Recall ( By Dr.

Neeta)
Preconception counseling for 32 year old who has a
Valve replacement at 9 years of age due to aortic stenosis
She has been on warfarin current INR 3.5 .she is a smoker
BMI of 36

 Introduction
 Make agenda
 Concerns ,expectations

Information gathering
History:
 Time since diagnosed with this heart problem
 Symptoms at the time of diagnosis
 Review of surgery notes
 How was recovery,any complications
 What treatment taking now
 How does it affect ur life
 How well is it controlled
 Who looks after you
 How is your health in general
 Last visit to cardiologist,any tests (ecg ,echo) performed
 Ay recent admission
 Have you been pregnant before if yes mode of delivery,any
 Complications during or after delivery,history of heart disease
 In her baby
 Any other medical condition followed by GP
 Any other surgery
 Family history of cardiac problem
 Menstrual /cervical smear history /contraception
 No of cigarette she is smoking/offer NHS smoking cessation
 Alcohol/recreational drug abuse
 What do u do for living
 Support at home /partner support
 Drug allergies
Summarize
Examination (chaperone) ,check investigations (recent echo,
INR)
Communication with patient
 Patient and partner debriefing about the condition
 Prognosis and effect on pregnancy
 Need for frequent visits if pregnant
Communication with colleagues
 Involve cardiologist,obstetrician,anesthetist,midwife
 Make a well organized plan of care
Applied clinical knowledge
Preconception
 MDA
  Tell about that optimization of condition associated with
Healthy pregnancy
 If disease not controlled offer contraception till controlled
 As disease is well controlled (INR controlled)reassure about
Outcome
 Optimize BMI (increase complications with Increased BMI
 During pregnancy as well as delivery)
 Smoking cessation
 Folic acid 5mg 3 months prior to conception
 Review medication
 Rubella titter
 As pregnancy is a hypercoagulable state condition may get worse once pregnant
 Although taking warfarin,risk of getting blood clots will increase
 About warfarin medication will be discussed in MDT whether this will be changed on first period
Of fetal development or not as warfarin associated with high risk of fetal loss and fetal defects )
Antenatal
 MDA
 Need for booking early in consultant led unit
 Folic acid 5mg
 Dating scan /screening for Down syndrome
 Detailed anomaly scan including echocardiography of baby
 Serial growth scans for baby
 If decision made for continue warfarin throughout pregnancy it will be stopped at 38 weeks and
Substitute with lmwh and lmwh stopped once in labor or if decision for induction or elective cs
Stop lmwh 12 hrs before
 Vaginal delivery not contraindicated if no other comorbidity
 Discuss about analgesia /anesthesia
Intrapartum
 Avoid fluid depletion and hypotension
 Left lateral position (avoid postural hypotension )
 Avoid bolus dose of oxytocin at time of delivery
 If pph (early recourse to bimanual compression and misoprostol)
Postpartum
 Warfarin can be switched over 3-5 days after delivery
 Assess thromoprophylaxis
 Contraception
 Follow up with cardiologist
Safety points
 Involvement of consultant
 Debriefing
 Drug allergies
 Smoking cessation
 Warfarin Safe in breastfeeding