Preconception counselling
Dr Geetha emphasises the importance of
preconception counselling. This should start when
women reach puberty and continue in subsequent
years, especially prior to marriage and at least three
to six months before pregnancy, and should involve
partners and families.
She adds that it’s important to get a comprehensive
medical assessment and to review important past
medical and obstetric issues, including medications
because some can be detrimental to the baby.
The modified World Health Organization (mWHO)
cardiovascular risk stratification, which is also endorsed
by the Malaysian Clinical Practice Guidelines on Heart
Disease in Pregnancy, classifies heart disease in
pregnancy into four risk groups.
If a woman falls into mWHO cardiovascular risk I or II,
the outcome of the pregnancy is expected to be good.
But if a woman is in mWHO cardiovascular risk IV, the
risk for maternal death may be up to 30 percent or more,
and pregnancy is not recommended.
Dr Geetha says the majority of heart patients fall into
mWHO risk group three, which has a maternal mortality
ranging between five and 15 percent and a high risk
of complications for both the mother and baby. When
women have certain heart defects, fetal loss can be
between 15 and 30 percent.
Risk of prematurity and fetal growth restriction may
be significant in patients with artificial metal valves,
those on blood thinners, and patients with cyanotic heart
defects or those with poor heart function.
Women with congenital heart disease are at an
increased risk of transmitting the condition to their
offspring, so it’s important to check the foetus’ heart at
18-22 weeks of gestation. Some syndromes, like Marfan
and Di George syndrome, have a 50 percent risk of being
Congenital heart disease can be passed to their offspring
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passed down to the baby.
She recommends an individualised “care plan” for
patients with pre-existing heart disease. This includes
determining the level of care, important management
considerations, and potential complications.
The plan should be disseminated to all healthcare
personnel involved in the care of the mother and should
include the name of the doctors to be contacted if
problems occur. This is meant to remove the barriers of
referral and communication that might arise.
Contraception and heart disease
At the IJN- HTA (WCHKL) cardiac obstetric combine
clinic (IJN-HTA (WCHKL) COCC), contraceptive advice
is provided to women with heart disease who are in
the childbearing age group to enable them to plan
their pregnancies.
“Oral contraception and barrier methods (condoms)
may not be the best of options for all patients. In fact, the
standard oral contraceptive pills may not be suitable in
many women with heart diseases,” she said. “We also
have religious counsellors to help resolve conflicts with
regard to contraception.”
Dr Geetha says that these women should be
counselled and managed by a multidisciplinary team,
consisting of cardiologists, obstetricians, specialised
nurses, obstetric and/or cardiac anesthetists, and
counsellors. The advice of geneticists, neonatologists,
and cardiothoracic surgeons are also helpful in certain
cases.
At the IJN-WCHKL COCC, all the experts team up
to ensure optimal care for women with heart disease.
Their services have also expanded to include caesarian
sections performed at IJN and supported by the
obstetricians and obstetric anaesthetists from WCHKL
for high risk patients who need close intensive care
monitoring.
“We hope that our resources and combined expertise
can help support hospitals and health care personnel
throughout Malaysia,” she said. “We also work closely
with obstetricians and physicians from the government
and private hospitals throughout Malaysia so that these
women can deliver in their hospital of choice whenever
possible without compromising care.”
There are also plans to work with non-governmental
organisations, including IJN Foundation, to create
greater patient awareness about heart disease and
pregnancy and to look at funding poorer patients.
“Our mantra is ‘planned pregnancy for safer
outcomes’, and we continue to endeavour towards
making every pregnancy safe, especially in mothers with
heart diseases.”
For further information you can check these web pages:
http://www.ijn.com.my/pchc/services/combine-cardiac-
obstetric/
http://www.ijn.com.my/pchc/services/foetal-cardiac-
clinic/
If a woman falls
into mWHO
cardiovascular
risk one or two,
the outcome of
the pregnancy
is expected to
be good. But
if a woman
is in mWHO
cardiovascular
risk four, the
risk for maternal
death may be up
to 30 percent
or more, and
pregnancy is not
recommended
Dr Geetha
Kandavello
Senior
Consultant
Paediatric
Cardiologist, IJN
MARCH 2020
35