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The cardiac patient in pregnancy
THE CARDIAC PATIENT IN PREGNANCY A Five-Year Survey LOUIS
II.
M.D.,
DOUGLASS,
BALTIMORE,
MD.,
(From
the Department
of
AND
L.
LORMAN
M.D.,
HOOPES,
D. C.
WASHINGTON, Obstetrics,
University
of Maryland
Hospital)
UCH has been written about this subject by those who have made detailed studies of the associated conditions, and there are on record excellent recommendations, rules, and regulations for the care of this group. It is felt that any statements of this nature made here would be useless repetition. But for purposes of comparison, our experience and results should be of some value and it is with this idea in mind that this report is being made.
M
Material The period covered is five years, from Jan. 1, 1942, through Dec. 31, 1946, during which 13,908 patients were delivered and discharged from the Obstetrical Service of the University Hospital, Baltimore, Maryland. Of these, 88 were classified as having heart disease of varying severity. Ten were delivered twice in the five-year period, so that we actually treated 98 patients, an incidence of 0.71 per cent. This is considerably smaller than is generally reported, and may in part be due to the fact that the incidence of heart disease in this community is somewhat lower than in other centers. TABLE CARDlAG CLASSIFICATION Class I Class II Class III Class IV Total Patients delivered Incidence
1942 13 7 2 7 29 2,991
1943 10 6 3 0 19 2,960
0.97%
0.6470
I 1944
1945
9 5 1 1 16 2,960
4 4 4 4 16 2,312
0.54% TABLE
ii&ON
/ Class Class Class Class Total
I II III IV
;;z
( 25 ii 31
0.69%
TOTAL 48 25 12 13 98 13,908 0.71y&*
0.67yo
II
PIUMIPPbR;T:ULTIP. 20 28 12 13 3 9 4 9 39 59 373
1946 12 3 2 1 18 2,685
1
PRIVATE 23 8 5 6 42
)
CLINIC 25 17 7 7 56
/
TOTAL 48 25 12 13 98
Tables 1, II, and III give some pertinent data about the classification of the heart disease, the parity, and t,he ages of these 88 women. They require no particular comment. Table IV is an effort to summarize the results of the 98 deliveries of the group. Many of the pertinent facts will be found here. whkh will he elaborated upon and further facts brought out later.
SUMMARY
___
...- ---_ -.“-
1. Number of patixdischargetl 2. Number of patients delivered and discharged (twins 2 sets) a. Patients delivered of viable infants (twins 1 set) h. Patients aborting (twins 1 set) 3. Maternal mortality a. Rate per 1,000 live births 4. Number of viable babies born a. Term h. Premature” 5. Number of living babies a. Term 1). Prema.ture’ A. Number of slillhirths a. Term h. Premature” 7. Number of neonatal deaths a. Term h. Premat~urc” 8. Total fetal mortality a. Rate per 1,000 births *A
premature
baby
is
one
which
101'
28
98
_--__--
--._-
33
40
27
32
39
.(I:!
26
31
33
I
1
i
:‘ 11 93 ‘13
1
2
1
10
betwem
Ai>
37 “7 21
l.MW
2.?
3i “9
(1
91 XI s 2 I I ., ; 1 4 43
weighs
--
35 33
r,
‘>
9
:,a
33
20 ti I I 0 0 0 0 1 37
‘7s n 1 0 1 ., i I 3 90
33 t’ 0 (I (1 n I1 (1 0 1)
and
2,RW
grams
at
birth.
