. Its incidence shows marked geographic and ethnic variation, being most common in Africa and among women of African descent. Most women present in the first month postpartum with typical heart failure symptoms such as dyspnea, lower extremity edema, and fatigue. These symptoms are often initially erroneously diagnosed as part of the normal puerperal process. Diagnosis can be aided by the finding of a significantly elevated serum brain natriuretic peptide. The etiology of PPCM is unclear; however, recent research suggests abnormal prolactin metabolism is seminal in its development, and prolactin antagonism with bromocriptine shows promise as a novel treatment for PPCM.
Cardiovascular disease in pregnancy is becoming increasingly evident, as women with congenital heart disease (CHD) have longer life-expectancies than previously. Scientific advances in medical care in recent years have resulted in survival rates of up to 85% of people with congenital heart disease (Swinburne, 2004). It is estimated that there are between 16,000 and 20,000 people in the United Kingdom with congenital heart disease. This number is expected to increase at a rate of about 2,000 per year (Swinburne, 2004). Most women with heart disease can have successful pregnancies and cardiac complications during pregnancy tend to be rare. Women with serious cardiac disease generally carry the highest maternal mortality risk, irrespective of their underlying cardiac condition. Those women with less serious underlying cardiac diseases tend to have a higher rate of successful pregnancies.
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MR and AS are the most common causes of heart failure, secondary to valvular disease. MR and AR lead to volume overload, in contrast with AS which leads to pressure overload. The progression of heart failure in patients with valvular heart disease is dependent on the nature and extent of the valvular disease. In aortic stenosis heart failure develops at a relatively late stage and without, valve replacement, it is associated with a poor prognosis. In contrast, patients with chronic mitral or aortic regurgitation generally decline in a slower and more progressive manner. (Teerlink, et al 1991).
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Obesity plays a central role in the insulin resistance syndrome, which is associated with hyperinsulinemia, hypertension, hyperlipidemia, type 2 diabetes mellitus, and an increased risk of atherosclerotic cardiovascular disease. An extract of leaves given to rats for three weeks influenced lipid metabolism, improving serum cholesterol and triglyceride levels. 37 The present study was done to assess the effect of Gymnema sylvestre extract (GSE) in the high fat diet (HFD)-induced cellular obesity and cardiac damage in Wistar rats. Adult male Wistar rats (150–200 g body weight) were used in this study. HFD was used to induce obesity. Furthermore, treatment with standardized ethanolic GSE (200 m/kg/p.o.) for a period of 28 days resulted in significant decrease in total cholesterol, triglycerides, LDL, apoprotein–b, blood pressure. This reveals that Gymnema sylvestre has potent cardioprotective activities (Kumar V et al., 2012).
risk among Ischaemic (Dou et al., 2015; Larsen et al., 2010). We must remember, also, that the answer of the SOM is given on biological basis and not on subjective assessments. In the light of the results obtained, we can hypothesize that the ischemia, with its cell membrane molecular characteristic, could be responsible of the induction of a “depres- sive” state, a condition shared by the majority of subjects with ischemic heart disease.
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Abstract: Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treat- ments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.
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(LMWH)0.6 mg sc bd and Tab. Aspirin 75 mg 1 od. They also advised to start oral anticoagulants after delivery,overlappingit with heparin for 3-4 days until INR 2.5-3.5 is achieved in 2 reports 24 hours apart. Ultrasonography (USG) done at the time of admission was suggestive of single live intrauterine pregnancy with 30 weeks maturity, increased liquor (AFI 20) and placenta towards maternal left side. No gross congenital anomaly was detected on USG done by the radiology department in our hospital. Antenatal Doppler study showed reduced diastolic flow in umbilical artery, S/D ratio of 4.73 in umbilical artery and cerebro-placental ratio of 1.33, suggestive of mild Uteroplacental insufficiency and was advised for follow up Doppler study for fetal surveillance. Her follow up antenatal Doppler study, 15 days later showed severely reduced diastolic flow and raised S/D ratio (14.39) in umbilical artery with cerebro-placental ratio less than 1. Hence, a decision to terminate the pregnancy was taken in view of adverse intrauterine environment and risk to fetal wellbeing with continuing pregnancy. After discussion with the patients and relatives regarding the mode of delivery, a decision of elective lower segment caesarean section (ELLSCS) was made out. Follow up cardiologist opinion was taken and Inj LMWH and Tab. Aspirin was stopped 24 hours prior to ELLSCS. Inj. Betamethasone 2 doses given 24 hrs prior to ELLSCS for fetal lung maturity. Inj. Ampicillin was given for antibiotic prophylaxis against infective endocarditis. A preterm ELLSCS was carried out under general anaesthesia.Male child of 1.3 kg was delivered out. Baby cried after bag and mask ventilation and found to have an imperforate anus. Baby was given a maturity of 32-34 weeks and an APGAR score of 3 at birth, 4 at 1 min and 5 at 5 min of birth. He was taken to NICU for further management and kept under oxygen with prongs. He was also diagnosed as having duodenal atresia and tracheo-esophageal fistula. He underwent a surgery of anoplasty and jejunostomy. On 3 rd day, his condition worsened and