1. Heart Diseases inHeart Diseases in
PregnancyPregnancy
Faisal Alatawi ,M.DFaisal Alatawi ,M.D
Consultant CardiologistConsultant Cardiologist
PSCCPSCC

2. OutlineOutline
PhysiologyPhysiology
Incidence& Risk assessmentIncidence& Risk assessment
Congenital heart diseaseCongenital heart disease
Acquired heart diseaseAcquired heart disease
AnticoagulationAnticoagulation
SBE prophylaxisSBE prophylaxis

3. Basic heamodynamicsBasic heamodynamics
Stroke volume(SV)=amount of bloodStroke volume(SV)=amount of blood
ejected per cycleejected per cycle
COP=SV*HRCOP=SV*HR
Blood pressure=COP*SVRBlood pressure=COP*SVR
Starling’s low:increase preload SVStarling’s low:increase preload SV
Systemic vas. resistance(SVR) SVSystemic vas. resistance(SVR) SV

5. Heamodynamics In pregnancyHeamodynamics In pregnancy

6. Heamodynamics In pregnancyHeamodynamics In pregnancy

7. Haemodynamic changesHaemodynamic changes
Supine hypotensive (uterocaval)Supine hypotensive (uterocaval)
syndrome of pregnancy occurs in 11 % ofsyndrome of pregnancy occurs in 11 % of
womenwomen
Decrease HR&BP due to compresion onDecrease HR&BP due to compresion on
IVCIVC
Weakness ,nausea and dizziness evenWeakness ,nausea and dizziness even
syncope avoid by lateral positioningsyncope avoid by lateral positioning

8. Haemodynamic changesHaemodynamic changes
Changes during labor:Changes during labor:
3 fold increase in oxygen consumption3 fold increase in oxygen consumption
Increase COIncrease CO
Increase in BP mainly in 2Increase in BP mainly in 2ndnd
stagestage
Pain reduction, local and epidualPain reduction, local and epidual
anesthesia limit hamodynamic changesanesthesia limit hamodynamic changes
and O2 consumptionand O2 consumption

9. The hemodynamic changes duringThe hemodynamic changes during
thethe post-partumpost-partum statestate
Mainly due to relief of vena cavalMainly due to relief of vena caval
compression after delivery.compression after delivery.
Increase in venous return augmentsIncrease in venous return augments
cardiac output and causes a brisk diuresis.cardiac output and causes a brisk diuresis.
The hemodynamic changes return to theThe hemodynamic changes return to the
pre-pregnant baseline within 3 to 4 weekspre-pregnant baseline within 3 to 4 weeks
following deliveryfollowing delivery

10. CharacteristicCharacteristic signs and symptomssigns and symptoms of normalof normal
pregnancypregnancy
Due to hemodynamic changes associated with pregnancyDue to hemodynamic changes associated with pregnancy
Fatigue, dyspnea, and decreased exercise capacity.Fatigue, dyspnea, and decreased exercise capacity.
Pregnant women usually have peripheral edema and jugular venousPregnant women usually have peripheral edema and jugular venous
distension.distension.
Most pregnant women have Full and collapsing pulseMost pregnant women have Full and collapsing pulse
Displaced and enlarged apex, RV heaveDisplaced and enlarged apex, RV heave
A physiologic third heart sound (S3), reflecting the volume overloaded state,A physiologic third heart sound (S3), reflecting the volume overloaded state,
can often be appreciatedcan often be appreciated
Most have audible physiologic systolic murmurs, created by augmentedMost have audible physiologic systolic murmurs, created by augmented
blood flow.blood flow.
Normal exam can mimic heart diseaseNormal exam can mimic heart disease
Not normal : S4, Loud SM, DM, Fixed split S2Not normal : S4, Loud SM, DM, Fixed split S2

11. Cardiac assessmentCardiac assessment
Electrocardiogram:Electrocardiogram:
The electrocardiogram may reveal a leftward shift of the electrical axis, especiallyThe electrocardiogram may reveal a leftward shift of the electrical axis, especially
during the third trimester when the diaphragm is pushed upwards by the uterusduring the third trimester when the diaphragm is pushed upwards by the uterus
Chest radiograph:Chest radiograph:
Routine chest radiographs should be avoided, especially in the first trimesterRoutine chest radiographs should be avoided, especially in the first trimester
Echocardiography :Echocardiography :
Of choice tool for diagnosis and evaluation of suspected cardiac disease in theOf choice tool for diagnosis and evaluation of suspected cardiac disease in the
pregnant patient.pregnant patient.
Normal changes attributable to pregnancy include increased left ventricularNormal changes attributable to pregnancy include increased left ventricular mass andmass and
dimensionsdimensions

