ATRIAL SEPTAL DEFECT IN

PREGNANCY
PATIENT DETAILS:

Name: Puan NS

R/N: 8450 - 10

Age: 20 years old

Sex: Female

Race: Malay

Occupation: Housewife

Date of Admission: 31th of March 2010

Date of Clerking: 1st of April 2010

Gravida: 1

Para: 0

Last Normal Menstrual Period (LNMP): 25th of July 2009 (not sure of date, irregular
menses)

Revised Expected Date of Delivery (REDD): 25th of April 2010

Period of Amenorrhea (POA): 36 weeks, 4 days

CHIEF COMPLAINT:

She was a known case of atrial septal defect (ASD) diagnosed at 27 weeks of gestation,
referred from Klinik Kesihatan Sanggang, Temerloh for further management of
moderate anemia as the patient can not tolerate oral iron tablets since early pregnancy.

HISTORY OF CURRENT PREGNANCY:

Her last normal menstrual period (LNMP) was on 25th of July 2009 but she was
not sure of the date, and her menses were irregular since menarchy, the REDD given by
the first scan done at 19 week of POG was 25th April 2010. Puan SN suspected her
pregnancy when she missed her menses for 1 month associated with nausea and
vomiting. But, she did not do urine pregnancy test by herself to confirm the pregnancy.
She went to KK Sanggang and UPT was done. The result was positive. Actually, this is an
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unplanned pregnancy but she is happy with it. After that, she did not bother to go to any
clinic or health center for her booking visit as she claimed that she was too busy with
her job and did not have time to go to for her booking. Before she did her booking, she
claimed that she was having repeated episodes of dizziness since early pregnancy which
were precipitated by heavy work, and prolong walking. But upon resting and normal
physical activity, the dizziness disappeared. She denied any episodes of palpitation,
dyspnoea or easily fatigue upon a heavy work. At first, she thought that was normal, but
later she became worried. Thus, she did her booking visit at 19 weeks of POG which was
done at KK Songsang. Her weight, height and blood pressure were measured, severe
blood tests and urine test were done, but she forgot the values but she said that she
was told that the result were normal except that her hemoglobin level was low at that
time which was about 9g/dl. The first scan was done to date the pregnancy, and given
her REDD was on 25th April 2010. She told one of the nurse that she was having dizziness
since early pregnancy upon a heavy work. Then, a doctor did a thorough physical
examination on her. The doctor told her that he detected some abnormal heart sounds.
Then, she was asked to go to MOPD, HoSHAS next 2 weeks for confirmation. At that visit
she was given double hematinic, folic acid and vitamin c tablets. She claimed that she
complied to medication given, but she can not tolerate hematinic although she tried to
swallow it but she will kept on vomited them. She quitted from her job as she afraid that
recurrent episodes of dizziness may recur if she continue to work. At home, she only had
several episodes of dizziness upon a heavy house chore. But, she was comfortable at
rest and during normal activity. But she denied other symptoms of anaemia or heart
failure such as orthopnoea or paroxysmal nocturnal dyspnoea.

Then, at 21 weeks of POG, she went to MOPD HoSHAS. At this visit, she told that
her hemoglobin was around 9g/dl. Again, she was told that abnormal heard sound was
detected but they can not specify the problem yet. Thus, she was referred to klinik
pakar perubatan HoSHAS one week later at about 22 weeks of POG where ECHO was
done on her and she was told that she was having congenital heart disease and she was
categorized as having class I heart disease. She was told that an appointment with IJN
will be arranged for her further investigation on her heart problem.

At 27 weeks of POG, she went to IJN. ECHO and ECG were done on her. She was
told that she has secundum atrial septal defect at birth, but the hole was a small one,
which was about 2.5mm in diameter. They planned to do a surgical intervention on her
in August, after her delivery. She was also told that the prognosis of her pregnancy was
good because she was having class I heart disease and she can deliver vaginally.

