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Title: The management of pregnancy and labour in women with cardiac disease
Author: Cauldwell, Matthew
ISNI:       0000 0004 6422 7933
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2017
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Within my thesis I have shown that women with congenital heart disease are amenable to preconception counselling, but that many women are not referred to see a specialist cardiologist or obstetrician prior to pregnancy. Women with more severe forms of heart disease such as a Fontan repair have worse obstetric outcomes with high rates of miscarriage, preterm delivery and postpartum haemorrhage (PPH), hence the importance of comprehensive counselling prior to pregnancy. When women are counselled prior to pregnancy regarding the potential risks that they face, I have shown that the quoted risk of an adverse event assessed by an experienced clinician has a better correlation with actual outcome than other validated scoring systems such as the modified WHO score. Women with congenital heart disease are at much greater than average risk of postpartum haemorrhage (PPH). My analysis has shown that after correcting for known risk factors for PPH, women with a Fontan repair are at the highest risk of increased blood loss, and that low molecular weight heparin at both a prophylactic and therapeutic dose is associated with higher rates of PPH even when stopped at an appropriate time prior to delivery. I have focussed on the management of labour in women with heart disease, in particular of the second and third stages. Having shown that a restricted second stage for women with heart disease recommended by the multidisciplinary team (MDT) is often not adhered to in our actual clinical practice, my pilot study showed that there was only a modest measured haemodynamic effect of pushing (bearing down), with a small but significant increase in maternal heart rate in the active second stage of labour. I have found from a literature review and from our own historical dataset that the practice of a restricted oxytocin regimen for the management of the third stage (designed to minimise cardiovascular side-effects) is associated with greater rates of PPH, mainly due to uterine atony. In a prospective cohort study, women with heart disease were allocated to either a low dose infusion or a combination of the low dose infusion with an initial bolus of 2IU of oxytocin over ten minutes; those receiving the additional oxytocin had a significantly lower volume of blood loss and rate of PPH. Importantly, the women receiving the higher dose of oxytocin had no measured deleterious cardiovascular side effects.
Supervisor: Johnson, Mark ; Steer, Philip Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral