Proactive vs Reactive Management

1. ProactivevsReactive Management And some of the lessons we learned

2. PREGNANT CARDIAC POPULATION - MSH

3. PERHAPS The pregnancy outcome in our cardiac population is better because we engage in proactive management

4. In the ideal world the defences would be impervious to any hazards. However defences are made by humans and because humans are fallible these defences are not perfect and have holes in them. This is the real world. Most of the time these holes do not line up and the hazard is kept from causing harm at the sharp end. In the ideal world the defences would be impervious to any hazards. However defences are made by humans and because humans are fallible these defences are not perfect and have holes in them. This is the real world. Most of the time these holes do not line up and the hazard is kept from causing harm at the sharp end.

5. Case 1Ms CS Fontan procedure Anxious SROM at 32 weeks, breech Spontaneous labour at 33 weeks Delivered on Antenatal floor Neonate permanent neurological damage

6. Case 2Ms CP Dilated Cardiomyopathy Grade IV LV Dysfunction NYHA Class II

7. Consultations

8. Ms CPSpont labour at 36 weeks OB: No need for epidural as her heart is good, did not see the patient till presenting part was crowning following expulsive efforts in the second stage and pt c/o SOB Cardiology: It was Saturday night Anaesthesia: No need for PA line, though CVP line would be reasonable

9. MULTIDISCIPLINARY APPROACH Nursing Neonatology Anaesthesia Psychiatry Ethics Perinatology Cardiology Hematology Chaplaincy Patient and her family

10. PATIENT CARE CONFERENCE Ante, peri, and postpartum management How when where who Contingency plans for emergencies Postmortem CS

11. Documentation Initial consult letters are on electronic chart the nature of the lesion pathophysiology of this lesion in pregnancy antepartum and peripartum management Complete electronic chart

12. Education Nursing Anaesthesia Obstetrics Cardiology

13. CASE 3Ms AP Partially Corrected Tetralogy of Fallot

14. HISTORY 33 yo cyanotic at rest G4 P2 A1 GA 12 wks Tetralogy of Fallot Rt Pulmonary Artery Atresia Lt Blalock-Taussing Shunt Pulmonary Hypertension NYHA Class III

15. LABORATORY INVESTIGATIONS Hb 182 g/l PO2 = 70 mmHg Cardiac catheterization Functional Lt Blalock-Taussing shunt PAP - 50/40 Maternal Echo Gr 2/4 LV function Large VSD with Rt to Lt shunting Fetal Echo VSD

16. PATIENT CARE CONFERENCE Nursing Perinatology Neonatology Cardiology Anaesthesia Hematology Antepartum management Peripartum management When where how who Contingency plans for emergencies

17. ANTEPARTUM PERIOD 23 wks Worsening SOB IUGR Decrease in AFV 26 wks Cx 3 cm Breech Admitted to L&D Bed rest, Trandelenberg,

18. ANTEPARTUM PERIOD Hemoptysis at 31 wks CXR Lt upper lung mass associated with Lt pulmonary artery CCU

19. TETRALOGY OF FALLOT - A P Pulmonary artery atresia

20. CAUSES OF MORTALITY Pulmonary Thrombosis Congestive Heart Failure Worsening of Rt to Lt Shunting Rupture of PA Aneurysm SBE Arrhythmias

21. DELIVERY Spontaneous labour 31 wks

22. DELIVERY Breech extraction Entrapment of the after-coming head Apgar Score 0 7 8

23. DELIVERY PPH - 3 L Central and arterial line Oxytocin, Ergometrine D & C Intramyometrial Pitressin, PG Intracavitary cryop, thrombin, calcium Intraoperative bronchoscopy Bleeding from Lt upper lobe Lt main bronchus displaced by extrinsic pulsatile mass - Adrenaline Lt upper lobe 14 U RBC 12U platelets 2U FFP

24. AFTER PREGNANCY SIDS Two years later Pregnant Hb 201

25. PRE-PREGNANCY COUNSELING If you have heart disease do not fall in love; If you fall in love do not have sex; If you have sex don�t get pregnant !

26. HIGH RISK CONDITIONS NYHA III & IV Pulmonary hypertension Marfan syndrome Critical aortic stenosis Peripartum cardiomyopathy Significant CAD

27. OBSTETRICALLY Congenital anomalies Fetal echo IUGR BPP Prematurity Celestone

28. PATIENT EDUCATION Teach patients about symptoms

29. ANTEPARTUM PERIOD Anticoagulate Monitor effectiveness of anticoagulation Look for and treat aggressively PIH, anemia, and infections Decrease activity, hospitalize Avoid shunt reversal

30. PERIPARTUM PERIOD Consider induction Early epidural If CHF or arrhythmia Treat medically and early before fetal stress occurs Decrease expulsive efforts Prolong second stage of labour Avoid shunt reversal

31. SBE PROPHYLAXIS Low risk for SBE and uncomplicated delivery: NONE Ampicillin 2g IV30 min before delivery Gentamicin 1.5 mg/kg IV30 min before delivery

32. INTRAPARTUM MONITORING STANDARD IV ECG Oximetry Electronic FHR

33. INTRAPARTUM MONITORING INVASIVE MONITORING NYHA class III & IV Severe MS AS Grade III & IV LV Function Pulmonary Hypertension Cyanosis

34. CONCLUSION Anticipate problems Plan ahead Be Proactive