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 Since that, she had few biweekly antenatal check ups at KK Sanggang and
monthly visit to O&G clinic. Her hemoglobin level was range from 8.5 to 9.0g/dl during
these visits but she still did not have any other symptoms of anaemia except dizziness
upon heavy work. She did not bother to tell the health personal in the clinic that she
was not tolerating hematinic until she was at 34 weeks of POG, she told the doctor that
she can not tolerate hematinic and it was change to Ibaret. During 2 weeks period she
also can not tolerate Ibaret and kept on vomiting the medication upon swallowing.
During her antenatal visit when she was at 36 weeks of POG, she told the problem to
the doctor, and she was referred to HoSHAS this time to start her on parenteral iron as
her hemoglobin level was at low level throughout her visits inspite of iron tablets given.
Currently, upon admission, her Hb level was 8.8g/dl and she was clinically pale. Her vital
signs were stable. She did not have any symptoms of anaemia but she complaining of
dizziness upon prolong walking and heavy work. Other than that, she denied any
symptom of labour such as contraction pain, show or leaking liquor. Fetal movement
was good. In the ward, test dose of 0.5ml IV Imferon was given and her Hb level
increased to 9.6. Then, she was told to get daily jab of IM Imferon at KK Sanggang and
she was discharged.

SYSTEMIC REVIEW:

1) Central nervous system: no headache, no blurring of vision

2) Musculoskeletal system: no back pain, no muscle or joint pain

3) Cardiovascular system: no chest pain, no palpitation

4) Respiratory system: no shortness of breath, no cough or hemoptysis

5) Genitourinary system: no polyuria, no dysuria or hematuria

6) Gastrointestinal system: no nausea, no vomiting, no abdominal pain, no diarrhea

or constipation

Systemic reviews were unremarkable and she also denied of fever.

PAST OBSTETRIC HISTORY:

Nil

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PAST GYNAECOLOGICAL HISTORY:

She attained her menarchy at the age of 13 year old. Her menstrual cycle was irregular,
her menses last for about 6 to 7 days with normal flow. She denied episode of
dysmenorrhoea and menorrhagia. For this pregnancy, she was not on any form of
hormonal contraception prior to the LNMP.

PAST MEDICAL AND SURGICAL HISTORY:

Other than secundum ASD, which was diagnosed at 25 weeks of POA, she had no known
medical illness such as asthma, diabetes mellitus, hypertension or ischaemic heart
disease. She has no history of surgical intervention done on her.

FAMILY HISTORY:

Her father is asthmatic. But both parents do not have other medical illnesses like
diabetes mellitus, hypertension or ischaemic heart disease. Neither the parents nor her
siblings are known to have congenital heart disease and all of them are healthy without
any known medical illness. There is no history of twin pregnancy or congenital
abnormality in the family.

SOCIAL HISTORY:

She is married for 1 year. She is a housewife, currently lives in Bukit Tingkat, Songsang
with her husband her family. She does not smoke or drink alcohol. Her husband is a
promoter. He is a smoker who smokes half pack per day but he does not consume
alcohol. Total income of her family is around RM1700 per month. She claimed that she
is financially stable.

DRUGS AND ALLERGY HISTORY:

She took hematinics and Ibaret during this pregnancy but she was intolerate to them
throughout her pregnancy. Other than that, she does not take any other medication,
drug over the counter or traditional medication. She has no drug or food allergy.

CASE SUMMARY:

Puan SN, a 20 years old Malay housewife, gravid 1 para 0 currently at 36 weeks 4 days of
POA who is a known case of ASD with NYHA class I diagnosed at 25 weeks of POG, was
referred to HoSHAS due to moderate anaemia and for further management as she

5
intolerate to oral iron . Otherwise, she is asymptomatic of anaemia and she denied
symptoms of heart failure. She also denied of abdominal pain, show and leaking liquor.
Fetal movement is good.

PHYSICAL EXAMINATION:

a) General inspection:

The patient was lying comfortably on the bed. She is alert, conscious but pale. Hydration
status was moderate.

