Maternity Medicine Network

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vivamus lorem dolor, tincidunt a nunc ac, venenatis bibendum velit. Ut tincidunt efficitur nunc hendrerit dapibus. Nunc rhoncus quis lectus et mattis. Ut malesuada eu dignissim. Nulla eget nisl semper sapien dapibus fringilla.

Cardiology

  mWHO I mWHO II mWHO II-III mWHO III mWHO IV
Diagnosis (if
otherwise well and
uncomplicated)

Small or mild

– pulmonary stenosis

– patent ductus arteriosus

– mitral valve prolapse

Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage) Atrial or ventricular ectopic beats isolated

Unoperated atrial septal or ventricular defect

Repaired tetralogy of Fallot

Most arrhythmias (supraventricular arrhythmias)

Mild left ventricular impairment (EF >45%)

Hypertrophic cardiomyopathy

Native or tissue valve disease not considered WHO I or IV (mild mitral aortic stenosis)

Marfan or other HTAD syndrome without aortic dilatation

Aorta <45 mm in bicuspid aortic valve pathology

Repaired coarctation Atrioventricular septal defect

Turners Syndrome

All channelopathies (event rate not applicable)

Moderate left ventricular impairment (EF 30-45%)

Previous peripartum cardiomyopathy without any residual impairment of left ventricular function

Systemic right ventricle with good or mildly decreased ventricular function

Fontan circulation. If otherwise the patient is well and the cardiac condition uncomplicated

Unrepaired cyanotic heart disease

Other complex heart disease

Moderate mitral stenosis

Severe asymptomatic aortic stenosis

Moderate aortic dilatation

Ventricular tachycardia

Pulmonary arterial hypertension (managed in Sheffield PH service)

Severe left ventricular dysfunction (EF <30% or NYHA class III-IV)

Previous peripartum cardiomyopathy with any residual left ventricular impairment

Severe mitral stenosis

Severe symptomatic aortic stenosis

Systemic right ventricle with moderate or severely decreased ventricular function

Severe aortic dilatation

Vascular Ehlers-Danlos

Severe (re)coarctation Fontan with any complication

Mechanical valve

Risk No detectable increased risk of maternal mortality and no/mild increased risk in morbidity Small increased risk of maternal mortality or moderate increase in morbidity Intermediate increased risk of maternal mortality or moderate to severe Significantly increased risk of maternal mortality or severe Extremely high risk of maternal mortality or severe
Maternal cardiac event
rate
2.5-5% 5.7-10.5% 10-19% 19-27% 40-100%
Pre-pregnancy
Counselling
Optional- local unit Yes-local unit Yes- local unit Yes: expert counselling
required
Yes: expert counselling
required
Care during pregnancy At the Local hospital. If there are concerns, or a lack of expertise or timely review in the local hospital, refer to the obstetric cardiology clinic at the local MMC forreview or advice. At the Local hospital. If there are concerns, or a lack of expertise or timely review in the local hospital, refer to the obstetric cardiology clinic at the local MMC for review or advice. Refer to the Obstetric Cardiology Clinic at the local MMC for MDT consideration about where antenatal care and delivery is most appropriately located irrespective of where they usually attend for their cardiac care. For some women, delivery may be appropriate in their local unit. Refer to the Obstetric Cardiology Clinic at the local MMC for MDT consideration about where antenatal care and delivery is most appropriately located irrespective of where they usually attend for their cardiac care.

Refer to the Obstetric Cardiology Clinic at their local MMC for regional MDT discussion and decision about transfer of antenatal care and delivery.

