///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Peripartum Management of a Woman with Congestive Heart Failure Secondary to Sickle Cell Anemia

Abstract Number: 140
Abstract Type: Case Report/Case Series

Aaron M Rund MD1 ; Susan D Dumas MD2

Introduction: Peripartum physiologic changes are a large stress on the maternal cardiovascular system. In the setting of pre-existing maternal cardiac disease, the stress of childbirth can provoke further morbidity and mortality.(1) We present the peripartum management of a woman with congestive heart failure due to the chronic effects of sickle cell disease.

Case Report: The patient was a 22 year old G1P0 at 33 weeks who presented with worsening dyspnea, fatigue, and edema. Her sickle cell disease had been complicated with several episodes of acute chest syndrome, AV block requiring a pacer, ventricular tachycardia arrest with subsequent biventricular pacemaker ICD implantation, and CHF with an ejection fraction of 20-25%. The patient was admitted to the cardiac ICU where she was treated for a heart failure exacerbation and sickle cell pain crisis with a blood transfusion, diuresis, morphine PCA, and oxygen. The plan was to induce labor at 34 weeks, and anesthesiology received a consult at this point. Prior to induction of labor on the OB ward, we placed a 9F sheath introducer under ultrasound guidance in the right IJ for venous access and CVP monitoring, and we placed an arterial line. We also placed a continuous labor epidural catheter and slowly dosed it to the patients comfort. We requested that the pacemaker rate be increased from 70 to 100 bpm to accommodate the increased cardiac demands of labor. Shortly after developing a fever and presumed chorioamnionitis, the patient underwent a forceps-assisted vaginal delivery in the operating room under close hemodynamic surveillance by the anesthesiology team. There were no acute cardiovascular complications. The patient was transferred back to the cardiac ICU for close post-partum monitoring and then to the floor before being discharged 8 days after delivery.

Discussion: Of greatest concern for this patient was cardiovascular stability during the hemodynamic stress of the third trimester, labor, and immediate postpartum period. A slowly titrated labor epidural helped to minimize blood pressure fluctuation while providing labor analgesia.(2) With the contractions of labor in the normal parturient, there is increased venous return to the heart, and cardiac output can elevate by 10-25%. The greatest stress occurs shortly after placental delivery when cardiac output increases by approximately 80%.(3) Without the ability to compensate via higher cardiac output, this patient was at high risk for developing an acute CHF exacerbation. Our arterial line and central venous catheter could have provided immediate feedback had this occurred. Finally, we looked vigilantly for signs and symptoms of a sickle cell crisis or acute chest syndrome, which can be precipitated by acute stressors such as labor and delivery.

References:

(1) Crit Care Nurse Q 2006 Jan-Mar;29(1):32-52.

(2) Am J Obstet Gynecol 1969; 103:8.

(3) Barash et al. 2009. Clinical Anesthesia 6th ed. 43:1155.

SOAP 2010