Management of pregnancy in a woman with previous cardiomyopathy (Cardiomyopathy of pregnancy )

Cardiomyopathy of pregnancy in literal terms is development of heart failure either during pregnancy or following delivery.

·         Find out when she developed PPCM? (Antenatally or postnatally)

·         Was her previous pregnancy complicated by hypertension/PET?

·         Is she 40+ years old?

·         Is she Afro-Caribbean descent?

·         Also find out how much was her ejection fraction on cardiac echo?

Things to check at each antenatal visit:

·         Maternal pulse

·          respiratory rate,

·         pulse oxymetry,

·         Urine for proteinuria

Things to ask at each antenatal visit

·         Any breathing difficulty (h/o breathlessness, SOB)

·         Any h/o becoming breathless for routine tasks  (Reduced physical capacity)

·         Rule out palpitations

·         Ask any swelling of limbs, face and back

Diagnostic criteria for PPCM

·         Echo is a must to diagnose PPCM

·         Left ventricular ejection fraction <45 p="">

·         Fractional shortening by 30%

·         Enlargement of heart  and global dilation of all four chambers and markedly Lt.ventricular function

Management of pregnancy

·         If develops antenatally, if baby viable and closer to term, consider elective delivery

·         Thromboprophylaxis once there is impaired left ventricular dysfunction or arrhythmia

·         Closely liaise with Cardiologist

·         ? Three monthly cardiac echo and monthly ECG or earlier if she becomes symptomatic.

·         Holter monitoring

·         FBC, U/Es, LFTs

Intrapartum and postpartum management

-          Consider intervening the pregnancy, only if she becomes symptomatic and echo proves PPCM

-          Avoid prolongation of second stage

-          Avoid ergometrine/methylergometrine. This is because following delivery, there is immediate rise in cardiac output due to the pressure off from inferior vena cava. Cardiac output increases by 70% followed by rapid decline to prelabour levels within one hour of delivery.

-          Avoid excessive intravenous fluids.

-          Consider giving Syntocinon by syringe driver rather than by syntocinon infusion.

-          Encourage early ambulation.

Mirror Syndrome of Pregnancy

It is the unusual association of fetal and placental hydrops  with maternal pre-eclampsia. "Mirror syndrome" refers to the similarity between maternal oedema and fetal hydrops. Cause may be any of the variety of  obstetric problems  which  range from Rh iso-immunisation disorders,  to fetal infections, metabolic disorders, and fetal malformations. Ballantyne syndrome can result from the maternal reaction to a fetus that has hemoglobin Bart's disease due to inherited double thalassemia trait from both parents. This syndrome may present in a mother with missed Trisomy 21 screening and where in pregnancy continues and baby develops hydrops and mother may present with features of PET

Signs and Symptoms

 Edema always present, mild proteinuria and PET

Differential diagnosis

The etiology of severe fetal hydrops may cause Mirror  syndrome when the fetal status greatly worsens and that the syndrome is only a manifestation of the extreme severity of the fetus-placental pathology. Platelet count, ALT, AST are usually normal and may be used to distinguish from HELLP syndrome

Explaination for hemoperitoneum in abruptio placenta

If you do KB count,  it  will be normal as most of the blood is escaped into the peritoneum.  So one can have masssive abruption and almost a dead baby with normal Kleihauer count.

Preterm rupture of membranes at 28 weeks – Management

• In women with preterm PROM remote from term, 50% will go into labor within 24 to 48 hours and 70% to 90% within 7 days. Women with preterm PROM at 24 to 28 weeks of gestation are likely to have a longer latency period than those with preterm PROM closer to term.
• Degree of oligohydramnios. The more severe the degree of oligohydramnios, the shorter the latency period.
• Severe oligohydramnios may represent a larger hole in the membranes or evidence of early fetal compromise with diminished
  urine output
• Digital cervical examinations also cause an average nine-day decrease in the latent period. Therefore do not do digital examination

• Sonographic myometrial thickness. Evidence of excessive thinning of the myometrium in nonlaboring women with preterm PROM ( 12 mm) as measured by transabdominal ultrasound has been associated with a shorter latency interval
• Evidence of pregnancy complications (such as intra-amniotic infection, placental abruption, or active labor) or nonreassuring fetal testing (previously referred to as fetal distress) will lead to early delivery and a shortened latency interval.

