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Unanticipated Post Partum Right Ventricular Heart Failure
Abstract Number: S-29
Abstract Type: Case Report/Case Series
Introduction: The parturient undergoes significant cardiovascular and physiologic stress in the peripartum period, however the vast majority tolerate labor well. We present a rare diagnostic conundrum in obstetric anesthesia,; a patient with no known cardiac history develops acute and florid right ventricular heart failure post spontaneous vaginal delivery with epidural analgesia.
Discussion: Appropriate consent was obtained directly from the patient to publish this case report. We describe the case of a 32 year old female, G6P4 presenting in active labor at term. She had four previous uneventful spontaneous vaginal deliveries, all with intermittent intravenous analgesia. The patient did not describe any prior history of cardiac issues. She requested an epidural for analgesia, which was placed by the obstetrical anesthesia fellow after appropriate consent was obtained. Starting immediately post partum she had progressive bilateral leg swelling and periorbital edema. A chest X ray was obtained which showed an unusually enlarged and globular shaped heart. She was noted to have the clinical signs of florid right heart failure and borderline hypoxic with room air sats of 91% and a P02 of 66. The obstetrical anesthesiology fellow performed a bed side echocardiogram without doppler color images which revealed a moderately dilated right ventricular with no other obvious pathology. Cardiology was consulted for stat formal echo, and a CT to rule out PE was ordered. Pending consultations and tests, the decision was made to start IV heparin anticoagulation for the high index of suspicion that a large post partum pulmonary embolus was causing right ventricular failure. The CT chest eventually showed no evidence of pulmonary embolus, and the formal echo confirmed a moderately dilated right ventricle with normal valves and left sided function. It was noted however the patient had a 11-19mm atrial septal defect with significant left to right shunt, enough to explain the right ventricular failure. Her heparin was discontinued, she was diuresed with furosemide, and arrangements were made to have a percutaneous closure of her atrial septal defect once she was clinically stable.
Results and Discussion: Although common complications such as pulmonary embolus should continue to remain high on the differential for pregnant patients, Anesthesiologists and Obstetricians should keep a broad differential that includes rare cardiovascular conditions when managing the peripartum complications of labor and delivery. This also serves to highlight the diagnostic role of bed side echocardiography in obstetric anesthesia.