IF MATERNAL PROGNOSIS IS BAD, SHOULD THE PREGNANCY WITH HEART DISEASE BE TERMINATED ?
THE ANSWER IS (must be) : NO
Made Kornia Karkata
Division of Feto-maternal Department of Obstetrics and Gynecology
PROLOGUE
Actually there is almost no such situation in which the option of either YES or NO should be absolutely chosen in making a clinical medical decision. In most practical clinical decisions, instead of just YES or NO , we should first consider all aspects related to the best possible option for the patient based on scientific and professional point of view. Since every case is distinct and unique, the attitude to only choose YES or NO without respect to the individual case will result in a mindset as if the doctor were a robot.
Obviously such a mindset should be avoided.
INTRODUCTION
Pregnancy causes extensive physiological changes to the , which normally are well adjusted by healthy women. In the case a pregnant woman has cardiac disease, however, these changes may threat the woman’s life. The overall incidence of heart disease in pregnancy is < 1% (1). Although rare , it is a major cause of both maternal and perinatal morbidity and mortality. Cardiac disease is the leading cause of death in women in the United States
The pattern of cardiac disease has changed over the four last decades in well developed countries , with a greater number of congenital heart lesions rather than rheumatic heart disease . This change of disease pattern has resulted from the steady decline of rheumatic heart disease and better outcome of surgical treatment of congenital heart disease. But in developing countries, including Indonesia
CLASSIFICATION OF CARDIAC DISEASE
The incidence and classification of cardiac disease are shown below.
Table 1. Incidence and classification of cardiac disease (4)
Congenital cardiac lesions Number %
Atrial septal defect 20 38.5
Ventricular septal defect 15 28.8
Patent ductus arteriosus 5 9.6
Acquired cardiac lesions
Rheumatic
Mitral stenosis 45 45.0
Mitral incompetence 32 32.0
Aortic incompetence 14 14.0
Aortic stenosis 5 5.0
Pulmonary stenosis 4 4.0
Non-rheumatic
Hypertrophic obstructive cardiomyopathy 2
Wolf-Parkinson-White syndrome 1
NORMAL PHYSIOLOGIC CHANGES IN PREGNANCY (1,3)
Striking adjustments takes place in the maternal cardiovascular system. Profound haemodynamic changes occur during pregnancy, labor and immediately post labor.. Plasma volume start to increase as early as sixth week of pregnancy and reaches its peak at the third trimester to approximately 150% of the normal volume. There is a rise in heart rate and stroke volume causing the cardiac output to rise by 45% . An auto-transfusion of 500 mL of blood occurs during contractions. Systemic and pulmonary vascular resistance is concomitantly decreased and most of all there was no change in intrinsic left ventricular contractility. The enlarging uterus also results in complicating complaints. Those changes will return to normal during the puerperal stage , at least 2 weeks of delivery.
PREGNANCY WITH CARDIAC DISEASE
Although rare, it is most likely that a woman with cardiac disease with no complaint may then get worse when she is pregnant.. Most women with severe cardiac dysfunction may experience worsening of heart failure before mid-pregnancy , while in most cases heart failure develops after 28 weeks of pregnancy.
The effects of the haemodynamic changes on the maternal and fetal well-being depends on the nature of the cardiac lesion and the gestational age in addition to the functional classification by New York Heart Association (NYHA). The higher the risk the worse the clinical appearance would be. It becomes a critical point if there is blood concentration due to hyper-emesis during pregnancy, peak of increased plasma concentration at the third trimester, and culminating in the final stage of labor and immediately after delivery. (1,3,4,5)
Tabel 2 .Risks forMaternal Mortality Caused by Various Types of Heart Disease
(ACOG , 1992) (5)
Cardiac disorder Mortality (%)
Group 1 – Minimal Risk 0 – 1
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Pulmonic or triscupid disease
Fallot Tetralogy , correccted
Bioprosthetic valve
Mitral stenosis , NYHA , class I - II
Group 2 – Moderate Risk 5 - 15
2A
Mitral stenosis , NYHA class III – IV
Aortic stenosis
Aortic coarctation without valvular involvement
Fallot Tetralogy , uncorrected
Previous myocardial infarction
Marfan syndrome , normal aorta
2B
Mitral stenosis with atrial fibrillation
Artificial valve
Group 3 – Major Risk 25 - 50
Pulmonary hypertension
Aortic coarctation with valvular involvement
Marfan syndrome with aortic involvement
The clinical presentation of decompensated cardiac disease in pregnant women are complaints of dyspnea, orthopnea, nocturnal cough, hemoptysis, syncope, chest pain with signs of cyanosis , cervical venous distention, diastolic murmur, cardiomegaly , arrythmia and dystress due to pulmonal hypertension.
