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Cesarean section for a patient with Hypertrophic Obstructive Cardiomyopathy
Abstract Number: F 67
Abstract Type: Case Report/Case Series
Hypertrophic obstructive cardiomyopathy(HOCM)is the most common genetic cardiovascular disorder transmitted as an autosomal dominant trait. It is characterized by asymmetric hypertrophy of the interventricular septum,resulting in obstruction of the left ventricular outflow tract ( LVOT). The hallmark of the condition is the dynamic obstruction of the LVOT, which can be precipitated by sympathetic stimulation and a decrease in preload and afterload to the left ventricle, and can lead to sudden death. Aortocaval compression due to the gravid uterus decreases the preload and labor pains increase the heart rate and hence pregnant patients with HOCM may have an increased risk of LVOT obstruction. We present here the case of a 25 years old Spanish speaking female, diagnosed with HOCM at the age of 11 years, now 39 weeks pregnant, with a positive history of chest pain on exertion, shortness of breath and palpitations, wearing a life vest with no adverse events like NSVT on record,who presented for a repeat elective cesarean section. She was regularly followed up with both the OB/GYN and the Cardiology/EP clinics during her current pregnancy. The EP Cardiologists recommended delivery of the fetus prior to the placement of an Automatic Implantable Cardioverter Defibrillator (AICD). On physical examination,the patient's height was 5 feet, 2 inches and she weighed 172 pounds. Her airway exam was Mallampati 1, with free range of motion of the neck. Auscultation of the heart revealed a systolic ejection murmur, and transthoracic echocardiogram revealed an Ejection fraction of 70% with grade 2 diastolic dysfunction and severe LVOT obstruction. There was mild systolic anterior wall motion of the mitral valve leaflet. Her medications included Metoprolol 25 mg twice a day and Prenatal vitamins. After discussion with the EP cardiologists, the plan to remove the life vest for the cesarean section was made.. R2 pads were placed on the patient and connected to the defibrillator and she was monitored throughout the procedure. After obtaining good peripheral access by means of two large bore indwelling catheters, we infused a liter of saline to optimize preload. She was administered Metoprolol 25mg orally preoperatively. A left Radial arterial line was placed preoperatively for closer monitoring of the blood pressure. A continuous lumbar epidural block was performed without difficulty in the operating room and was dosed incrementally with 2% Lidocaine with 1:200,000 Epinephrine until a T4 level was achieved. An intravenous infusion of Phenylephrine was run throughout the procedure and titrated to effect. The baby was delivered, and had an Apgar scores of 9 and 9 at 1 and 5 minutes respectively. The intraoperative course was uneventful and the life vest was put back on the patient in the Recovery area. An AICD was placed the following day by the EP cardiologists under monitored anesthesia care.
The patient was discharged home on on post operative day 5.