13. 27 years female27 years female
,pregnant,pregnant
C/O SOBC/O SOB
EchocardiographyEchocardiography

14. Heart disease in pregnancyHeart disease in pregnancy
1-4% of pregnancies involve maternal CV1-4% of pregnancies involve maternal CV
diseasesdiseases
CV disease does not preclude pregnancyCV disease does not preclude pregnancy
but poses increased risk to mother andbut poses increased risk to mother and
fetusfetus

15. RISK ASSESSMENTRISK ASSESSMENT
Preconception counselingPreconception counseling
Discussion of contraception,Discussion of contraception,
Maternal and fetal risks during pregnancy,Maternal and fetal risks during pregnancy,
Potential long-term maternal morbidity andPotential long-term maternal morbidity and
mortality.mortality.
The New York Heart Association(NYHA)The New York Heart Association(NYHA)
functional class is often used as a predictor offunctional class is often used as a predictor of
outcome.outcome.

16. RISK ASSESSMENTRISK ASSESSMENT
Women with NYHA class III and IVWomen with NYHA class III and IV
face a mortality rate upwards of 7%face a mortality rate upwards of 7%
and a morbidity rate of over 30%.and a morbidity rate of over 30%.
These women should be stronglyThese women should be strongly
cautioned against pregnancy.cautioned against pregnancy.

17. In a study of 252 completed pregnancies inIn a study of 252 completed pregnancies in
women with cardiac disease, five factors werewomen with cardiac disease, five factors were
found to be predictive of maternal cardiacfound to be predictive of maternal cardiac
complicationscomplications
Prior CHF, TIA, stroke or arrhythmiaPrior CHF, TIA, stroke or arrhythmia
Baseline NYHA class >II or cyanosisBaseline NYHA class >II or cyanosis
Left heart obstructionLeft heart obstruction
MVA <2 cmMVA <2 cm22
, AVA <1.5cm, AVA <1.5cm
LVOT gradient >30 mm Hg by echoLVOT gradient >30 mm Hg by echo
systemic vent dysfunction (EF <40%)systemic vent dysfunction (EF <40%)
RISK ASSESSMENTRISK ASSESSMENT

18. Low RiskLow Risk
•• Ventricular septal defectVentricular septal defect
Atrial septal defectAtrial septal defect
•• Patent ductus arteriosusPatent ductus arteriosus
•• Asymptomatic AS with low mean gradient and normal LV functionAsymptomatic AS with low mean gradient and normal LV function
(EF>50%)(EF>50%)
•• AR with normal LV function and NYHA class I or IIAR with normal LV function and NYHA class I or II
•• MVP (isolated or with mild/moderate MR and normal LV function)MVP (isolated or with mild/moderate MR and normal LV function)
•• MR with normal LV function and NYHA class I or IIMR with normal LV function and NYHA class I or II
•• Mild/moderate MS (MVA >1.5 cmMild/moderate MS (MVA >1.5 cm22
, mean gradient <5 mm Hg) without, mean gradient <5 mm Hg) without
severe pulmonary hypertensionsevere pulmonary hypertension
•• Mild/moderate PSMild/moderate PS
Repaired acyanotic congenital heart disease without residual cardiacRepaired acyanotic congenital heart disease without residual cardiac
dysfunctiondysfunction

19. Intermediate RiskIntermediate Risk
Large left to right shuntLarge left to right shunt
Coarctation of the aortaCoarctation of the aorta
Marfan's syndrome with a normal aortic rootMarfan's syndrome with a normal aortic root
Moderate/severe MSModerate/severe MS
Mild/moderate ASMild/moderate AS
Severe PSSevere PS
History of prior peripartum cardiomyopathy withHistory of prior peripartum cardiomyopathy with
no residual ventricular dysfunctionno residual ventricular dysfunction