The quest,ion of therapeutic abortion is one which has caused considerable discussion and one about which there appears to be marked difference of opinion among both obstetricians and cardiologjsts. Reports from well-arganizsd and generally recognized clinics report an incidence of t,herapeutic abortion varying from zero per cent to a figure so high that it seems ext,remely radical. For example there is a report of one ,clinic in which more t-ha,n 16 per rent of a-11 the therapeutic abortions were done for this indication. It is admitted that the risk of a pregnancy added to a sevc>rcheart disease is great and that these women would without doubt be better off if pregnancy had not occurred. But, faced with the fact of a pregnancy, it is difficult to decide in the individual case whether therapeutic abartion increases greatly the life expectancy. Individual cases should not be used to prove or disprove statements, but the history of one patient under the care of one of us is father interest.lng in this regard. from
A X-year-old t,mo well-trained
woman, para cardiologists
1-O-O-l that
was her
Been early pregnancy
in pregnancy be interrupted
with recommendations because of Grade
IV
Volume 61 Number 2
CARDIAC
PATIENT
IN
375
PREGNANCY
heart disease (rheumatic). Her first pregnancy had been conducted without great difficulty and without decompensation. It terminated in delivery from below about 18 months prior to the onset of the present pregnancy. Since this delivery there had been 2 episodes of severe decompensation, from which recovery was quite prolonged. It was the opinion of the cardiologist who had watched her through her first pregnancy that her cardiac status had definitely worsened. A therapeutic abortion was done and the patient made an uneventful recovery, remaining in the hospital 14 days after operation. (This patient was treated after the period c:overed by this report.) About 3 months later, or when she would have been some 18 to 20 weeks pregnant, she developed a respiratory infection, with decompensation, and died. Had the pregnancy been allowed to continue, it would almost certainly have been considered a main contributing factor in her death.
In the five-year period under consideration pregnancy was interrupted once for heart disease, this being in a patient with an advancement to Grade IV, seen early in her pregnancy. The operation was done on the definite recommendation of the cardiac consultant, was followed later by tubal ligation, and was without incident. In this same period 21 therapeutic abortions were done for various indications., an incidence of 4.7 per cent of all therapeutic abort,ions being done for heart disease. In order properly to evaluate this rather conservative policy as regards therapeutic abortion a complete follow-up report of these 88 patients should be available. Unfortunately this could not be obtained, since many of them belonged to the clinic group who moved frequentlv and without leaving forwarding addresses. Others were transients, living in Baltimore under war conditions, and returning to their homes later. If the 4 maternal deaths are studied from this angle it might be claimed that in one of them (No. 3 summarized below) death might not have occurred had the pregnancy been terminated in the very early weeks. On the other hand, it can be argued that if the patient had sought care early in pregnancy and had she been treated properly, she would most likely have had a successful termination of the pregnancy. While it is our conviction that abortion is indicated only in rare instances and then only when done at the optimum time, we feel rather strongly that a number of these patienis should have no further pregnancies, and a number of them are offered and accept sterilization. These are summarized in Table V. The data presented here are not remarkable and require little comment. One fact of some interest is that the procedure accompanied section four times. TABLE
CARDIACCLASS
Class Class Class Class
Class Class class
TOTALNO. STERILIZATIONS
STERILIZATION TOTALNO. INEACIICASE
% OF STERILIZATIONS
I
6
48
12. .5
3 7 2
25 12
12.0
service service
CARDIACCLASS
-Class
POSTPARTUM
II III IV
SOURCE
White Negro Private
V.
I II 111 IV
TOTALNO. 4 4
10 ACCOMPANYING SECTION
54.5 16.3
13 POMEROY P.P. 2 4 7 WHITE
ACCOMPANYING SECTION
X-RAY
i 3
ii 0
NEGRO
PRIVATE
1 1 0
0 0 0
0 0 0
1 1
2
1
0
n
i
