MEDICAL ILLNESS COMPLICATING PREGNANCY

HEART DISEASE IN PREGNANCY The cardiac failure occurs during pregnancy around 30 weeks, during labour and soon following delivery FACTORS RESPONSIBLE FOR HEART FAILURE Advanced age Cardiac arrhythmias or left ventricular hypertrophy History of previous heart failure HEART DISEASE IN PREGNANCY

Predominant congenital lesions include Patent ductus arteriosus atrial or ventricular septal defect pulmonary stenosis coarctation of aorta fallot’s tetralogy

RISK FACTORS Infection Anaemia Hypertension Excessive weight gain Multiple pregnancy Inadequate supervision

PROGNOSIS Maternal Functional capacity of the heart Quality of medical supervision provided Fetal Abortion IUGR Prematurity

CLASSIFICATION Grade I – uncompromised Grade II – slightly compromised Grade III – markedly compromised Grade IV – severely compromised

GENERAL MANAGEMENT PRINCIPLES Early diagnosis and evaluation Detect the high risk factors Combined care and mandatory hospital delivery

ANTENATAL CARE Supervised in a tertiary care hospital Initial assessment in consultation with a cardiologist Counselling Special care in each visit to detect risk factors like infections

ADVICES GIVEN Adequate rest To avoid undue excitement and strain To avoid caffeine,alcohol,betamimetics,drugs and high calorie or spicy diet Anemia is to be corrected Cold and infection are to be avoided Adequate dental care

ROLE OF ANTICOAGULANTS congenital heart disease pulmonary hypertension artificial valve replacement atrial fibrillation.

Warfarin should discontinue as soon as pregnancy is diagnosed and replaced by heparin 5000 units twice daily SC up to 12 wk. Then replace by warfarin 3mg up to 36 wks. Thereafter replaced by heparin upto 7 days of postpartum.

ADMISSION Elective Grade I - at least 2 wks prior to EDD Grade II - at 28th week specially in case of unfavourable social surrounding Grade III & IV – as soon as pregnancy is diagnosed Emergency Appearance of dyspnoea,cough,anaemia, pre-eclampsia

MANAGEMENT DURING LABOUR LABOUR-FIRST STAGE Position –patient should be in bed with lateral recumbant position Oxygen is to be administered if required Analgesia is best given by epidural anaesthesia Fluids should not be infused more than 75 ml/ hr to prevent pulmonary edema Careful watch of pulse and respiration Intravenous digoxin 0.5mg Cardiac monitoring and pulse oxymetry

PROPHYLACTIC ANTIBIOTICS Antibiotic prophylaxis during labour and 48 hrs after delivery is considered appropriate

SECOND STAGE Delay in the second stage of labour is managed by forceps or ventouse IV ergometrine with the delivery of anterior shoulder should be withheld to prevent sudden overloading of the heart

THIRD STAGE If excess blood loss ,oxytocin can be given. IV Frusemide CESAREAN SECTION caesarean section for obstetric indications PUERPERIUM Observe closely 1st 24 hrs Oxygen is administered Hourly pulse, B.P and respiration Breast feeding is not contraindicated

TUBERCULOSIS IN PREGNANCY OBSTETRICAL MANAGEMENT TB is not an indication for termination of pregnancy Breast feeding is not contraindicated when a women is taking anti-tuberculous drugs Breast feeding is avoided it the infant is also taking the drugs to avoid drug overload In active lesion the baby is isolated from the mother following delivery

BCG should be given to the baby as early as possible Contraception –spacing can be achieved by any methods -oral contraceptives should be avoided when rifampicin is used -puerperal sterilisation should be seriously considered, if family is completed

EPILEPSY Effects on pregnancy Fetal malformations cleft lip/plate Mental retardation Cardiac abnormalities Limb defects IUGR Oligohydramnios Still births

MANAGEMENT OF EPILEPSY Phenobarbitone 60 – 180 mg daily Phenytoin 150 – 300 mg Carbamazeipine 0.8 -1.2 mg IV Diazepam 10 – 20 mg Folic acid 1mg throughout pregnancy Vitamin K 10 mg a day orally is to be given in the last two weeks

THYROID DYSFUNCTION HYPERTHYRODISM Maternal risk Cardiac failure Fetal Abortion IUGR Stillbirth Neonatal mortality

DRUGS DRUG DOSE MAINTENANCE DOSE Carbimazole 20-60mg 5-15mg Propylthiouracil 300-450mg 50- 150mg

Drugs can cause fetal goitre and hypothyrodism Drugs are not contraindicated during breast feeding close monitoring of the neonatal thyroid functions is carried out. Thyroidectomy can done safely in the 2nd trimester Preconceptional counselling Oral pills is to be withheld

HYPOTHYROIDISM Mostly related to thyroid autoimmunity Untreated hypothyroidism in early pregnancy can cause high fetal wastage in the form of abortion Stillbirth Prematurity subnormal mental development of the neonate Pre-eclampsia and anaemia are high

Dose of pre-pregnancy state is need to increased during pregnancy Detailed fetal anatomy scan at 18wks Termination of pregnancy with the consultation of neurologist No contraindication for breastfeeding