OBSTETRIC MANAGEMENT (1,3,6)
As a general rule , once we are dealing with pregnant women with heart disease, it should be classified as high risk group and therefore managed jointly involving the obstetrician, cardiologist , pediatrician , anesthesiologist and if possible, a cardiothoracic surgeon.. Consultation to cardiologist may result in precise lesion diagnosis and functional class of the disease. Investigation may involved electro-cardiography , echocardiography , chest radiography (by strict precaution) , magnetic resonance imaging (MRI) and even invasive cardiac catheterization .
Ideally , management should begin with pre-pregnancy counseling due to several condition , pregnancy will be contraindicated such as in Eisenmenger’s syndrome, pulmonary hypertension and Marfan’s syndrome and history of previous peripartum cardiomyopathy.. In some cases, after profound counseling, induced abortion based on medical reason.is indicated If the pregnancy is to be maintained, every effort should be made to avoid factors that may worsen the cardiac performance , such as over exercise , anemia , infection mostly of the genito-urinary tract, pre-eclampsia or hypertension, over weight and general edema , development of arrhythmias and multiple pregnancies..
With rare exceptions, pregnancy with class I – II usually goes well without any serious morbidity. Serial fetal investigation should be done to monitor fetal growth and well being by clinical signs and USG examination searching for possible congenital anomaly and retarded growth. Special attention should be paid to prevention or early recognition of heart failure. In developed countries efforts are taken to do causal specific therapy such as valve correction (closed mitral valvotomy) , ligation of persistent Ductus Botalli , both before and during pregnancy.. Subsequently , antibiotic and anticoagulant should be administered properly.(7,8,9,10,11,12,13,14,15,16,17)
Decisions regarding timing and mode of delivery, analgesia and anaesthesia used, cardiac monitoring and site of delivery should be made well in advance especially for high risk group. In general , delivery should be accomplished vaginally unless there is obstetrical indication for cesarean delivery and labor should not be induced for cardiac reasons. Induction of labor is generally safe (18) and should be delayed until 34 weeks or beyond . During labor, the preferred position is semi recumbent with lateral tilt , to minimize the stress and relief from pain by epidural analgesia .
Vital sign should be monitored frequently, pulse rate > 100 / minute and respiratory rate > 24/minute , and appearance of dyspnea , signaling impending ventricular failure A shorter labor period will minimize the stress on the mother and adverse affect of hypoxia on the fetus so forcep or vacuum extraction should be introduced at second stage of labor. In high risk cardiac disease the use of Swan Ganz catheter to monitor wedge pressure is mandatory. Blood loss during delivery should be minimized and replaced promptly .Many centers routinely administer prophylactic antibiotics at delivery and puerperium.
Management of Class III – IV These severe cases are uncommon today and the important question in these women is whether pregnancy should be terminated. Profound counseling should be done by a team of doctors , with the patient to decide the prognosis. If seen in first trimester, induced medical abortion should be considered. Epidural analgesia for labor and delivery is still recommended. Vaginal delivery is still preferred and induction of labor can be done safely by closed continuous monitoring. (18). In certain maternal condition ,cesarean section could be undertaken in a medical center having experience dealing with complicated cardiac disease.
WHAT IS OBSTETRICS DECISION IF MATERNAL PROGNOSIS IS BAD .
SHOULD THE PREGNANCY BE TERMINATED ?
As mentioned previously , the high risk group of cardiac disease with pregnancy is practically rare and usually suffer and complain before pregnancy. Physically looking sick , these women are obviously difficult to become pregnant. If at all they do become pregnant , should to some extent the pregnancy be maintained until the fetus is viable and survive after delivery.
The answer is NO , with following reasons :
- evidence that cardiac disease with class I and II , can go through pregnancy, labor and puerperium without serious morbidity and mortality
- termination should be based on obstetrics indication
- majority of cases in
- many challenges invite the other disciplines to do more before giving up and deciding that “prognostic is bad”
- as far as possible termination should be cancelled until close to term or at least the Neonatal Intensive Care Unit (NICU) can “guarantee” the survival of the baby born.
