INTRODUCTION
Mitral valve
replacement procedure has been on the increase in recent time, which has given
hope of living to many patients that suffered various degrees of valvular
diseases.1,2Cardiogenic shock is a rare and scary clinical
incidence/ emergency during childbirth, but in patient on antithrombotic medications,
increased vigilance and monitoring are indispensable to ensuring the integrity
of the valve in place. Cardiogenic shock is often associated with high
incidence of morbidities and mortality, hence should be avoided as much as
possible especially in patients that have prosthetic valves in place.3Following
any incidence of cardiogenic shock, there is usually systemic hypoperfusion,
circulatory compromise, systemic inflammatory responses and subsequent multi
organ dysfunction.5
Clinically, the
patient presents with symptoms of breathlessness, weak, in some instances,
there may be gasping for breath and acute confusional state. There are always
features of tachypnoea, absent or thread pulse as well as hypotension or even
unrecordable blood pressure.6,10
Hemodynamics of the
cardiovascular physiology in a patient with mitral valve prosthesis may be unpredictable
being a potential danger of complication.
Cardiac function may
be compromised during labour, delivery and peripartum. Statutory precautions
most times prevent or avert eminent danger, such as cardiac arrest,
fibrillations and cardiogenic shock and even death.7
Stable clinical and
therapeutic fibrinolytic or antithrombotic agents and surveillance remain the
benchmark or gold standard to maintaining the integrity of the prosthetic
valve, prevention of cardiogenic shock and its sequel as well as ensuring an
optimum living. 8
CASE
REPORT
Mrs. PO, a 28 year
old Nigerian born, security officer with tertiary education, of Igbo extraction
and a Christian by faith. She is P1+0 (alive).
She presented to the
facility with complaints of breathlessness of 12 days cough of 1 week and
epigastric pain of a day duration. Breathlessness was of sudden onset. It was
initially mild, and increased in severity, weakness, orthopnea, paroxysmal
nocturnal dyspnea. There was also cough productive of frothy sputum, but not
bloody.
The abdominal pain
was sudden, sharp, severe, located at right hypochondrium and epigastric area. No
abdominal swelling, distension or change in bowel habit. She presented to University
of Port Harcourt Teaching hospital, having been delivered of a live male baby
with birth weight 3.3kg two weeks before.
Her menache was at 13
years
A known cardiac
patient with mitral valve replacement since 2012(6 years).
She is currently on Metoprolol,
Sedenafil, Xareto, Digoxin, Bromocriptin, fluconacillin, Laxis, Omeprezole, and
warfarin. Her latest INR was 1.37/ used to monitor the warfarin. Her BMI is
34.01kg/m2
DISCUSSION
Choice of valve here
unfortunately negates the haemodynamic changes in labour for a woman in her
reproductive years. Child bearing remains a determinant factor for women
between mechanical and biological prosthetic valves.1-8
The obese features
were not favorable in her clinical state as this worsens the cardiac output, and
poses her to increased risk of cardiogenic shock and its sequel.9She
was not compliant to her medications, hence had episodes of atrial fibrillation
which predisposed her to cardiogenic shock. Other factors include the anticoagulating
agent “Warfarin” that was discontinued during labour for clexane. It is usually
advisable to adjust the anticoagulant therapy over the different trimesters. Discontinuing warfarin for clexane at term before labour is
the standard practice to avoid increased bleeding risk at labour.1,2,10
However worthy of note was the patient’s choice of vaginal delivery against
medical advice. This documentary offers to refresh memories of health care
providers and practitioners of this very rare clinical entity of great
importance.
In conclusion,
management of obstetrics patient is multidisciplinary involving the
obstetrician/gynaecologist, cardiologist, cardiac surgery team and other stake
holders for a favourable outcome for both the mother and baby.
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