Heart murmur=IV? Please help urgently!(x-posted from Birth and Beyond)

[beatee]

Wow, I am absolutely distraught.

I have a mild heart murmur that was diagnosed 4 years ago. It has never caused me any problems, I just know that I am supposed to have antibiotics before dental work or some surgical procedures. The heart murmur has been prominently visible in my notes (that every single one of my care providers has seen) throughout my pregnancy, as I mentioned it to my MW when first asked about any pre-exisiting medical conditions. I have been booked for a homebirth with no problems, and told by many midwives that this is OK.
Today, I had to see a consultant at the hospital for confirmation over my dates (my LMP EDD was 12 May, but from the u/s it was 22nd, and for some daft reason nobody bothered to give me a clear confirmation of which one I was 'allowed' to go with, so I've been classed as past term for the last week and a half when I wasn't even 40 weeks. Grr). He was fine with going with the later date, but took one look at the mention of the heart murmur and said that I have to be on an IV in hospital for labour and delivery.

WTF???????????????!

WHY has this not been mentioned to me until AFTER MY DUE DATE. If it's so standard, WHY have none of the people who have seen my notes mentioned it? Heart murmurs aren't that rare, I find it hard to believe that none of the midwives know that you 'have' to have IV antibiotics during labour.

I am beyond livid. He explained the risks of delivery without the antibiotics, which I understand. But I can't find any decent information on the use of antibiotics during labour for heart murmurs, anywhere on the net. Everything just says that it may be necessary to take them before dental work and some surgeries, no mention of birth. Birth is not an abnormal event, surely around 50% of people with heart murmurs will experience it? So why is no mention of it's impact on this made anywhere?

I was very stroppy with him in the appointment. He admitted that they cannot make me come into hospital, but strongly advised that I do. My boyfriend was with me, and is now absolutely terrified of the risks to my health of not getting the antibiotics (especially as they may not be apparent for many years).

I don't know what to do. Going into hospital and being on an IV for the whole of labour means giving up everything I wanted for this birth. As I kind of shouted at the doctor, it may seem like a tiny thing to him but it's a huge thing to me. For 9 months I've been dreaming of a peaceful non medical homebirth, and only prepared to give that dream up in the case of real risk to the baby or me. Now I'm told that there will be a risk to me, but I can't find any decent information on how big that risk is. Every inch of me wants to stay at home, but now I feel like people (my boyfriend) will think I'm taking a stupid risk.

I just can't believe this has been sprung on me now. I am so stressed and upset, I've been crying since we left the hospital. Way to mess with all the birth hormones that should be building up now.

Please please please, does anyone have any advice? Midwives, what are your views on patients with pre existing heart murmurs? Does anyone have any links on studies to do with this?

What the hell do I do now? If I go into labour today or tomorrow, I have no idea whether to stay home or go to hospital and suck it up. This is is so unfair.

[memiles]

Please post the information to the board if anyone has anything to share. I have a client with the same questions.

[debsagos]

Hi Beatee,

shocking that noone has mentioned this before!!!!

I have never encountered a heart murmur that 'required' antibiotix and as far as I'm clinically aware benign heart murmurs rarely carry a particularly large risk without prophylactic abx.....

BUT i can't for the life of me find any good information on this!!!

do your own risk assessment for YOURSELF and if happy with homebirth kindly decline IV prophylaxis and further discussion about it.....then get cocooned up at home and let those birth hormones brew up a lovely birth for you and your babe......all this negativity is not useful at this time....eat well, do some yoga or such....relax and pamper yourself!!

relaxing vibes to you and babe....

debs x

[sevenkids]

Do you have mitral valve prolapse?

Prophylactic antibiotics during labor and birth and c-sections used to be the standard of care for Mitral Valve Prolapse, and still is for dental and peritoneal surgery IF there is pronounced regurgitation, a "click", or thickened valve tissue, or if the patient has had a valve replacement surgery.

It's no longer recommended for labor or c-sections, because there is practically no risk of bacteria entering the blood stream and pooling in the heart chambers unless the woman has a most severe form of MVP.


What your doctor should have done is refer you to a cardiologist to asses the severity of your murmur, and ask the cardiologist if antibiotics are warranted. An OB or a GP is not a cardiologist and cannot decide if you need antibiotics or not.

Next question, have you experienced symptoms, like dizziness, heart palpitations, fainting, cyanosis, severe headaches, anxiety attacks, or chest pains?

