In sub Saharan Africa, this is often of rheumatic heart disease origin.
- Rheumatic fever in childhood, or known rheumatic heart disease
- Body oedema
- Easy fatigability
- Evidence of heart enlargement
- Left parasternal heave
- Prominent neck veins, and tachycardia.
There may also be hepatomegaly, ascites, and basal crepitations.
- Shielded chest x-ray in early pregnancy
- Routine antenatal profile (haemoglobin, VDRL, blood group, urinalysis)
- Urine C&S, blood culture, urea and electrolytes
- This depends on functional classification of the New York Heart Association:
- Class I Asymptomatic
- Class II Symptomatic with heavy work
- Class III Symptomatic with light work or exercise
- Class IV Symptomatic at rest
- Class I and II are managed as outpatients until 34–36 weeks when they are admitted for bed rest and observation in hospital level 4–6.
- Class III and IV are admitted on first visit at any gestation for entire duration of pregnancy.
Management – Supportive
- Bed rest
- Haematinic supplementation: Ferrous sulphate 200mg TDS + folic acid 5mg OD combination.
- Treat intercurrent infections: Dependent on organisms identified and site of infection.
- Avoid undue physical and emotional stress.
- Regular urine analysis and culture.
- Ensure dental hygiene.
- Regular urea and electrolyte determination.
Management – Pharmacological
- Digitalization is indicated in imminent and overt cardiac failure, if not previously on digoxin. Consult cardiologist on medication regimes.
- Rapid digitalization by mouth, 1–1.5mg in divided doses over 24 hours, less urgent digitalization 250–500mcg daily (higher dose may be divided).
- Continue maintenance therapy with digoxin 0.25mg, frusemide 40–80mg.
- Continue prophylactic IM benzathine penicillin 2.4 mega units monthly.
Labour and Delivery
- Spontaneous labour and delivery are preferred.
- Prop up.
- Keep oxygen and emergency tray available.
- Start antibiotics PO amoxicillin 2g + IV gentamicin 160mg STAT then PO amoxicillin 1g 8 hourly and IV gentamicin 80mg 8 hourly for 2 weeks.
- Adequate analgesia with morphine 10mg IM STAT at 4–6cm cervical dilatation.
- Avoid lithotomy position.
- Assisted vacuum delivery in second stage.
- Massage uterus after delivery of placenta to achieve uterine contraction.
- Give oxytocin 10 IU IM if needed to achieve uterine contraction or to control postpartum haemorrhage.
- Give frusemide 80mg IV STAT after 3rd stage of labour
- Observe closely for evidence of cardiac failure
- Keep in hospital for 2 weeks. Continue antibiotics for entire period. Discharge through the cardiac clinic.
- Advise on family planning. Cardiac patients should have small families of 1 or 2 children or none. Suitable methods include minilaparotomy tubal ligation under local anaesthesia, vasectomy, barrier methods, progesterone-only
agents pills or implants. Oestrogen containing methods are contraindicated such patients.