The fetal membranes serve as a barrier to ascending infection. Once the membranes rupture, both the mother and fetus are at risk of infection and of other complications.

Multiparous woman with a non-progress of labour (Obstructed labour)

Signs of Obstructed labour in a Multiparous woman at term

1. When the history was dug deeper,  it is usually  apparent that woman is contacting for 2-3 days.  So do not take admission to labour ward as the onset of labour.  The actual labour may have started few days ago.

2. Sunken eyes because of labour pains and dehydration and dehydration.

3. Urinary ketones (2+ and above)

4. Sub-umbilical flattening and evident bladder bulge. This is classical of  occipitoposterior position causing obstrction of labour.  Baby's sinciput hitching against pubic symphysis causing urethral swelling and swollen bladder.

5. If you scan such a woman, you will see star gazing fetus.

6. Occasionally there is presence of Bandl's ring.

Mistakes people do when confronted with Shoulder dystocia

When confronted with shoulder dystocia, doctors and midwives do all sorts of mistakes. This is a situation where split second accurate decisions are required. These correct or incorrect decisions do account for the final clinical outcome.

1. 1. The common mistake done is the belief that, just pulling the baby's head will effect the shoulder delivery. This is totally wrong.
2.  Sinking feeling in the heart of the acoucher.
3.  Not knowing which maneuver to do first. In the end, not doing any one maneuver properly.
4.  Some health professionals also feel that they are going to loose the job whilst all of this is going on
5. It does not matter, which maneuver you select to do first, whatver you do, do it correctly.
6. write what time the head was born and what time the baby's body was born
7. Which way baby was facing when the head came out
8. Estimate the blood loss correctly by weighing the swabs, and do not do eyeball estimation of blood loss.
9.  Rule out third and fourth degree tears.
10.  Debrief the mother to say how badly your shoulders and arms are hurting to get the baby's shoulders out safely.

Resistant Hyperemesis Gravidarum Management

If symptoms so out of control refer patient to Gastroenterologists for consideration of Oesophago-gastroduodenoscopy. Rule out gastric or duodenal ulcer dyspepsia.


Perform liver and gall bladder USS to rule out gall stones and liver pathology.

One can consider following,

1. Omeprazole 40mg OD

2. Regular cyclizine 50 PO/IV TDS

3. Amitriptyline 10mg OD

4. Buscopan 10 mg IM TDS

5. Magnesium Tricylicate 10mls PO TDS

6. Ranitidine 50mg IV TDS

7. Folic Acid 5mg OD

8. Thiamine 50mg PO OD. (Pabrinex)

Weekly weight monitoring, refer patient to dietitian.

But if patients’ vomiting is still continuing, I would try Ondansetron before steroids 4mg TDS and then 8mg TDS if some help.

If no help one could consider Hydrocortisone 100mg intravenous twice a day for 3 doses. If no improvement, STOP.

If symptoms improve, convert to oral Prednisolone 40 mg OD and continue for 5 days before reducing by 5 mg every week until symptoms recur and then hold at minimum dose

Intolerable Morning Sickness Management

If symptoms so out of control refer patient to Gastroenterologists for consideration of Oesophago-gastroduodenoscopy. Rule out gastric or duodenal ulcer dyspepsia.


Perform liver and gall bladder USS to rule out gall stones and liver pathology.



One can consider following,

1. Omeprazole 40mg OD

2. Regular cyclizine 50 PO/IV TDS

3. Amitriptyline 10mg OD

4. Buscopan 10 mg IM TDS

5. Magnesium Tricylicate 10mls PO TDS

6. Ranitidine 50mg IV TDS

7. Folic Acid 5mg OD

8. Thiamine 50mg PO OD. (Pabrinex)

Weekly weight monitoring, refer patient to dietitian.

But if patients’ vomiting is still continuing, I would try Ondansetron before steroids 4mg TDS and then 8mg TDS if some help.

If no help one could consider Hydrocortisone 100mg intravenous twice a day for 3 doses. If no improvement, STOP.

If symptoms improve, convert to oral Prednisolone 40 mg OD and continue for 5 days before reducing by 5 mg every week until symptoms recur and then hold at minimum dose