20. High riskHigh risk
Eisenmenger's syndromeEisenmenger's syndrome
Severe pulmonary hypertensionSevere pulmonary hypertension
Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA,Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA,
tricuspid atresia)tricuspid atresia)
Marfan's syndrome with aortic root or valve involvementMarfan's syndrome with aortic root or valve involvement
Severe AS with or without symptomsSevere AS with or without symptoms
Aortic and/or mitral valve disease with moderate/severe LV dysfunctionAortic and/or mitral valve disease with moderate/severe LV dysfunction
(EF<40%)(EF<40%)
NYHA class III to IV symptoms associated with any valvular disease orNYHA class III to IV symptoms associated with any valvular disease or
with cardiomyopathy of any etiologywith cardiomyopathy of any etiology
History of peripartum cardiomyopathy with persistent LV dysfunctionHistory of peripartum cardiomyopathy with persistent LV dysfunction
AS = aortic stenosis, LV = left ventricle, EF = ejection fraction, AR = aortic regurgitation, NYHA = New York Heart Association, MVP = mitral valve prolapse, MS = mitral stenosis, MVA = mitral valve area, PS = pulmonary stenosis, TOF = tetralogy of
Falot, TA = Truncus arteriosus, TGA = transposition of the great arteries
Adapted from reference 3.

21. High riskHigh risk
The high-risk conditions are associatedThe high-risk conditions are associated
with increased maternal and fetalwith increased maternal and fetal
mortality. Pregnancy is not advised.mortality. Pregnancy is not advised.
If pregnancy should occur, therapeuticIf pregnancy should occur, therapeutic
abortion to be considered .abortion to be considered .
These patients are best managed with theThese patients are best managed with the
assistance of a cardiologistassistance of a cardiologist

22. Women with congenital heartWomen with congenital heart
disease outcome of pregnancydisease outcome of pregnancy
Good outcome is expected inGood outcome is expected in
presence of acyanotic CHDpresence of acyanotic CHD
– Disease natureDisease nature
– Surgical repairSurgical repair
– PAP, LV dysfunction,PAP, LV dysfunction,
– Functional capacityFunctional capacity
– LV obstructionLV obstruction
– ArrhythmiaArrhythmia

23. Fetal wastage in 45 % of cyanotic mothersFetal wastage in 45 % of cyanotic mothers
compared tocompared to
20 % in non cyanotic20 % in non cyanotic
Low birth weightLow birth weight
PrematuriteyPrematuritey
Risk of Cong.HD (4 to 8 %)Risk of Cong.HD (4 to 8 %)
Women with congenital heartWomen with congenital heart
disease outcome of pregnancydisease outcome of pregnancy

24. Women with congenital heartWomen with congenital heart
disease :disease :Labor and deliveryLabor and delivery
Elective induction of labor when maturity isElective induction of labor when maturity is
confirmedconfirmed
Vaginal delivery is recommendedVaginal delivery is recommended
Oxygen, pain control, fluid lossOxygen, pain control, fluid loss
management, Antibiotic prophylaxismanagement, Antibiotic prophylaxis

25. ASDASD
– Well tolerated even with large shunts. NoWell tolerated even with large shunts. No
need for AB prophylaxis( if no association)need for AB prophylaxis( if no association)
VSDVSD
– Usually tolerated. CHF, arrhythmia areUsually tolerated. CHF, arrhythmia are
reported. Hypotension and fluid loss canreported. Hypotension and fluid loss can
enhance shunt reversal in those withenhance shunt reversal in those with
pulmonary HTNpulmonary HTN
PDAPDA
– Shunt reversal need to be avoided. CHF hasShunt reversal need to be avoided. CHF has
been reportedbeen reported

26. Congenital Aortic StenosisCongenital Aortic Stenosis
– Moderate and severe AS has been associatesModerate and severe AS has been associates
with maternal morbidity and mortalitywith maternal morbidity and mortality
– Symptoms include SOB, chest pain andSymptoms include SOB, chest pain and
syncopesyncope
– Severe AS managed by abortion followed bySevere AS managed by abortion followed by
AVR, or continuation of pregnancy with AVR,AVR, or continuation of pregnancy with AVR,
or AVB in case of clinical deteriorationor AVB in case of clinical deterioration
AO CoarctationAO Coarctation
– HTN, CHF, Aortic dissection have beenHTN, CHF, Aortic dissection have been
reported. Avoid exertion, control BPreported. Avoid exertion, control BP