Vital signs:

1) Pulse rate: 80 beats per minute, regular rhythm and good volume

2) Respiratory rate: 24 breaths/min

3) Temperature: 370C , afebrile

4) Blood pressure: 110/70 mmHg

Her height was 158 cm while her weight was 60 kg. BMI was 24.

b) General examination:

Hand examination

Hands were warm and dry. Pallor of palmar crest noted. No peripheral cyanosis. No
clubbing, no Osler’s nodes, no Janeway lesion, no splinter hemorrhage, good capillary
filling.

Head and facial examination

No mitral facies (rosy cheek with bluish tinge). Her conjunctiva were pale but no
jaundice noted. Oral hygiene was good and hydration status was moderate. No central
cyanosis. No high-arched palate, no mucosa petichae.

Neck examination

Thyroid gland not enlarged. JVP not raised. No palpable lymph nodes. Carotid pulse was
palpable, normal character and volume.

Leg examination
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Slight pitting oedema up to middle of the leg, no calf tenderness, no varicous vein noted

c) Systemic examination:

Breast examination

Both breasts were symmetrical in size and shape. The overlying skin was normal and no
visible or palpable lump. Nipples were not inverted and the areolar were
hyperpigmented and Montgomery tubercle were seen. Axillary lymph nodes were not
palpable.

Cardiovascular examination

On inspection, no deformities and no scars noted. The apex beat was felt at left 5 th
intercostal space, midclavicular line. There were no thrills or parasternal heave. The first
and second heart sounds were heard. There was systolic murmur heard on the left 2 nd
and 3rd intercostals space, it was grade 3 murmur.

Respiratory examination

No scar or deformities noted. Equal air entry bilaterally and normal vesicular sound
breath. No added sound like ronchi or crepitation.

Central nervous system examination

All cranial nerves were grossly intact. Normal tone and muscle power for all 4 limbs.
Reflex and sensory component were intact.

d) Specific examination:

Abdominal examination

Inspection: the abdomen was distended by a gravid uterus as evidenced by linea nigra.
No obvious striae gravidarum and no scar noted.

Palpation: clinical symphysio-fundal height was about 36 weeks, and it measured 35cm
which was corresponded to 36 weeks of gestation. On palpation, there was singleton
fetus, at longitudinal lie with cephalic presentation. The fetal back lied on the right side
of the mother. The head was not engaged yet, it was 5/5 palpable. Liquor was adequate
and estimated fetal weight was 2.4 to 2.6kg.

Auscultation: fetal heart rate was heard,140 beats/minute

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CASE SUMMARY:

Puan SN, a 20 years old Malay housewife, gravid 1 para 0 currently at 36 weeks 4 days
of POG who is a known case of secundum ASD with NYHA class I diagnosed at 25 weeks
of POG, was referred to HoSHAS due to moderate anaemia and for further management
as she intolerate to oral iron. She complained of dizziness upon heavy work and prolong
walk. Otherwise, she is asymptomatic of anaemia and she denied symptoms of heart
failure. She also denied of abdominal pain, show and leaking liquor. Fetal movement is
good. On examination, her vital signs were normal and stable. She was pale but not
cyanosed. The abdomen was distended by a gravid uterus which corresponded to the
date. On cardiovascular examination, systolic murmur was heard over left intercostal
spaces. Other systemic examinations were unremarkable.

PROBLEM LIST:

1) Secundum ASD with NYHA class I diagnosed at 25 weeks of POG

2) Moderate anaemia throughout pregnancy (Hb: 8.5 – 9.6)

3) Intolerated to oral iron tablets

4) Dizziness upon heavy works or prolong walk.

MANAGEMENT:

Management and plan done in O&G Kenanga 3 ward, HoSHAS are:

1) FBC: Hb level on admission was 8.8g/dl

2) BP and pulse rate 4-hourly

3) Infusion of test dose of Imferon, .05ml

4) Labour progress chart (LPC)

5) Fetal heart rate is monitored 4 hourly to ensure that the fetal well-being.