- once , the prognostic becomes bad and the condition is threatening life then termination of pregnancy should be prepared and done with careful and thorough action.
EPILOGUE
Cardiac disease in pregnancy includes to high risk group resulting in higher morbidity and mortality for both the mother and infant. It is best to recognize the cardiac disease before pregnancy so any treatment or surgical correction can be determined through deep and delicate counseling . Pregnancy with cardiac disease of functional class I-II have good prognosis and the majority can go through the pregnancy, labor and early post delivery. For class III – IV the prognosis outcome is poor and should be managed by a team of widely experienced experts in their respective fields. A certain group of cardiac disease are contraindicated to pregnancy so there should be consideration of doing induced abortion on medical reasons . So there are challenges to the team of multi-discipline experts on how serious it is to deal with the case before to giving up and saying , the prognosis is bad.
REFERENCES
1. Chia P., Chia H.,Subramaniam R. The management of Cardiac Disease in Pregnancy Part 1: Aetiology, Diagnosis and Investigations. Journal of Pediatrics, Obstetrics and Gynecology Jul/Aug 2000 Vol .26 No 4 :34-37
2. Anderson RN . Deaths : Leading causes for 2000. Natl Vital Stat Healt Rep Vol. 50, No 16, Sptember 16, 2002.
3. Cunningham FG, Hauth JC, Leveno KJ, Gilstrap III L, Bloom SL, Wenstrom KD (Eds).Williams Obstetrics 22nd Edition. McGraw-Hill , New York, Chapter 44 Cardiovascular Disease : 1017-37.
4. de Swiet M. Heart disease in Pregnancy. In : De Swiet M (Ed). Medical disoders in obsterics practice. Third edition. Blackwell Scientific Publication, 1995.
5. American College of Obstetricians and Gynecologists: Cardiac disease inpregnancy . Technical Bulletin No 168, June 1992.
6. Chia P., Chia H.,Subramaniam R. The management of Cardiac Disease in Pregnancy Part 2 : Clinical Management Sept/Oct 2000 Vol.26 No 5 : 27-33
7. Van der Meer JTM, Van Wijk W, Thomson J , et al. Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet 339; 135
8. Goon MS, Raman S, Sinnathuray TA. Closed mitral valvotomy in pregnancy – a Malaysian experience. Aus NZ J Obstet Gynaecol 1987; 27: 173-77
9. Meffert WG, Stansel HC. Open heart surgery during pregnancy. Am J Obstet Gynecol 1968; 102, 1116-20.
10. American College of Obstetricians and Gynecologist: Prophylactic antibiotics in labor and delivery. Practice Bulletin No 47 , October ,2003
11. Lowenstein BR, Vain NW, Perrone SV, et al. Succesful pregnancy and vaginal delivery after heart transplantation. Am J Obstet Gynecol 158; 589, 1988
12. Lao TT, Sermer M, Colman JM. Pregnancy following surgical correction for transposition of the great arteries. Obstet Gynecol 83; 655 , 1994
13. Lao TT, Adelman AG, Sermer , et al .Baloon valvuloplasty for congenital aortic stenosis in pregnancy. Br J Obstet Gynaecol 100; 1141, 1993a.
14. Abouzied AM, Abbady MA, Gendy MF, et al. Percutaneous ballon mitral commisurotomy during pregnancy. Angiology 52: 205, 2001
15. Leyh RG, Fischer S, Ruhpawar A, et al . Anticoagulant therapy in pregnant women with mechanical heart valves. Arch Gynecol Obstet 268 : 1 , 2003.
16. Tang LCH, Chan SYW, Wong VCW, et al. Pregnancy in patients with mitral valve prolapse. Int J Gynaecol Obstet 1985; 23: 217-21.
17. Avilla WS, Rossi EG, Ramires JA, et al: Pregnancy in patients with heart disease : Experience with 1000 cases. Clin Cardiol 26; 135 , 2003.
18. Oron G , Hirsch R, Ben-Haroush A, et al : Pregnancy outcome in women with heart disease undergoing induction of labour . BJOG 111; 669,2004.
* * * * *
Tidak ada komentar:
Posting Komentar