In my last year in residency training, I came across a 21-year old woman in the third trimester of pregnancy. She was ambulatory, but she complained of shortness of breathing. She was cyanotic, a term we use for violet color of nail beds and lips. It indicated lack of oxygen in her circulation. She admitted that she had an uncorrected congenital heart disorder. However, she was not able to have a 2-D echocardiography to determine the kind and the severity of the problem. Pulse oximeter registered 70 % O2 saturation. The normal O2 sat is 80 to 100 %.She suddenly deteriorated to stuporous condition. Her fetal heart beat fortunately ranged from 140 to 160 bpm, which were normal. Her blood pressure suddenly dropped to 70/50 bpm. She further deteriorated to coma. Her Glasgow coma score decreased to 3, which was the lowest score. An immediate cesarean delivery was done to save the baby, who was 31 weeks by Ballard Score. She had cardiac arrest 12 hours postoperatively.
The economic conditions made it hard for people to consult with their obstetricians. Thus, they do not have any idea about the severe effect of the heart diseases in pregnancy. If the woman mentioned sought help early during her gestation before she had any symptoms. Perhaps, if she did give some effort, she could be saved. Padolina wrote that in the U.K., heart disease was the cause of 16.5 % of all maternal deaths from 1997 to 1999. She also mentioned in the “Textbook of Obstetrics” that there are physical findings that could set the gravidocardiacs apart from the normal pregnant women. The difficulty of breathing typical during pregnancy becomes progressive. There could be cough during the night. Chest pain, bloody sputum production and fainting spells could also be experienced. As seen from one patient, the cyanosis or the violet discoloration of nail beds and the mucosa are obvious and it could be a sign of pulmonary hypertension. Doctors could hear systolic and diastolic murmurs, persistent second heart sound (S2) and detect heart enlargement by palpation.
The cardiac patients who plan to have children should be given advised even when during their adolescence. Padolina wrote they should have thorough cardiovascular history and assessment, which include a 12-lead ECG and transthoracic echocardiogram. The cyanotic women should have percutaneous oximetry. Surgical correction should be done prior to the conception.
The gravidocardiac patients with severe condition are asked to limit physical exertion. Admission could also be advised during the second trimester. Betablockers like metoprolol could be given to control heart rate among those who have mitral stenosis. It is also given to those with pathology with the aorta. Antiarrhythmic drugs are avoided during the first 14 weeks of pregnancy. Anticoagulants could be prescribed to prevent embolism. Antibiotic prophylaxis for the prevention of bacterial endocarditis are given to those with severe structural defects. Epidural anesthesia should be provided during labor. The use of forceps or vacuum extractor is encouraged and the cesarean delivery is only done for obstetric indications only.
List of Sources:
Padolina CS.Cardiovascular Diseases. In: Sumpaico WW, Ocampo-Andres IS, Capito LRB, Diamante AN, Carnero S, Gamilla Z. Textbook of Obstetrics, 3rd ed. 2002 . Association of Writers of Philippine Textbook of OBGYN,Inc. Quezon City.