27. Pulmonary StenosisPulmonary Stenosis
– Well tolerated. Balloon valvoplasty isWell tolerated. Balloon valvoplasty is
considered in case of progressive Rconsidered in case of progressive R
ventricular failure, increased cyanosis due toventricular failure, increased cyanosis due to
associated shuntsassociated shunts
Tetrology Of FallotTetrology Of Fallot
– Repaired ( do well)Repaired ( do well)
– Un repaired or those with residual lesionsUn repaired or those with residual lesions
have increase risk mainly due to deteriorationhave increase risk mainly due to deterioration
of cyanosisof cyanosis

28. Eisenmenger SyndromeEisenmenger Syndrome
High risk of maternal morbidity and mortality (40 %)High risk of maternal morbidity and mortality (40 %)
Pregnancy is not allowed, and abortion isPregnancy is not allowed, and abortion is
recommended.recommended.
Close follow-up for those insist to proceed withClose follow-up for those insist to proceed with
pregnancy. hyperviscositey, infection should bepregnancy. hyperviscositey, infection should be
monitored. Anticoagulation is recommended in thirdmonitored. Anticoagulation is recommended in third
trimester.trimester.
Vaginal delivery is preferred with shortening of 2Vaginal delivery is preferred with shortening of 2ndnd

29. Women with Rhematic HDWomen with Rhematic HD
Acute RF:rare during pregnancyAcute RF:rare during pregnancy
Chronic RHDChronic RHD
Restriction of activity in symptomatic patientsRestriction of activity in symptomatic patients
Antibiotic prophylaxisAntibiotic prophylaxis
Haemodynamic monitoring during labour and 24Haemodynamic monitoring during labour and 24
hour post partum in patients who hadhour post partum in patients who had
– LV FailureLV Failure
– with severe diseasewith severe disease
– pulmonary HTNpulmonary HTN

30. Rheumatic heart disease inRheumatic heart disease in
pregnancypregnancy
Stenotic lesions: get worseStenotic lesions: get worse
– Because of increase flowBecause of increase flow
Regurgitant Lesions : well toleratedRegurgitant Lesions : well tolerated
– Because of decrease vascular resistantBecause of decrease vascular resistant

31. Rheumatic Mitral stenosisRheumatic Mitral stenosis
Increase maternal morbidity but no mortalityIncrease maternal morbidity but no mortality
Symptoms in moderate and severe stenosisSymptoms in moderate and severe stenosis
worsens by 1, or 2 NYHA classworsens by 1, or 2 NYHA class
Increased blood volume, HR increase MVIncreased blood volume, HR increase MV
gradient and hence LA pressure and predisposegradient and hence LA pressure and predispose
AF and pulmonary edema.AF and pulmonary edema.
Rx: activity restriction, fluid and salt restriction.Rx: activity restriction, fluid and salt restriction.
B-blockers, digoxin, diuretics.B-blockers, digoxin, diuretics.

32. In severe cases unresponsive to medicalIn severe cases unresponsive to medical
therapy Balloon valvoplastey or surgery istherapy Balloon valvoplastey or surgery is
recommendedrecommended
Maternal Risk of MV repair or replacementMaternal Risk of MV repair or replacement
is comparable to non pregnant women.is comparable to non pregnant women.
Foetal daeth during open heart surgeryFoetal daeth during open heart surgery
(20-30%)(20-30%)
Closed commissurotomy is associatedClosed commissurotomy is associated
with minimal risk to the fetus.with minimal risk to the fetus.
Rheumatic Mitral stenosisRheumatic Mitral stenosis

33. Rheumatic heart disease inRheumatic heart disease in
pregnancypregnancy
MR is well toleratedMR is well tolerated
AR well toleratedAR well tolerated
Aortic stenosis : severe disease mandateAortic stenosis : severe disease mandate
termination or valve surgery,Valvoplasty intermination or valve surgery,Valvoplasty in
experienced centerexperienced center

34. Present in 1.2 % of pregnant womenPresent in 1.2 % of pregnant women
B-blockers can be used for significantB-blockers can be used for significant
symptomssymptoms
AB prophylaxis:if associated with MRAB prophylaxis:if associated with MR
Mitral valve prolapse