6) Daily fetal kick chart to assess fetal well-being.

7) To ask medical team to review on the heart problem

8) She was told to inform the nurse or doctor in-charged immediately if she
symptom of anaemia such as dyspnoea or palpitation, or any symptom of heart
failure such as orthopnoea or PND.
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9) Upon discharge, the plan given by O&G specialist were:

 To continue daily IM Imferon 2mg for 10 day at Klinik desa Songsang

 To repeat Hb level in KK Sanggang after 2 weeks

 Not to allow the pregnancy beyond REDD (25th April 2010)

 Antibiotic prophylaxis ( infective endocarditis) during delivery

 Continue with IJN plan after delivery

DISCUSSION:

Heart disease in pregnancy is rare, but potentially serious and complicates

approximately 1% of all pregnancies. Congenital heart disease now accounts for
approximately 50% of the heart disease in pregnant women in UK 1. Atrial septal
defect (ASD) is one type of congenital heart disease. A secundum atrial septal defect can
result from inadequate formation of the septum secundum so that it does not
completely cover the ostium secundum. More often, the ostium secundum is
excessively large because of increased resorption so that septum secundum cannot
cover it. The shape of the defect varies from circular to oval. Less often, strands of
tissue cross the defect creating a fenestrated appearance that suggests multiple
defects. Rarely, a defect can extend posteriorly and inferiorly, approaching the site
of inferior vena cava entrance into the right atrium 2. Defects were defined as small
(> 3 mm to < 6 mm), moderate (> or = 6 mm to < 12 mm), or large (> or = 12 mm) 3.
The foramen ovale mechanism remains patent in at least 15% of adults
(echocardiography can identify clinically insignificant shunts with this frequency).
Some of these individuals could be classified as having a small secundum atrial
septal defect 4. In this case, Puan SN is having secundum ASD in which the defect is
about 2.5mm which is a very small defect.

Heart diseases can be classified into 4 classes by New York Heart Association
(NYHA) as summarized in the table below5 :

No limitation to ordinary activities. Ordinary activity does not cause

Class I fatique,dyspnoea or palpitation .
 The patient has no symptoms and she can undertake all physical
activities. Woman in this class does not need additional treatment.

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 Symptoms with ordinary activity. Slight limitation of activity.
Class II  The woman is comfortable at rest but normal activities causes
fatigue, palpitations and dyspnoea.

Symptoms with less than ordinary activity. Mark limitation of activity

Class III  The woman is comfortable at rest but complaints of fatigue,
dyspnoea with less than ordinary activity.

Symptoms at rest. Inability to carry out any activity without

Class IV discomfort.
 The patient is breathless even when resting. Women in this class
are seriously ill.

In this case, Puan SN was categorized as having class I heart disease as she was
asymptomatic at rest and with normal physical activities which can be carried out as
usual without discomfort. She was only complaining of repeated episodes of
dizziness which were precipitated by heavy works or prolong walk.

In general, the pregnancy prognosis is good for cardiac patients in NYHA class I
and II, although modifications in therapy may be required. For NYHA class III
patients the prognosis is fair with therapy. Special attention during pregnancy and
early admission in labour are recommended. Pregnancy is generally contraindicated
for patients with NYHA class IV. As Puan SN is having NYHA class I, so the prognosis
of her pregnancy is good.

Effect of pregnancy on heart disease

Normal physiological changes in the cardiovascular system in pregnancy may

aggravate underlying cardiac disease. Pregnancy is one of the physiological
conditions that place a considerable burden on the heart, forcing it to work harder
for to move all the blood volume which has increased by up to 50 percent. While the
normal heart is quite capable of taking extra workload in its stride, a disease heart
may not be able to cope with it. Patients with cardiac disease who are unable to
tolerate these changes may decompensate and develop congestive heart failure. In
this case, Puan SN was healthy and asymptomatic within the period when she was
born until her pre pregnancy state. But, since early pregnancy, she started to feel
dizzy on heavy works or prolong walk only. Otherwise, she was asymptomatic of

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anaemia at rest and during normal physical activities. Currently she does not have
any symptoms of heart failure such as orthopnoea or PND.
Effect of heart disease on pregnancy

The fetus is at risk of growth restriction and premature delivery in pregnancies

complicated by cyanotic congenital heart disease, when total of fetal loss rate may be
as high as 40%. If a parent is affected, the risk for congenital heart disease in the
fetus is increased by 5 times. Thus, as the patient is having ASD which is one of the
type of acynotic heart disease, thus, the prognosis of her fetus and pregnancy
generally quite good, but there is still a probability of her fetus having congenital
heart disease.
Diagnosis of heart disease

Most cases of heart disease have been diagnosed before pregnancy, and very
few become apparent for the first time during gestation. Making the diagnosis on the
basis of patient complaints or physical examination of the heart is very difficult since
most of the changes of normal pregnancy can mimic heart disease. A chest x-ray is
not of much help except in advanced cases of heart failure, and an electrocardiogram
is too non-specific to detect anything but rhythm disturbances. An echocardiogram is
the cornerstone of diagnosis of heart disease during pregnancy. It is safe, as it
involves no radiation that can harm the fetus, and can provide a wealth of
information in skilled hands.

Management of pregnancy in a patient with heart disease

A) ANTEPARTUM MANAGEMENT:

1. Ideally, the patient should be fully assessed before embarking on a pregnancy

and pre-pregnancy counseling is done to explain on maternal and fetal
complication
2. At each visit, vital signs like pulse and blood pressure are carefully noted. A
rapid pulse rate >100 beats per minute or rapid weight gain are often signs of
impending heart failure. Ask the patient on symptoms of anaemia and heart
failure.
3. To avoid risk factors which predispose the woman to heart failure. The focus
of care early in pregnancy is on avoiding risk factors that may cause heart
failure or worsening heart disease. These include:
 Infection, especially urinary or chest infection
 High blood pressure
 Obesity
 Multiple pregnancies

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  Anaemia
 Arrhythmia
 Acute bacterial endocarditis
Any concurrent disease (especially anaemia) should be treated vigorously.
Acute bacterial endocarditis should be suspected when there is fever
associated with Osler’s node and increasing in murmur.
4. To treat vigorously, if heart failure occur. Admission in hospital and treated
vigorously. It has a high mortality in pregnancy. The principles of treatment
remain the same, with digoxin and diuretics being the cornerstones of
therapy. Other precipitating causes are treated like rhythm disturbances or
anaemia. Once heart failure is brought under control, most women can be
discharged from hospital.
5. To avoid unnecessary stress to the disease heart:
 Her daily activities should be evaluated and changes if this is appropriate.
 The cooperation of her family members should be obtained, especially in
taking over part of her daily activities.
 Frequent 20 to 30 minutes rests in bed should be advised. This extra bed rest
can minimize the heart’s workload.
6. The use of prophylactic antibiotic. Prophylactic antibiotics are required
following dental extraction.
7. Book for hospital delivery. Pregnant women with heart disease should be
encouraged to book in at antenatal clinic and for hospital delivery.
8. Fetal monitoring. An ultrasound examination is done to confirm gestational
age, to rule out IUGR and to detect fetal anomalies. Cardiotocography to
measure fetal heart rate and Doppler flow studies to measure fetal and
maternal placental blood flow are also can be done.
9. Timing of delivery. Heart disease is not an indication for induction of labour,
and timing of delivery is based solely on obstetric considerations. Vaginal
delivery at term provides the optimal conditions for successful outcome in the
pregnant cardiac patient.
10. Indication for heart surgery:
 Medical treatment fails to control heart failure
 Symptoms are intolerable to the patient despite medical therapy
Second trimester of pregnancy is usually preferred for any heart surgery.

B) INTRAPARTUM MANAGEMENT

1. Maternal position: Maternal position during labour is important. During

labour the patient should be nursed either on her side or well propped up, as
compression of the aorta in the supine position may cause marked
hypotension.
2. Monitoring of heart failure: Pulse, respiratory rate, blood pressure, and the
presence of basal pulmonary crepitation should be assessed every 20
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 minutes during the first stage of labour and more frequently (every 10
minutes) during the second stage.
3. Good analgesia during labour: Pain and anxiety during labour increase the
cardiac load. It is advisable to reduce this extra work on the heart. Good
analgesia should be administered early to allay stress and apprehension.
Epidural analgesia is effective in relieving pain during labour and delivery.
4. Prophylactic antibiotics are required. Antibiotic covers during the period of
delivery are recommended to prevent any risk of infective endocarditis.
6. Treatment of cardiac failure during labour: If cardiac failure does develop,
patient must be treated in HDU and treat her with:
 Position- prop her up to 45 degree
 Diuretic – intravenous fursemide, 80mg
 Digitalis – rapid acting glycoside such as digoxin
 Oxygen – this is administered by face mask or by nasal prongs
 Morphine – to relieve pain and anxiety
 Antihistamine
 Start on antibiotic
 Rotating tourniquets to the extremities. This is to reduce the venous return
to the heart
7. Delivery:
 Shorten the second with ventouse or forceps, as maternal bearing down
markedly increases the venous pressure.
 Third stage of labour: Following delivery, prompt removal of the placenta
will minimize blood loss. Avoid ergometrine and syntometrine, as these
oxytocics may cause vasoconstriction, an increased in blood pressure, and
precipitate heart failure. Give syntocinon.

C) POSTPARTUM MANAGEMENT
The burden on the heart continues into the puerperium. Close monitoring for signs
of decompensation should be observed for 24 to 48 hours after delivery.
 Keep longer in the hospital.
 Ensure adequate rest in bed for the first two days.
 Close monitoring of the maternal vital signs.
 Active movement in bed and early ambulation are to be encouraged (under
supervision). This is to prevent venous thrombosis.
 Any urinary or respiratory tract infections should be vigorously treated.
 Status of the heart needs to be assessed by the cardiologist before the patient is
allowed to go home.
 Encourage lactation

D) LONG TERM POSTNATAL MANAGEMENT

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  Communicate with health provider (klinik kesihatan, klinik desa) about status of
the patient and home visit
 Document all finding in the based card
 Counsel on contraception involving the husband and family members

For conclusion, this patient who is a known case of heart disease came with moderate
anaemia and was admitted this time to change her medication from oral iron to
parenteral iron due to intoleration of oral iron tablets throughout her pregnancy. The
principle of the management of this patient is to prevent her from developing heart
failure secondary to anaemia which may worsen the outcome of the pregnancy to
mother and fetus.

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REFERENCES:

1. Philip N. Baker et al. Obstetric by Ten Teachers. Medical diseases complicating

pregnancy- Heart Disease. Chapter 15: page 180, 2006.

2. Vick GW, Titus JL. Defects of the atrial septum, including the atrioventricular canal. In:
Garson A, Bricker JT, Fisher, DJ, Neish, SR eds. The Science and Practice of Pediatric
Cardiology. Vol 2. Baltimore, MD: Lippincott Williams & Wilkins; 1998

3. McMahon CJ et al. Natural history of growth of secundum atrial septal defects and implications
for transcatheter closure. Heart. 2002 Mar;87(3):256-9.

4. Ira H Gessner. Atrial septal defect, ostium secundum. eMedicine Paediatric and critical
care medicine. Website: http://emedicine.medscape.com/article/890991-overview

5. M.N. mohd Azhar. 2002. Obstetrics Companion for the undergraduates. Heart Disease in
Pregnancy. Chapter 21, Page 244-257

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