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IVF Pregnancy in a Patient With Fibrotic Eosinophilic Myocarditis and Precipitous Labor
Abstract Number: T-35
Abstract Type: Case Report/Case Series
In hypereosinophilic syndrome (HES), the sustained overproduction of eosinophils leads to organ dysfunction. Cardiac involvement leads to morbidity and is a significant risk factor for mortality.
A 31 y.o. G3P0 at 26 weeks gestation from IVF presented with shortness of breath and a 10 lb weight gain, she was noted to be in acute on chronic heart failure. She was administered Lasix for 8 weeks. Her history was significant for right heart failure secondary to eosinophilic myocarditis with resulting endomyocardial fibrosis. Her previous transthoracic echo demonstrated an extremely small right ventricle, large tricuspid regurgitation, very dilated right atrium and dilated inferior caval vein (2.8cm without respiratory variation). A right heart cath two months prior showed no change in the pressure tracing morphology from the right atrium through to the pulmonary artery suggesting minimal right ventricle contractile performance. With exercise there was a fall in cardiac output from 3.56 to 2.78 l/min. She was anticoagulated with lovenox. A multidisciplinary plan was developed with input from obstetrics, cardiac surgery, cardiology, cardiac and obstetric anesthesiology. Patient was counseled regarding the high risk nature of her pregnancy and her options. The tentative plan was to place an arterial line, central line and early labor epidural with transfer to a cardiac operating room during 2nd stage. The appropriate teams would be on standby in the event that she required invasive cardiac support. In addition, a heart transplant workup was initiated.
She experienced PPROM and contractions at 31 weeks and was started on betamethasone with expectant management. The patient precipitously progressed from stage 1 to 2 within 20 mins and a lumbar epidural was placed without difficulty or hemodynamic consequences. Delivery was imminent in the obstetric operating room. The delivery was uneventful and the baby was transferred to the NICU. Following delivery she demonstrated signs of right heart failure with cyanosis of the lips but required no pressors, an arterial line and central line were placed. She was stable and transferred to the cardiac ICU. She received postpartum diuresis and was discharged to the regular postpartum floor 2 days later.
Cardiac manifestations contribute to most of the deaths associated with HES. The pathogenesis of cardiac involvement is characterized by an acute necrotic stage, an intermediate thrombotic stage, and a final fibrotic stage. The final stage involves scarring of the heart due to fibrous replacement of endocardial and myocardial tissue. The fibrosis can lead to impaired diastolic function and result in restrictive cardiomyopathy. This case demonstrates the complex physiology of right heart failure during pregnancy, which can be very challenging to manage. Our patient also presented ethical issues regarding assisted reproduction and the multidisciplinary planning required to ensure good outcomes in complex cases.