Table 6.

Valvular heart diseases (VHD) and infective endocarditis (IE) in obstetric ICU

SI. No.	Condition	Challenges	Management
1	Mitral stenosis (MS)	Mostly rheumatic Low, fixed output Tachycardia detrimental, atrial fibrillation often present, large volume infusion not tolerated, sudden rise in pulmonary vascular resistance (PVR), fall in Systemic vascular resistance (SVR) poorly tolerated, PAH may be present in long-standing cases May present during pregnancy with hemodynamic compromise and CCF	Initiate oxygen therapy/ventilator support early CVP-guided fluid administration Avoid tachycardia, vasodilation, hypoxia, hypercarbia, acidosis Vasoconstrictors to be used with great caution Antibiotic prophylaxis
2	Mitral regurgitation (MR)	May be rheumatic or Mitral valve prolapse (MVP) Eccentric cardiac hypertrophy with poor contractility in long-standing cases, PAH leading to RV dysfunction	Initiate oxygen therapy/ventilator support early CVP-guided fluid administration Avoid tachycardia, vasodilation, hypoxia, hypercarbia, acidosis Vasoconstrictors to be used with great caution Pulmonary vasodilators like phosphodiesterase III inhibitors to manage PAH Antibiotic prophylaxis
3	Aortic stenosis (AS)	Rheumatic or congenital bicuspid aortic valve disease (BAVD) Fixed output state LV hypertrophy may lead to ischemia Bradycardia and junctional rhythm poorly tolerated Sudden vasodilation or myocardial depression may lead to cardiovascular collapse very difficult to resuscitate	Close monitoring of ECG with ST-T changes Control of blood pressure and protection against ischemia with nitrates or NTG infusion Antibiotic prophylaxis They may come to ICU once cardiovascular collapse has occurred and require resuscitation/defibrillation
4	Aortic regurgitation (AR)	Poor myocardial contractility Prone to ventricular arrhythmias, low EF, poor peripheral perfusion	Initiate oxygen/ventilatory management early CVP-guided fluid Inodilators like dobutamine in combination with adrenaline for hemodynamic support May need IABP also
5	Infective endocarditis (IE)	In the acute phase, infective emboli may lodge in various end-arteries of the body leading to infarction in vital organs (lung, kidney, brain, retina) May rapidly decompensate into severe sepsis	Antibiotic prophylaxis/therapeutic as advised by a cardiologist Ventilatory support, fluid management, inotropic support according to sepsis guidelines
6	Cardiac prosthesis	May be mechanical/bioprosthetic valves, other prosthetic material Patients on anticoagulants which may undergo dose alteration during pregnancy Pregnancy being a hypercoagulable state may cause “stuck valve” especially in the mitral position, formation of atrial thrombi and embolism	Urgent review of coagulation status and referral to cardiologist/cardiothoracic surgery department for definitive management