.Abdominal delivery was considered necessary ‘i times in this group of 88 women ; however, heart disease i&elf was not among the indications. Contracted pelvis necessitated the operation in 2 instances, pre-eclampsia, breech presentation, and congenital anomalies of the vagina and cervix once each, while one was a post-mortem section. The final abdominal delivery was 1~~ laparot,omy for rupture of a. previous s&ion scar. The treatment was repair of the rent. and sterilization. There has been a good deal of discussion between the cardiologists and the obstetricians as t,o the optimum time in the puerperiurn to sterilize these individuals. Were we always to follow the generallp recommended procedure oF waiting three to six months, many of our patients would not be sterilized. Either they would refuse t,o re-enter the hospital or they would a.gain be pregnant. Therefore, it has been our general practice to observe these patients for two weeks after delivery, and if they show no evidence of decompensation to sterilize them at this time. If the paGent happens to fall in the category of (‘lass IV, this routine is a.bantloned and I he t,hrctt to six mont,hs’ rule is enforced. This routine has been in effect for longer than the five-year period being reported, and up to the present has cbaused neither mortality or decompensation. It should be added that, in each instance the patient is cvaluat,ed by the cardiologist prior to operat,ion and his consent obtained. There did occur one instanc!e in whic+h the above prec%iutitJllS were not, followed, t,he patient, being sterilized on the third postpartum day. (See summaries of maternal deaths.‘! Fetal RfisuZfs.---There were 93 viable babies born in this series (one set of Iwins‘). Of this number 91 were born alive. The 2 stillborn infants were those of (li a patient who died undelivered and upo~l whom a post-mortem section was done and of (2) a patient in whom the fetal heartbeat was absent prior to the onset of labor. There were 2 neonatal deaths, one from prematurity, and one from a proba.ble cerebra,1 injury at birt,h. This gives us ;I total fetal mortality of 4. or a rate of 43 per 1,000 viable births. Maternal Mortal&--There were 4 deaths among these SS women or 98 pregnancies. On the former basis t,he rate is 4.42 per cent and on the latter 4.08 per cent. On the usual basis of li\r birt,hs, the mortality rate is 43.9 per 1,000. The over-all rate for the clinic for the same period was 2.13 per 1,000 live births. This indicates the seriousness of heart disease to the pregnant woman ; in this report the risk appears to he more than 20 times as great,. A summary OF these 4 deaths follows : t !ASR I.----I,. IV.. No. 60549, a l-1.year-old. para 4-O-I)-+, 3 an arlmi tteti f.ti th hospitw I Feb. 25, 1942, in the last trimester of pregnancy, having been referred by her family physician because of hypertension, orthopnea, and blurring of vision. Her past history was negative for hypertension or symptoms of heart disease until the present pregnancy. She reported to her physician for the first time in this pregnancy about 2 months prior to admission to the hospital. We were told that her blood pressure at this time was 185 (diastolic not given). She was not seen again until the day of admission. When she enteqed the hospital her blood pressure was 206/126 and she presented the typical picture of severe hypertensive cardiovascular disease with pronounced decompensation. Under very vigorous txeatment she gradually improved to the point where she was allowed out of bed for! short intervals. On March 31, 1942, about five weeks after entering the hospital, she went into spontaneous labor and 1. hour and 20 minutes later delivered without assistance :L full-term dad male child, weighing 3,150 grams. The patient withstuotl labor very well and did nicely for the first eleven days. However, on the twelfth postpartum day she suffered a cerebral accident, I&ath occ~urred t\vo days lttf PT. resulting in a right-sided1 hemiptegia.
Volume 61 Number2
CARDIAC
PATIENT
IN
377
PREGNANCY
Comment: This is not in its strictest sense a death from cardiac disease, but is included Is it a preventable death? One may because of the severe decompensation on admission. well doubt that she had developed such a severe hypertensive disease during this pregnancy. Had the condition been recognized, and had she received proper treatment, including prevention of pregnancy, it might be that she would have lived for some years longer. The treatment Certainly a patient as ill as at the hands of her family physician seems open to criticism. she was when first seen deserved much more care and attention than she received. After Altogether it admission to the hospital she appeared to have been treated rather well. would seem that this was a preventable death. CASE 2.-P. T., No. 67985, a 30-year-old, Negro, para 5-1-l-4, was admitted Dec. 10, Past history was negative from cardiac standpoint. 1943, from the outpatient department. A heart murmur was heard in the prenatal clinic and the patient referred to a cardiac consultant. Diagnosis : functional murmur. She was admitted with severe upper respiratory infection and apparent cardiac failure. The opinion of medical consultant was that the heart condition was probably on a syphilitic basis. Labor began spontaneously Dec. 12, 1943; a full-term living child was delivered spontaneously after a total labor of 4Q hours, with no analgesia or anesthesia. The patient died two hours post partum. No autopsy was performed. The apparent causes of death were diffuse bronchiolitis, severe toxemia from infection, and cardiac failure. Comment: While not directly resonsible for the death of this patient, it must be admitted that the failure of the cardiac consultant to recognize the cause of the heart murmur Had everyone been when she was seen by him early in pregnancy was a contributing factor. aware of the true nature of the condition, she would have been watched more closely, and might have reported earlier with the respiratory infection. This can be only a postulation in this case, however, and it is likely that this would not be classified as a preventable death. CASE 3.-L. M., No. 73346, a 23-year-old, Negro, para 4-O-O-4, was admitted to the medical service from the cardiac clinic June 30, 1944, because of severe decompensation. She gave a very vague history of swelling of the right knee as a child, otherwise her early medical history was noncontributory. The cardiac condition first became apparent in January of 1943, several months after the birth of her last ehild. She was admitted to the medical service July 21, 1943, with a diagnosis of rheumatic heart disease, Grade IV accompanied by decompensation and fibrillation. Under routine treatment there was gradual improvement The last menstrual period was Dec. 15, 1943. She and she was discharged Dec. 14, 1943. was follow&i in the cardiac clinic, but did not mention the possibility of pregnancy until the last visit on the day of admission. Decompensation was well established at this time. The usual treatment was instituted and it was planned that she would remain in hospital until after delivery. On July 26, 1944, after about one month of hospitalization, she complained of sudden shortness of breath and fell back in bed dead. By post-mortem section, a premature dead child, weight 2,268 grams, was delivered. Autopsy showed scarring of mitral valve, chronic passive congestion. Comment : While it is true that this patient should not have died at this time, it is difficult to place the blame on any one person. Had it been realized by the medical service when she was in the hospital in 1943 that she would become pregnant as soon as discharged, and had she been sterilized at that time, the result might have been delayed. Again, therapeutic abortion or more intensive treatment early in pregnancy might also have lengthened her life somewhat. The failure of the patient to report the pregnancy was prohably a contributory factor. If this is to be classified as a preventable death, it would appear that the responsibility rests largely with the patient herself. CASE
I.-c.
H.,
NO.
13038,
a
mitted June 1, 1945, in active labol(. 8 years, followed by joint involvement, terminated at term 5% years prior
31-year-old,
white,
Past history and rheumatic to admission.
pdra
was
l-o-O-1,
privdte
pdtient,
1~:~s a(]-
positive for scarlet fever at age of fever at age 24. Her first pregnancy The heart disease was present at that
In defense il might IW stat& tllnt 111~ I)cCocI cove~r~d by this report ~-as during the war, when personnel was Iwkin g and demand exceedingly heavy. The house officers were frequently c>hanped and facilities for their instruction were none too good. Time was a most acute factor. What lesson may IN learned from Ihis study:’ Prol)ahly 1.1~ lwincipal C)JIC is that, the cardiac patienl during pregt1aw.v is most unpredictable and requires extremely close supervision, careful evalnation, and prompt. treatment.
II.
M.D.,
DOUGLASS,
BALTIMORE,
MD.,
(From
the Department
of
AND
L.
LORMAN
M.D.,
HOOPES,
D. C.
WASHINGTON, Obstetrics,
University
of Maryland
Hospital)
UCH has been written about this subject by those who have made detailed studies of the associated conditions, and there are on record excellent recommendations, rules, and regulations for the care of this group. It is felt that any statements of this nature made here would be useless repetition. But for purposes of comparison, our experience and results should be of some value and it is with this idea in mind that this report is being made.
M
Material The period covered is five years, from Jan. 1, 1942, through Dec. 31, 1946, during which 13,908 patients were delivered and discharged from the Obstetrical Service of the University Hospital, Baltimore, Maryland. Of these, 88 were classified as having heart disease of varying severity. Ten were delivered twice in the five-year period, so that we actually treated 98 patients, an incidence of 0.71 per cent. This is considerably smaller than is generally reported, and may in part be due to the fact that the incidence of heart disease in this community is somewhat lower than in other centers. TABLE CARDlAG CLASSIFICATION Class I Class II Class III Class IV Total Patients delivered Incidence
1942 13 7 2 7 29 2,991
1943 10 6 3 0 19 2,960
0.97%
0.6470
I 1944
1945
9 5 1 1 16 2,960
4 4 4 4 16 2,312
0.54% TABLE
ii&ON
/ Class Class Class Class Total
I II III IV
;;z
( 25 ii 31
0.69%
TOTAL 48 25 12 13 98 13,908 0.71y&*
0.67yo
II
PIUMIPPbR;T:ULTIP. 20 28 12 13 3 9 4 9 39 59 373
1946 12 3 2 1 18 2,685
1
PRIVATE 23 8 5 6 42
)
CLINIC 25 17 7 7 56
/
TOTAL 48 25 12 13 98
Tables 1, II, and III give some pertinent data about the classification of the heart disease, the parity, and t,he ages of these 88 women. They require no particular comment. Table IV is an effort to summarize the results of the 98 deliveries of the group. Many of the pertinent facts will be found here. whkh will he elaborated upon and further facts brought out later.