[KsMum]

I have MVP with regurgitation, and after meeting with my cardiologist was advised that I needed antibiotics during labour. I do have symptoms of MVP, including fainting, and little heart 'coughs'.
Any chance you can see a cardiologist pronto?

[JillChristina]

My murmur is called Pulmonic Stenosis (dx at birth) and I have always taken antibiotics at dental visits. I did have IV antibiotics at both of my births (OB and CNM attended - in a hospital). This was recommended to me by a cardiologist, OB, and my midwife. But take all that with the grain of salt that I'm sure all of those practictioners are coming from a "better safe than sorry" standpoint. I think it comes down to you examining all of the information and weighing your risks.

Here is a link to a page about bacterial endocarditis: http://www.americanheart.org/present...dentifier=4436

Best of luck to you!
Jill

ETA: After reading that entire AHA article, I'd be tempted not to worry about abx if I were you. Still, consulting with a cardiologist might set your mind more at ease (hopefully). I'm also tempted to stop taking abx *myself* when I go to the dentist!

"Therefore, the current practice of giving patients antibiotics prior to a dental procedure is no longer recommended EXCEPT for patients with the highest risk of adverse outcome resulting from endocarditis."

[Turtlemum]

YOu're right, that should have been caught early in pregnancy (aka the first visit) and a consult with a cardiologist should have been made if a copy of your diagnostic tests were unavailable. If they were available, an ob could let you know what the standard of care is for your heart condition. Where I am antibiotics can be given at home by a midwife, including those for the prevention of endocarditis. In fact it is usually the family doctor that writes the prescription and the the woman fills it and has it on hand for the birth...could the midwives you are with arrange this? Good luck and big hugs.

[beatee]

Thanks for your responses. I have just been to see my GP in the hope that she will refer me to a cardiologist, which she was unwilling to do as she said it was unlikely I could see someone this late on and that they would probably just say the same as the OB.

This is really really frustrating. I probably should have demanded she make an appointment anyway, but I was getting really stressed and upset so thought I should leave it. She did dig out a copy of my original diagnosis, which simply says that I have 'Trivial Mitral Regurgitation' (no mentione of cause), and will need antibiotics before surgery and dental work.

From what I can gather from my frantic, stressed reasearch,protocols on this vary throughout the country. In Leeds, IV antibiotics are standard, and so it is unlikely that any doctor will be willing to diverge from this. However, in other areas of the country it is no longer the protocol and I have managed to get in touch with people who have delivered without abx with consultants blessing. This lack of consistency makes me so furious. However, my instinct is that if there are some places that no longer insist on them, they can't be that necessary.

No alternative to the IV is available on the NHS.

I do not understand why none of the many, many MWs I have seen have picked this up, and it makes me livid. I really think that our system of maternity care is very screwed up. There is just no continuity of care. How on earth can all the doctors at a hospital know about this and none of the Midwives? It's not a rare condition, this makes no sense. Unfortunately, in Britain midwives are pretty much subservient to the OBs, so now that I have this meeting with the OB in my notes, none of them are likely to disagree with him. Everyone just wants to cover their back (but obviously not enough to pick up on it, say, 8 months ago???!!)

However, I still have every right to have my baby at home, and this can't be changed. It's just that now it will be with additional stress and against medical advice. But that medical advice seems out of date and overcautious to me after reading the American Heart Organisation article. My insitincts definitely say to stay at home, but there is a niggling worry that he case of a bad outcome, it will be 100% my fault for being so stubborn.

But the thought of being in hospital on an IV for what may be no good reason other than overcautious protocol makes me sick.

The only good thing to come out my GPs visit this morning was that she will be bringing it up as a 'significant event' (ie failing) at the practice meeting, as it should have been noticed and addressed by MWs way way back. But then I worry that this will just lead to them being even more over cautious, and unlikely to go along with homebirths. Still, it's just unacceptable that this hasn't been picked up by anyone until after my due date.

I am still trying to make my mind up, which is really hard to do. I so so want to stay at home, but I do worry about making a foolhardy decision based on information I can find on the internet over that from the doctor (probably only because of the attitudes of those around me that 'doctor knows best'.) I don't think any of the doctors have an inkling of what a huge impact being in hospital and on an IV will have on my birth, and therefore cannot see any disadvantages in recommending this 'to be on the safe side'.

I could really do without this stress right now. I wanted a calm, peaceful last few days of pregnancy to prepare myself, and now because of no reason other than medical oversight and NHS failings I feel like my head is going to explode.