Pulmonary Hypertension cases discussed in MMC MDT -managed in Sheffield PH Service

Minimal follow-up visits
during pregnancy
Once or twice Once per trimester Bimonthly Monthly or Bimonthly Monthly
Location of delivery Local hospital Local Hospital or Individualised assessment after MDT review Individualised assessment after MDT review Expert centre for pregnancy and cardiac disease as decided at MMC MDT review Expert centre for pregnancy and cardiac disease as decided at MMC MDT or Regional MDT
Diagnosis (if otherwise well and uncomplicated)
Risk
Maternal cardiac event rate
Pre-pregnancy Counselling
Care during pregnancy
Minimal follow-up visits during pregnancy
Location of delivery
mWHO I
Small or mild
  • pulmonary stenosis
  • patent ductus arteriosus
  • mitral valve prolapse
  • Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage) Atrial or ventricular ectopic beats isolated
No detectable increased risk of maternal mortality and no/mild increased risk in morbidity
2.5-5%
Optional - local unit
At the Local hospital. If there are concerns, or a lack of expertise or timely review in the local hospital, refer to the obstetric cardiology clinic at the local MMC for review or advice.
Once or twice
Local hospital
mWHO II

Unoperated atrial septal or ventricular defect

Repaired tetralogy of Fallot

Most arrhythmias (supraventricular arrhythmias)

Small increased risk of maternal mortality or moderate increase in morbidity
5.7-10.5%
Yes-local unit
At the Local hospital. If there are concerns, or a lack of expertise or timely review in the local hospital, refer to the obstetric cardiology clinic at the local MMC for review or advice.
Once per trimester
Local Hospital or Individualised assessment after MDT review
”mWHO
mWHO III

Moderate left ventricular impairment (EF 30-45%)

Previous peripartum cardiomyopathy without any residual impairment of left ventricular function

Systemic right ventricle with good or mildly decreased ventricular function

Fontan circulation. If otherwise the patient is well and the cardiac condition uncomplicated

Unrepaired cyanotic heart disease

Other complex heart disease

Moderate mitral stenosis

Severe asymptomatic aortic stenosis

Moderate aortic dilatation

Ventricular tachycardia

Significantly increased risk of maternal mortality or severe
19-27%
Yes: expert counselling required
Refer to the Obstetric Cardiology Clinic at the local MMC for MDT consideration about where antenatal care and delivery is most appropriately located irrespective of where they usually attend for their cardiac care.
Monthly or Bimonthly
Expert centre for pregnancy and cardiac disease as decided at MMC MDT review
mWHO IV

Pulmonary arterial hypertension (managed in Sheffield PH service)

Severe left ventricular dysfunction (EF <30% or NYHA class III-IV)

Previous peripartum cardiomyopathy with any residual left ventricular impairment

Severe mitral stenosis

Severe symptomatic aortic stenosis

Systemic right ventricle with moderate or severely decreased ventricular function

Severe aortic dilatation

Vascular Ehlers-Danlos

Severe (re)coarctation Fontan with any complication

Mechanical valve

Extremely high risk of maternal mortality or severe
40-100%
Yes: expert counselling required

Refer to the Obstetric Cardiology Clinic at their local MMC for regional MDT discussion and decision about transfer of antenatal care and delivery.

Pulmonary Hypertension cases discussed in MMC MDT -managed in Sheffield PH Service

Monthly
Expert centre for pregnancy and cardiac disease as decided at MMC MDT or Regional MDT

Gastroenterology and Liver

Complex inflammatory bowel disease:
  • Active disease despite treatment
  • Biologics
  • Corticosteroids
  • Peri-anal disease
  • Pouch/stoma
Acute and chronic pancreatitis
Treated GI malignancy
Unexplained jaundice
Acute fatty liver of pregnancy
Achalasia
Intrahepatic cholestasis (bile acids ≥100)
Liver infarction/haematoma
Autoimmune hepatitis Wilson’s disease
Crigler Najjar syndrome Primary biliary cirrhosis
Primary sclerosing cholangitis
Portal hypertension
Complex pancreatitis
  • Not responding to treatment
  • Recurrent disease
  • Hypertriglyceridaemia
  • IR/surgical intervention
Active malignancy
Cirrhosis
Decompensated liver disease/liver failure*
Liver transplant

Diabetes

Gestational diabetes mellitus
Type I and II diabetes mellitus without complications or comorbidities
”Diabetic
”Diabetic