SUMMARY
___
...- ---_ -.“-
1. Number of patixdischargetl 2. Number of patients delivered and discharged (twins 2 sets) a. Patients delivered of viable infants (twins 1 set) h. Patients aborting (twins 1 set) 3. Maternal mortality a. Rate per 1,000 live births 4. Number of viable babies born a. Term h. Premature” 5. Number of living babies a. Term 1). Prema.ture’ A. Number of slillhirths a. Term h. Premature” 7. Number of neonatal deaths a. Term h. Premat~urc” 8. Total fetal mortality a. Rate per 1,000 births *A
premature
baby
is
one
which
101'
28
98
_--__--
--._-
33
40
27
32
39
.(I:!
26
31
33
I
1
i
:‘ 11 93 ‘13
1
2
1
10
betwem
Ai>
37 “7 21
l.MW
2.?
3i “9
(1
91 XI s 2 I I ., ; 1 4 43
weighs
--
35 33
r,
‘>
9
:,a
33
20 ti I I 0 0 0 0 1 37
‘7s n 1 0 1 ., i I 3 90
33 t’ 0 (I (1 n I1 (1 0 1)
and
2,RW
grams
at
birth.
The quest,ion of therapeutic abortion is one which has caused considerable discussion and one about which there appears to be marked difference of opinion among both obstetricians and cardiologjsts. Reports from well-arganizsd and generally recognized clinics report an incidence of t,herapeutic abortion varying from zero per cent to a figure so high that it seems ext,remely radical. For example there is a report of one ,clinic in which more t-ha,n 16 per rent of a-11 the therapeutic abortions were done for this indication. It is admitted that the risk of a pregnancy added to a sevc>rcheart disease is great and that these women would without doubt be better off if pregnancy had not occurred. But, faced with the fact of a pregnancy, it is difficult to decide in the individual case whether therapeutic abartion increases greatly the life expectancy. Individual cases should not be used to prove or disprove statements, but the history of one patient under the care of one of us is father interest.lng in this regard. from
A X-year-old t,mo well-trained
woman, para cardiologists
1-O-O-l that
was her
Been early pregnancy
in pregnancy be interrupted
with recommendations because of Grade
IV
Volume 61 Number 2
CARDIAC
PATIENT
IN
375
PREGNANCY
heart disease (rheumatic). Her first pregnancy had been conducted without great difficulty and without decompensation. It terminated in delivery from below about 18 months prior to the onset of the present pregnancy. Since this delivery there had been 2 episodes of severe decompensation, from which recovery was quite prolonged. It was the opinion of the cardiologist who had watched her through her first pregnancy that her cardiac status had definitely worsened. A therapeutic abortion was done and the patient made an uneventful recovery, remaining in the hospital 14 days after operation. (This patient was treated after the period c:overed by this report.) About 3 months later, or when she would have been some 18 to 20 weeks pregnant, she developed a respiratory infection, with decompensation, and died. Had the pregnancy been allowed to continue, it would almost certainly have been considered a main contributing factor in her death.
In the five-year period under consideration pregnancy was interrupted once for heart disease, this being in a patient with an advancement to Grade IV, seen early in her pregnancy. The operation was done on the definite recommendation of the cardiac consultant, was followed later by tubal ligation, and was without incident. In this same period 21 therapeutic abortions were done for various indications., an incidence of 4.7 per cent of all therapeutic abort,ions being done for heart disease. In order properly to evaluate this rather conservative policy as regards therapeutic abortion a complete follow-up report of these 88 patients should be available. Unfortunately this could not be obtained, since many of them belonged to the clinic group who moved frequentlv and without leaving forwarding addresses. Others were transients, living in Baltimore under war conditions, and returning to their homes later. If the 4 maternal deaths are studied from this angle it might be claimed that in one of them (No. 3 summarized below) death might not have occurred had the pregnancy been terminated in the very early weeks. On the other hand, it can be argued that if the patient had sought care early in pregnancy and had she been treated properly, she would most likely have had a successful termination of the pregnancy. While it is our conviction that abortion is indicated only in rare instances and then only when done at the optimum time, we feel rather strongly that a number of these patienis should have no further pregnancies, and a number of them are offered and accept sterilization. These are summarized in Table V. The data presented here are not remarkable and require little comment. One fact of some interest is that the procedure accompanied section four times. TABLE
CARDIACCLASS
Class Class Class Class
Class Class class
TOTALNO. STERILIZATIONS
STERILIZATION TOTALNO. INEACIICASE
% OF STERILIZATIONS
I
6
48
12. .5
3 7 2
25 12
12.0
service service
CARDIACCLASS
-Class
POSTPARTUM
II III IV
SOURCE
White Negro Private
V.