Thanks for your advice, if anyone has any other information please do share.

[beatee]

Oh, in response to a PP, my heart murmur is completely asymptomatic and I haven't had any problems since it was diagnosed (it was picked up when I saw a cardiologist about chest pains, but they were apparently unrelated and have now disappeared.)

[chandasz]

I have an irregular heartbeat caused by scarlet fever. It has never caused me any symptoms that I know of. I am also supposed to do the antibiotics before dental work (but never have).

I have never heard of the antibiotics in labor for this reason? Why would that be necessary? I understand the risk of bacterial infection in dental work but for a low risk vaginal birth??? Seems odd. Did you ask the dr. for the research to back up the necessity of this?

I've had 2 natural births...one was a waterbirth with NO interventions of any type.... no problems.... Your body. Your decision.

Please keep remembering that. They can't "make" you do anything. Please make sure you have informed consent or informed denial!

[sal42]

I have a Bicuspid Aortic Valve; I also need to take abx prior to seeing the dentist. My OBs were unsure whether I would need IV abx during labor so they referred me to a cardiologist. The cardio told me that abx were NOT recommended whether I delivered vaginally or had a c/s.
If you can't see a cardiologist, is it possible to even have a telephone consult or get in for an ECHO?
I hope it all works out and that you have a peaceful birth!

[beatee]

Well, I've decided, in the light of all the research I can find on the internet (from cardiology sources not just midwifery etc), that I want to be at home, and decline the abx (as they aren't available to me at home).

I feel pretty confident in my choice, although I can't deny that it has definitely raised my stress levels surrounding the birth, and I'm worried about what impact that will have on me going into labour, since I'm already 40+ weeks. The peaceful confidence and preparation that I have spent the last few months working on has all gone to pot and now I seem to be spending all day reading cardiology research and making myself feel queasy researching symptoms of endocarditis (which is the supposed risk, and is very very nasty indeed-but all the latest recommendations seem to indicate that antibiotics in labour do little to prevent it.) To be honest I'm now also completely paranoid about my constant bleeding gums during pregnancy, as that seems to be a far more likely source of infection!

I sent a letter yesterday to the Head of Midwifery at the hospital saying that I am declining the offer of hospital admission, on the basis of the latest research and the fact that I don't wish to reduce my chances of normal birth by being in a hospital (as this is far more likely to increase my chance of infection, as far as I can see-although, of course, there is no specific research on this).

I have also decided that I would be willing to transfer and recieve antibiotics in the case of prolonged rupture of membranes or prolonged labour-I don't know if it's a 100% necessary, but it seems like a reasonable compromise. I was kind of planning to be very stroppy and go against protocol in these circumstances, but now I feel that would be somewhat imprudent. So I guess I have 'downgraded' my hopes for the birth (and will probably now pack a hospital bag), which is crappy, but the fear is in me now and it won't go away.

I'm also going to be super super wary about any post partum fever, as this is the main indicator of endocarditis. Actually I'm just going to be super wary of it forever from now on, knowing what the risks are now.

Oh, I so hope I'm making the right choice and not making a stupid gamble with my health just so that I can have the birth I want. As I said, all the latest research that I can find supports my decision, but as it's in direct contradiction with what 2 'real live doctors' have said to me, it's difficult to fully reassure myself and be truly calm about everything.

I'm just so angry about how this has been (not) handled. I will definitely be making complaints once I have a baby and all is settled down.

Now I just want her to come soon so I don't have to spend any more days stressing over things!

[mamato3cherubs]

I am really sorry you have had to go through all of this. I just want to say I wish you a peaceful birth at home. I think you are making the right decision and have done all the research you should have to make it.
Best to you

[SleeplessMommy]

Yes ago, I was told that I have MVP, based on acoustics (stethoscope) as well as some minor associated body issues, such as a high arch in the mouth. For years, I took ABX with every dental appointment. When I finally had an $3,000 echo cardiogram (15 years after initial diagnosis) they determined that it is very mild regurgitation and no abx are required. I believe the echo cardiogram with doppler is the definitive way to tell if the MVP is "real" and how severe it is.

(By the way, I had no ABX with delivery despite an interventionist hospital and the suspected MVP.)

If you do end up with a transfer to hospital for any reason, demand that the IV be placed "above the wrist" .. much more comfortable that way. And I really hope you can have the baby at home!