35. Marfan syndromeMarfan syndrome
Patients with dilated aorta or with history ofPatients with dilated aorta or with history of
dissection should be advised against pregnancydissection should be advised against pregnancy
Progressive dilatation of the aorta leading to ARProgressive dilatation of the aorta leading to AR
and CHF. Aortic dissectionand CHF. Aortic dissection
Aortic diameter less then 40 mm is usuallyAortic diameter less then 40 mm is usually
toleratedtolerated
Avoid physical exertion. B-blocker decreaseAvoid physical exertion. B-blocker decrease
aortic dilatationaortic dilatation
CS is preferred in patients with dilated aorta orCS is preferred in patients with dilated aorta or
with dissectionwith dissection

37. Cardiomyopathy:Cardiomyopathy: HOCMHOCM
CHF is reported in 20 % of patientsCHF is reported in 20 % of patients
Arrhythmias (SVT,AF, VT). SCDArrhythmias (SVT,AF, VT). SCD
Up to 50% inheritanceUp to 50% inheritance
Rx: B-blockers, Ca-channel blockers, diuretics. Pacing.Rx: B-blockers, Ca-channel blockers, diuretics. Pacing.
ICDICD
Vaginal delivery with shortening of 2Vaginal delivery with shortening of 2ndnd
stage.stage.
Spinal and epidural anesthesia should be used withSpinal and epidural anesthesia should be used with
caution.caution.
Fluid replacement and AB prophylaxisFluid replacement and AB prophylaxis

40. Peripartum cardiomyopathyPeripartum cardiomyopathy
Form of DCM reported in up to 1in 1000 inForm of DCM reported in up to 1in 1000 in
certain parts of Africa. Develop duringcertain parts of Africa. Develop during
pregnancy or 6 mo post partumpregnancy or 6 mo post partum
Common in multiparous, preeclampsia, and twinCommon in multiparous, preeclampsia, and twin
pregnancy, as well as in women > 30 ypregnancy, as well as in women > 30 y
Unknown etiologyUnknown etiology
50 to 60 % of patients show complete or near50 to 60 % of patients show complete or near
complete recoverycomplete recovery
Death or cardiac Tx in 12 to 18 %Death or cardiac Tx in 12 to 18 %
Relapse can occur with a mortality of 2 % inRelapse can occur with a mortality of 2 % in
those with recovered LVF, and up to 17 % inthose with recovered LVF, and up to 17 % in
those with residual LVD.those with residual LVD.

41. CAD In PregnancyCAD In Pregnancy
Exclude Coronaries and aortic dissectionExclude Coronaries and aortic dissection
Coronary angio, aortic imagingCoronary angio, aortic imaging
PCI, CABGPCI, CABG
ThrombolysisThrombolysis
Consider if angio not availableConsider if angio not available
High-riskHigh-risk

42. Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
Most CV drugs cross placenta andMost CV drugs cross placenta and
secreted in breast milksecreted in breast milk
Weigh risk/benefit ratio - avoid whenWeigh risk/benefit ratio - avoid when
possiblepossible
Use drugs with long safety recordUse drugs with long safety record
Prescribe lowest dose for shortestPrescribe lowest dose for shortest
durationduration
Avoid multi-drug regimensAvoid multi-drug regimens
No drug is completely safeNo drug is completely safe

43. Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
ACE inhibitors - ContraindicatedACE inhibitors - Contraindicated
30% fetal morbidity30% fetal morbidity
Fetal renal tubular dysplasiaFetal renal tubular dysplasia
Neonatal renal failure - oligohydramniosNeonatal renal failure - oligohydramnios
Lack of cranial ossification, IUGRLack of cranial ossification, IUGR
Angiotensin II receptors blocker -Angiotensin II receptors blocker -
contraindicatedcontraindicated

44. Beta - blocker In PregnancyBeta - blocker In Pregnancy
Effective and relatively safeEffective and relatively safe
Metoprolol, Atenolol, LabetalolMetoprolol, Atenolol, Labetalol
IndicationsIndications
Arrhythmias, aortic disease, HCM, HTNArrhythmias, aortic disease, HCM, HTN
Concerns - fetal and neonatalConcerns - fetal and neonatal
IUGR, apnea, HR, hypoglycemiaIUGR, apnea, HR, hypoglycemia

