Continuous Cardiac Output Monitoring in a Laboring Patient With Peripartum Cardiomyopathy
Abstract Number: 145
Abstract Type: Case Report/Case Series
INTRODUCTION: Peripartum cardiomyopathy (PPCM) is potentially fatal with an incidence in the USA of up to 1/2000 live births (1) with a high recurrence rate with subsequent pregnancies. Good clinical care requires careful monitoring and a coordinated multidisciplinary team approach.
Case Report: We report on a 28-year-old G2P1 patient who developed PPCM four months after delivery. Cardiac work-up revealed an ejection fraction (EF) of 25% which improved to 55% following medical therapy. Two years later, at 36 weeks gestation, echocardiography revealed moderate mitral regurgitation and an EF of 45%. With input from perinatology, anesthesiology, cardiology, and the patient we decided on an elective induction at 37 weeks with a carefully titrated epidural. A vaginal delivery with minimal pushing, excellent pain control, and hemodynamic stability was the goal. Rather than an invasive pulmonary artery catheter, we used a minimally invasive cardiac function monitoring system (FloTrac System, Edwards Lifesciences, Irvine, CA) that continuously calculates cardiac output (CO), stroke volume (SV), and SVR (if CVP is available) using radial arterial waveform analysis (2). Prior to induction, we placed an epidural using normal saline (NS) for the initial dose and continuous infusion. We placed a radial artery catheter and central venous line for FloTrac monitoring. A "borrowed" SICU nurse and a L&D nurse with recent SICU experience provided continuous hemodynamic monitoring and obstetric nursing care. We started an oxytocin (Oxy) infusion at 07:00. At 08:00 we started infusing 0.125% bupivacaine with fentanyl 2 mcg/ml (B/F) at 10 ml/H, without giving a bolus. All hemodynamic parameters were stable (TABLE 1) and pain was well controlled.
Two hours prepartum a 10 ml bolus of 0.5% lidocaine with epi and bicarb (LEB) was given with continued hemodynamic stability. At 15:01, after a single pull of the vacuum and no pushing, a 2745 gram infant was delivered with good APGAR scores. The patient was transferred to the SICU three hours after delivery, to a monitored bed the next day, and home the following day. At thee months postpartum, the patient was asymptomatic with an EF of 45-50%.
CONCLUSION: Careful planning, multidisciplinary cooperation, and close hemodynamic monitoring with the FloTrac system allowed for a safe vaginal delivery in a patient with PPCM.
(1)Cleveland Clinic J Med 2009; 76:289-96. (2)Br J Anaesth. 2009 Aug;103(2):185-90