1. MEDICAL ILLNESS COMPLICATING PREGNANCY

3. 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

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

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

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

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

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

9. 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

10. 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

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

12. 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.

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

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

21. MANAGEMENT OF EPILEPSY
Phenobarbitone 60 – 180 mg daily
Phenytoin 150 – 300 mg
Carbamazeipine 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

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

23. DRUGS DRUG DOSE MAINTENANCE DOSE Carbimazole 20-60mg 5-15mg
Propylthiouracil mg mg

24. 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

25. 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

26. 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