45. Calcium Antagonists InCalcium Antagonists In
PregnancyPregnancy
Relatively safe for mother and fetusRelatively safe for mother and fetus
Tocolytic effect - stop near termTocolytic effect - stop near term
Dysfunctional labor, postpartum hemorrhageDysfunctional labor, postpartum hemorrhage
May uteroplacental perfusionMay uteroplacental perfusion
Beta-blocker preferred if toleratedBeta-blocker preferred if tolerated

46. Diuretics In PregnancyDiuretics In Pregnancy
Best not to use during pregnancyBest not to use during pregnancy
Fetal electrolyte and platelet effectFetal electrolyte and platelet effect
maternal intravascular volumematernal intravascular volume
utero-placental perfusionutero-placental perfusion
Use only in setting of CHFUse only in setting of CHF
Better to start before pregnancyBetter to start before pregnancy

47. Anticoagulation In PregnancyAnticoagulation In Pregnancy
Hematological changesHematological changes
clotting factor concentrationclotting factor concentration
platelet adhesivenessplatelet adhesiveness
fibrinolysisfibrinolysis
risk thrombosis and embolismrisk thrombosis and embolism

48. Anticoagulation In PregnancyAnticoagulation In Pregnancy
Low Dose AspirinLow Dose Aspirin
Safe - antithrombotic effect not provenSafe - antithrombotic effect not proven
Recommended for pt with shunts, cyanosis andRecommended for pt with shunts, cyanosis and
biological valvesbiological valves
Possible incidence of preeclampsiaPossible incidence of preeclampsia
Low molecular weight heparinLow molecular weight heparin
Not enough information available inNot enough information available in
Thrombolytic therapyThrombolytic therapy
Emergency use onlyEmergency use only

49. Warfarin EmbryopathyWarfarin Embryopathy
Bone and cartilaginous abnormality 30%Bone and cartilaginous abnormality 30%
ChondrodysplasiaChondrodysplasia
Nasal hypoplasiaNasal hypoplasia
Optic atrophy with micropthalmiaOptic atrophy with micropthalmia
Developmental delayDevelopmental delay
Miscarriage or stillbirth 37%Miscarriage or stillbirth 37%
Very low risk <5mgVery low risk <5mg

50. Bio-Prosthetic Valves:Bio-Prosthetic Valves:
PregnancyPregnancy
Tissue prosthesisTissue prosthesis
degeneration indegeneration in
youngyoung
73% in 10 years73% in 10 years
AcceleratedAccelerated
degenerationdegeneration
Possible inPossible in
pregnancypregnancy
Reoperation riskReoperation risk

51. Metallic Valve Disease InMetallic Valve Disease In
PregnancyPregnancy
MechanicalMechanical
Thrombosis riskThrombosis risk
High mortality 10%High mortality 10%
Limited Rx optionsLimited Rx options

52. Anticoagulation In PregnancyAnticoagulation In Pregnancy

55. Anticoagulation In PregnancyAnticoagulation In Pregnancy
Labor and Delivery
High Risk Time
Planned Delivery
Stop heparin peripartum
Resume after 4 - 6 hr

56. IE Prophylaxis In PregnancyIE Prophylaxis In Pregnancy
AHA guidelinesAHA guidelines
IE prophylaxis not required duringIE prophylaxis not required during
uncomplicated deliveryuncomplicated delivery
Not requiredNot required
Isolated ASDIsolated ASD
6 months after PDA or VSD closure6 months after PDA or VSD closure
Reasonable to administer IEReasonable to administer IE
prophylaxis in high-risk patientsprophylaxis in high-risk patients

57. Endocarditis ProphylaxisEndocarditis Prophylaxis
GI/GU regimenGI/GU regimen
Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) imAmpicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im
or iv 30 min before procedureor iv 30 min before procedure
6 hrs later6 hrs later
Ampicillin 1 gm im or iv or Amoxicillin 1 gm poAmpicillin 1 gm im or iv or Amoxicillin 1 gm po
PCN allergicPCN allergic
Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5
mg/kg (<120 mg) im or ivmg/kg (<120 mg) im or iv
Complete Rx within 30 min of procedureComplete Rx within 30 min of procedure

58. Thank youThank you
Best LuckBest Luck