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Management of an urgent cesarean delivery in a woman with methamphetamine-induced cardiomyopathy and pulmonary hypertension
Abstract Number: S 71
Abstract Type: Case Report/Case Series
Methamphetamine (meth) intoxication accounts for 5% of all cases of heart failure presenting in emergency rooms across the US, 40% of admissions for cardiomyopathy in patients under age 45 are due to meth use^1. Meth injection triggers neurotransmitter release that may cause placental abruption, IUGR, preterm birth, and fetal cardiac abnormalities, as well as MI, respiratory failure, stroke, pulmonary HTN (pHTN), aortic dissection, and sudden cardiac death^2. Chronic meth use is likely to increase in the obstetric population, therefore meth-induced cardiomyopathy should be considered in women presenting with heart failure^3. We present the delivery management of a primigravida using meth for over 20 years.
A 33 yo G1P0 was admitted @25 wks with chest pain, dyspnea, tachycardia, and hypertension (180/100). Transthoracic echo (TTE) showed EF 20%, severe global hypokinesis, PAP 35mmHg.The diagnosis of meth-induced cardiomyopathy with pHTN was established. Treatment included digoxin, atenolol, hydralazine, lasix and fluid restriction for an expectant management until delivery (vaginal delivery with neuraxial analgesia, arterial & central venous lines). At 29 wks concern for placental abruption with NRFHR prompted the call team to perform a semi-urgent cesarean delivery. The obstetrician argued strongly to transfer the case to the main OR and for insertion of a PA catheter. Pre-op TTE showed EF 40%. After an arterial line was inserted, an epidural catheter was placed. Despite negative CSF aspiration, epidural test dose revealed it was intrathecal (hypotension & T5 block). Upon PA catheter placement, the patient became so uncomfortable and uncooperative that a GA was performed. A RSI resulted in uneventful OT intubation. Initial PA catheter values were 41/25mmHg and stable throughout the case. Anesthesia was maintained with sevoflurane; a total of 25mg ephedrine, 600mcg of phenylephrine boluses & 0.2mcg/kg/min were also given. Time from GA to delivery was 45min, and total anesthesia time was 120min. Birth weight was 1222g, Apgar scores were 3,6 and 7; baby was admitted to the NICU. At the end of the case, spinal bupivacaine 1.25mg & duramorph 0.1mg was given and the catheter removed. The patient was transferred awake to the ICU where fluid restriction, carvedilol, furosemide, lisinapril were started. The PA catheter was kept for 48h and recovery was overall uneventful with no ensuing headache.
In sum, an unintended intrathecal catheter was placed in this patient with cardiomyopathy and pHTN. However, GA was induced for the patient to tolerate a PA catheter. A LidCO monitor may have been a useful tool in this case. This case is to our knowledge the 1st case report on meth-induced cardiomyopathy in pregnancy. It is unknown whether potentially neurotoxic effects of GA are worse in already compromised neonates exposed in utero to methamphetamine.
1. Am Fam Physian 2007, 76(8):1169-74
2. J Cardiovasc Magn Res 2009,11:46
3. Am J Med 2007,120(2):165-71