Alif and Nur, who are in their 20s, are looking forward to getting married but foremost on their minds is whether Nur can have a safe pregnancy as she was diagnosed with a heart problem when she was just six months old.
This is the main concern of young couples who walk into the consultation room of Dr Geetha Kandavello, consultant paediatric and adult congenital cardiologist at the National Heart Institute (IJN): whether women with heart disease can get married and have children.
This is a very valid concern and and as such it is crucial that young women are counselled early on, she advises.
"This is to ensure that they are mentally and physically prepared by the time they grow up and want to get married and become pregnant, ” said Dr Geetha.
Pre-pregnancy counselling crucial
Dr Geetha firmly believes that pre-pregnancy counselling for women with heart disease should begin when they are in their teens even though it is a taboo subject for many parents.
"Discussions (on pregnancy) must start at an early age as it will make it easier for the patient to plan their future... at the very least, they can seek the best advice in planning and managing their pregnancy and also after delivery care, ” she said.
Besides congenital heart disease, many women in Malaysia also have valvular heart disease such as rheumatic heart disease. Valvular heart disease occurs when any one of the four valves in the heart is damaged or diseased. The valve can either be repaired or replaced with an artificial valve.
Pregnant women whose damaged valve has been replaced with a mechanical valve face higher risks and have to take blood-thinning medication like warfarin.
Lately, there has also been a rise in cardiomyopathy cases caused by weakened heart muscle, which can occur due to various factors such as genetics, infections and other diseases, explained Dr Geetha.
Data from the Malaysian Confidential Enquiry into Maternal Deaths (CEMD) show that heart disease is the commonest cause of indirect maternal deaths and can be classified more specifically as valvular heart disease, congenital heart disease and cardiomyopathy.
"Pre-pregnancy counselling is absolutely crucial because from there we can conduct all the relevant tests to determine the type and level of risk faced by the patient. This will make it easier for the specialist to decide on the best medical strategy for the mother and the baby, ” she added.
Risk groups
Cardiologists basically categorise women with heart disease into four risk groups. The women in the first and second modified WHO cardiovascular risk groups face low to medium risk, and cardiovascular specialists and gynaecologists will give them the go-ahead to conceive.
For those in the third and fourth groups, explained Dr Geetha, it would hinge on the type of disease and the patient’s heart condition.
"If her valve is moderately narrow or she has an artificial valve made of metal or has cyanotic heart disease (low blood oxygen level) or her heart is not functioning well, she can still become pregnant but would need to be monitored strictly by specialists who are skilled in caring for high-risk pregnant women.”
Women in the third group will not only be required to undergo pre-pregnancy counselling but will also require specific medication and treatment and there may even be times when they have to be warded in the hospital for close monitoring.
Meanwhile, women in the fourth group are advised to avoid pregnancy due to the high risks involved.
But this fourth group can be subdivided into two categories, with the women in the first category not allowed to become pregnant unless they have undergone treatment for their heart disease while for those in the second category pregnancy is totally out of the question.
"Women are not allowed to become pregnant if their heart is weak (functioning at less than 30%) or there is no treatment to improve their heart condition.
"High or abnormal lung pressure can also endanger the life of the patient if she becomes pregnant,” said Dr Geetha.
Women in the third and fourth groups also face a higher risk of miscarriage, premature birth and improper development of the foetus, she said, adding that the baby also faces the risk of being born with congenital heart disease.
Combined clinic
Dr Geetha also said that in some cases of heart disease, the mother’s health may get worse after childbirth.
"This is why it is important for the mother’s health to be monitored for at least six months after delivery to ensure her heart is in good condition.”
She said during the second trimester of pregnancy, a woman’s blood volume will start to rise and by the 28th week of pregnancy, her blood volume would have increased by 40% as a result of which her heart has to work harder to pump more blood.
The heart of a normal woman can withstand the extra stress but in the case of a woman with heart disease, her heart may not be able to recover after going through all that stress during pregnancy.
Columbia Asia Hospital - Setapak consultant cardiologist Dr Ng Min Yeong, meanwhile, said women with heart disease who are pregnant should be attended to by a team of specialists from various disciplines of medicine.
He said they should first undergo a full examination at a government health clinic to assess their health condition and take note of any sign or symptom of heart disease such as breathing difficulty, chest pain at night, swelling on both legs or bluish marks on the skin.
Such patients are usually referred to a cardiac-obstetric combined clinic where the relevant specialists will provide comprehensive care to pregnant mothers with heart disease.
"For women with heart disease, not only should their pregnancy be well planned, but the childbirth method also requires careful planning to ensure the safety of the mother and baby, ” added Dr Ng. - Bernama
Heart disease, pregnant women with heart disease, national heart institute, pre-pregnancy counselling, combine clinic, hospital kuala lumpur
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