I II 111 IV
TOTALNO. 4 4
10 ACCOMPANYING SECTION
54.5 16.3
13 POMEROY P.P. 2 4 7 WHITE
ACCOMPANYING SECTION
X-RAY
i 3
ii 0
NEGRO
PRIVATE
1 1 0
0 0 0
0 0 0
1 1
2
1
0
n
i
.Abdominal delivery was considered necessary ‘i times in this group of 88 women ; however, heart disease i&elf was not among the indications. Contracted pelvis necessitated the operation in 2 instances, pre-eclampsia, breech presentation, and congenital anomalies of the vagina and cervix once each, while one was a post-mortem section. The final abdominal delivery was 1~~ laparot,omy for rupture of a. previous s&ion scar. The treatment was repair of the rent. and sterilization. There has been a good deal of discussion between the cardiologists and the obstetricians as t,o the optimum time in the puerperiurn to sterilize these individuals. Were we always to follow the generallp recommended procedure oF waiting three to six months, many of our patients would not be sterilized. Either they would refuse t,o re-enter the hospital or they would a.gain be pregnant. Therefore, it has been our general practice to observe these patients for two weeks after delivery, and if they show no evidence of decompensation to sterilize them at this time. If the paGent happens to fall in the category of (‘lass IV, this routine is a.bantloned and I he t,hrctt to six mont,hs’ rule is enforced. This routine has been in effect for longer than the five-year period being reported, and up to the present has cbaused neither mortality or decompensation. It should be added that, in each instance the patient is cvaluat,ed by the cardiologist prior to operat,ion and his consent obtained. There did occur one instanc!e in whic+h the above prec%iutitJllS were not, followed, t,he patient, being sterilized on the third postpartum day. (See summaries of maternal deaths.‘! Fetal RfisuZfs.---There were 93 viable babies born in this series (one set of Iwins‘). Of this number 91 were born alive. The 2 stillborn infants were those of (li a patient who died undelivered and upo~l whom a post-mortem section was done and of (2) a patient in whom the fetal heartbeat was absent prior to the onset of labor. There were 2 neonatal deaths, one from prematurity, and one from a proba.ble cerebra,1 injury at birt,h. This gives us ;I total fetal mortality of 4. or a rate of 43 per 1,000 viable births. Maternal Mortal&--There were 4 deaths among these SS women or 98 pregnancies. On the former basis t,he rate is 4.42 per cent and on the latter 4.08 per cent. On the usual basis of li\r birt,hs, the mortality rate is 43.9 per 1,000. The over-all rate for the clinic for the same period was 2.13 per 1,000 live births. This indicates the seriousness of heart disease to the pregnant woman ; in this report the risk appears to he more than 20 times as great,. A summary OF these 4 deaths follows : t !ASR I.----I,. IV.. No. 60549, a l-1.year-old. para 4-O-I)-+, 3 an arlmi tteti f.ti th hospitw I Feb. 25, 1942, in the last trimester of pregnancy, having been referred by her family physician because of hypertension, orthopnea, and blurring of vision. Her past history was negative for hypertension or symptoms of heart disease until the present pregnancy. She reported to her physician for the first time in this pregnancy about 2 months prior to admission to the hospital. We were told that her blood pressure at this time was 185 (diastolic not given). She was not seen again until the day of admission. When she enteqed the hospital her blood pressure was 206/126 and she presented the typical picture of severe hypertensive cardiovascular disease with pronounced decompensation. Under very vigorous txeatment she gradually improved to the point where she was allowed out of bed for! short intervals. On March 31, 1942, about five weeks after entering the hospital, she went into spontaneous labor and 1. hour and 20 minutes later delivered without assistance :L full-term dad male child, weighing 3,150 grams. The patient withstuotl labor very well and did nicely for the first eleven days. However, on the twelfth postpartum day she suffered a cerebral accident, I&ath occ~urred t\vo days lttf PT. resulting in a right-sided1 hemiptegia.
