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PREGNANT PATIENT WITH RHEUMATIC BIVALVULAR DISEASE FOR VAGINAL DELIVERY- IS IT SAFE?
Abstract Number: 230
Abstract Type: Case Report/Case Series
With a decreased in the incidence of rheumatic fever, the incidence of rheumatic heart disease has declined in the past 40 years. Women with mild moderate stenotic lesions usually have a good outcome during pregnancy.
35 Year old female, G2P1, with history of rheumatic heart disease, presents at 38 weeks gestation in active labor.
Echocardiogram report: EF 65%, moderate mitral stenosis, moderate to severe mitral regurgitation, mild left atrial enlargement, severe aortic insufficiency, and mild to moderate aortic stenosis. No LVH.
EKG shows a sinus rhythm with right axis deviation, and a right bundle branch block.
on admission patient denies chest pain, shortness of breath, or palpitations. Physical examination showed clear breath sounds, 3/6 pansystolic murmur, 2/6 diastolic murmur. vital signs: HR 97, BP 121/78, RR 14, Temp. 98.6. Combined spinal epidural anesthesia was planned for labor pain relief. Epidural space was located with LOR technic. Repeated efforts to enter the intrathecal space were not successful but epidural catheter was successfully placed. After a negative test dose, epidural block was slowly initiated with intermittent injection of 0.1% bupivacaine with fentanyl 2mcgs/ml followed by an infusion of 2 mcg/ml Fentanyl and 0.1% Bupivicaine. Patient remained hemodynamically stable. She delivered vaginally assisted with Vacuum extraction. Patient was transferred o Cardiac Care Unit. Patient remained hemodynamically stable for 24 and transferred to postpartum unit and discharged home the following day.
*When managing a parturient with multivalvular disease, it is imperative to have a multidisciplinary approach involving the cardiologist, obstetrician, anesthesiologist and the neonatologist for optimal outcome.
*Understanding the underlying pathology and its interaction with the physiologic changes of pregnancy are of vital importance.
*Epidural analgesia, especially CSE because of the rapid onset and minimal sympathetic block, is highly desirable to blunt the sympathetic response, tachycardia and arrythmias. Minimizing valsalva during pushing and using either low outlet forceps or vacuum extraction will reduce the hemodymanic disturbances. Also,in the event of a C-Section, epidural can be used effectively, without rapid decrease in the SVR and preload.
*Care should be taken to minimize fluids and to treat RV failure immediately after the baby is born because of autotransfusion