///2014 Abstract Details
2014 Abstract Details2019-07-18T14:34:47+00:00

To Section or Not? - the Management of a Parturient with Dilated Cardiomyopathy

Abstract Number: T-64
Abstract Type: Case Report/Case Series

Shelly S Norris MD1 ; James A Dolak MD, PhD2

Introduction:

Cardiac disease during pregnancy poses incredible challenges for the anesthesiologist and great risk to the mother and fetus. Maternal outcome is highly correlated with the New York Heart Association functional classification, with a 5% to 15% mortality rate in patients with Class III or IV disease. We present a patient with a dilated cardiomyopathy who was initially presumed to be optimized for the induction of labor, but instead was found to be in Class IV heart failure by the anesthesia team in the labor suite resulting in a change of delivery plan to urgent cesarean section (CS).

Case Report:

A 36 year-old, morbidly obese G5P3011 with a history of dilated cardiomyopathy (EF 15%) and an AICD was admitted for an acute exacerbation of CHF at 27 wk EGA. Other co-morbidities included asthma and hypothyroidism. After a 5-wk course of in-house medical optimization, she underwent induction of labor for vaginal delivery (VD) per recommendation of her cardiologist at 32 wk EGA. Upon anesthesia consultation for epidural placement, she was noted to be dyspneic, tachycardic, hypotensive and edematous. An ABG was ordered emergently which revealed a metabolic acidosis with respiratory compensation indicative of a poor perfusion state. A BNP obtained at the same time showed 802 pg/ml, which was consistent with her symptoms of a marked CHF exacerbation. The patient was taken to the OR urgently, an A-line was placed, and she received a dural-puncture epidural for CS with no pre-anesthetic fluid administration. Additionally, she was started on dobutamine and norepinephrine infusions for hemodynamic support. Post-delivery, n-methyl ergonovine maleate IV was titrated to increase uterine tone and avoid the fluid-retaining effects of pitocin; while permissive bleeding was used for acute intravascular volume reduction. The patient clinically improved in the OR with a marked reduction in work of breathing and subjective dyspnea. She was subsequently transported to the CCU for post-operative management.

Discussion:

There are several topics of discussion concerning the management of delivery for this parturient. While VD may be the preferred route of delivery, it poses unique hemodynamic challenges to the parturient with cardiomyopathy, and consideration for VD vs CS requires a multi-disciplinary approach and a careful assessment of the patient’s functional cardiac status. Currently no official recommendations on delivery approach exist, and thus, the appropriateness of VD vs CS must be individualized to the clinical scenario. Finally, the perioperative management of a patient in CHF involves a complex interplay between adequate anesthesia, appropriate fluid balance, and preservation of the already severely reduced cardiac function all of which were approached very deliberately during delivery of the anesthetic.

References:

Stergiopoulos, K et al. J Am Coll Cardiol, 2011. 58(4):337-350.

Siu, S et al. Circulation, 1997. 96: 2789-94.

SOAP 2014