Volume 61 Number2
CARDIAC
PATIENT
IN
377
PREGNANCY
Comment: This is not in its strictest sense a death from cardiac disease, but is included Is it a preventable death? One may because of the severe decompensation on admission. well doubt that she had developed such a severe hypertensive disease during this pregnancy. Had the condition been recognized, and had she received proper treatment, including prevention of pregnancy, it might be that she would have lived for some years longer. The treatment Certainly a patient as ill as at the hands of her family physician seems open to criticism. she was when first seen deserved much more care and attention than she received. After Altogether it admission to the hospital she appeared to have been treated rather well. would seem that this was a preventable death. CASE 2.-P. T., No. 67985, a 30-year-old, Negro, para 5-1-l-4, was admitted Dec. 10, Past history was negative from cardiac standpoint. 1943, from the outpatient department. A heart murmur was heard in the prenatal clinic and the patient referred to a cardiac consultant. Diagnosis : functional murmur. She was admitted with severe upper respiratory infection and apparent cardiac failure. The opinion of medical consultant was that the heart condition was probably on a syphilitic basis. Labor began spontaneously Dec. 12, 1943; a full-term living child was delivered spontaneously after a total labor of 4Q hours, with no analgesia or anesthesia. The patient died two hours post partum. No autopsy was performed. The apparent causes of death were diffuse bronchiolitis, severe toxemia from infection, and cardiac failure. Comment: While not directly resonsible for the death of this patient, it must be admitted that the failure of the cardiac consultant to recognize the cause of the heart murmur Had everyone been when she was seen by him early in pregnancy was a contributing factor. aware of the true nature of the condition, she would have been watched more closely, and might have reported earlier with the respiratory infection. This can be only a postulation in this case, however, and it is likely that this would not be classified as a preventable death. CASE 3.-L. M., No. 73346, a 23-year-old, Negro, para 4-O-O-4, was admitted to the medical service from the cardiac clinic June 30, 1944, because of severe decompensation. She gave a very vague history of swelling of the right knee as a child, otherwise her early medical history was noncontributory. The cardiac condition first became apparent in January of 1943, several months after the birth of her last ehild. She was admitted to the medical service July 21, 1943, with a diagnosis of rheumatic heart disease, Grade IV accompanied by decompensation and fibrillation. Under routine treatment there was gradual improvement The last menstrual period was Dec. 15, 1943. She and she was discharged Dec. 14, 1943. was follow&i in the cardiac clinic, but did not mention the possibility of pregnancy until the last visit on the day of admission. Decompensation was well established at this time. The usual treatment was instituted and it was planned that she would remain in hospital until after delivery. On July 26, 1944, after about one month of hospitalization, she complained of sudden shortness of breath and fell back in bed dead. By post-mortem section, a premature dead child, weight 2,268 grams, was delivered. Autopsy showed scarring of mitral valve, chronic passive congestion. Comment : While it is true that this patient should not have died at this time, it is difficult to place the blame on any one person. Had it been realized by the medical service when she was in the hospital in 1943 that she would become pregnant as soon as discharged, and had she been sterilized at that time, the result might have been delayed. Again, therapeutic abortion or more intensive treatment early in pregnancy might also have lengthened her life somewhat. The failure of the patient to report the pregnancy was prohably a contributory factor. If this is to be classified as a preventable death, it would appear that the responsibility rests largely with the patient herself. CASE
I.-c.
H.,
NO.
13038,
a
mitted June 1, 1945, in active labol(. 8 years, followed by joint involvement, terminated at term 5% years prior
31-year-old,
white,
Past history and rheumatic to admission.
pdra
was
l-o-O-1,
privdte
pdtient,
1~:~s a(]-
positive for scarlet fever at age of fever at age 24. Her first pregnancy The heart disease was present at that
In defense il might IW stat& tllnt 111~ I)cCocI cove~r~d by this report ~-as during the war, when personnel was Iwkin g and demand exceedingly heavy. The house officers were frequently c>hanped and facilities for their instruction were none too good. Time was a most acute factor. What lesson may IN learned from Ihis study:’ Prol)ahly 1.1~ lwincipal C)JIC is that, the cardiac patienl during pregt1aw.v is most unpredictable and requires extremely close supervision, careful evalnation, and prompt. treatment.