Problems in the management of patients with artificial valves during pregnancy

During the past 15 years, 12 patients with prosthetic valves were treated during 18 pregnancies in the four Dublin maternity hospitals. These patients were on long-term anticoagulants and their pregnancies were reviewed to assess the problems associated with anticoagulation. One baby had warfarin embryopathy, six pregnancies ended in spontaneous abortions and there were two intrauterine deaths. On the basis of the findings a policy on the most appropriate anticoagulant regimen in such cases was formulated.

Haemodynamic effects of pregnancy in patients with heart failure

Four patients, who were maintained on a constant regimen of treatment, developed congestive cardiac failure during pregnancy. They were examined regularly and carefully during the course of pregnancy to assess the progress of their failure. All four demonstrated unequivocal improvement during the third trimester attributable to obstruction of the inferior vena cava restricting venous return to the right side of the heart. This resulted in a fall in venous pressure in the neck and the resulting fall in right ventricular output could be very valuable in patients with left ventricular failure.

Q fever endocarditis

Despite a worldwide distribution of Coxiella burnetii, only single cases of Q fever endocarditis have been reported outside Great Britain and Australia. We present 10 patients; five were female, only four had a history of environmental exposure, and the mitral valve was involved as commonly as the aortic stenosis, and three patients had a prosthetic valve. We confirm the importance of hepatic involvement, thrombocytopenia and hypergammaglobulinemia as diagnostic features. Diagnosis was established by finding and elevated complement-fixing antibody to Phase I C. burnetii antigen. Tetracycline, with or without lincomycin or cotrimoxazole, was used in nine patients, and one patient received cotrimoxazole as as the sole antibiotic agent. Optimal duration of therapy is unknown. In one patient, relapse followed when treatment was stopped after 18 months. Valve replacement was necessary in five patients, because of hemodynamic problems. Five patients died, and the means survival is 36 months with a range of five to 66 months. We suggest that Q fever endocarditis is frequently missed, and we recommend clinicians to consider the diagnosis in all cases of culture-negative endocarditis.

Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Ireland, 1969 to 1978

Three hundred eighty-seven pregnancies (295 patients) complicated by maternal heart disease, managed at the National Maternity Hospital, Dublin, Ireland, during the years 1969 to 1978, were reviewed. The incidence was 0.5%. Three hundred twenty-three (83.5%) were of rheumatic origin, 52 (13.4%) were congenital, and the remaining 12 (3.1%) were a miscellaneous group and included cases of cor pulmonale and coronary artery disease. There were two maternal deaths--one from congenital heart disease and one from postpartum suicide, unrelated to mild rheumatic heart disease. The perinatal mortality rate was 3.3%. Five pregnancies (three patients) were complicated by surgically uncorrected cyanotic congenital heart disease. One of the maternal deaths and three of the perinatal deaths occurred in this group. There were 38 episodes of cardiac failure (38 patients) in cases of rheumatic heart disease. The New York Heart Association grading was grade 1 in 15 (39%) of these before the onset of failure. Prophylactic antibiotics were not used and infective endocarditis did not occur. Therapeutic abortion was not practiced and a conservative approach was adopted in obstetric intervention and in all drug therapy.

Antibiotic prophylaxis against infective endocarditis after normal delivery--is it necessary?

During the years 1959 to 1978 inclusive 2165 women with rheumatic or congenital heart disease had vaginal deliveries at three large Dublin maternity hospitals. There were two (0.09%) cases of puerperal infective endocarditis, neither of which was unequivocally related to preceding childbirth during this period. Routine peripartum antibiotic prophylaxis was not given to either. A questionnaire of the practice of 19 obstetricians in Ireland showed that 12 (63%) gave antibiotics routinely during labour and after delivery in cardiac patients, five (26%) did not, and two (11%) used them occasionally. Peripheral vein blood was drawn serially from 0 to 30 minutes after vaginal delivery to determine the incidence of asymptomatic puerperal bacteraemia. A total of 299 cultures was obtained from 83 normal women and single blood cultures were positive in three women (3.6% of patients, 1.0% of cultures). A review of the published reports showed that well-documented cases of infective endocarditis and of asymptomatic puerperal bacteraemia after normal vaginal delivery are uncommon. There is evidence that antibiotic prophylaxis may increase the risk of developing antibiotic-resistant endocarditis. Recommended prophylactic regimens carry a considerable risk of drug toxicity. These facts, coupled with a lack of direct evidence in support of the efficacy of antibiotic prophylaxis, suggest that routine peripartum antibiotic prophylaxis is not indicated.

Surveillance: retrospective versus prospective

A survey was undertaken to determine if a retrospective review of charts for nosocomial infections could be as accurate as a prospective review of charts. The retrospective review was done by medical record technicians using criteria established by the Infection Control Committee and the medical staff. The infection control nurse reviewed the data collected by the Medical Records Department before the monthly report was completed. Surveillance was done prospectively by the infection control nurse and an R.N. helper. The study was carried out on two nursing units. The infection control team used the same criteria as the medical record technicians. At the end of the 4-month study period, infections found by medical record technicians were compared to those found by the infection control team. The Medical Records Department identified more nosocomial infections than did the nurse team. It was concluded that the Medical Records Department can do an accurate review of charts for nosocomial infection and that their report is reliable to show basic trends. The infection control nurse is then able to spend her time on special studies and investigations as well as employee education.

Prenatal fetal abdominal ultrasonography and diagnosis

Despite the advent of gray scale recording, the feasibility and advantages of antenatal fetal ultrasound diagnosis have not received sufficient attention. This paper describes ultrasound fetal abdominal anatomy and illustrates prenatal diagnosis based on anatomical landmarks.

Correction of type IV (mixed level) total anomalous pulmonary venous drainage

Successful correction of type IV (mixed level) total anomalous pulmonary venous connexion (TAPVC) in a 5-year-old boy is reported. The actual pathway of the pulmonary venous drainage in this case has not previously been described in the literature.