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Management of labour and delivery in congenitally corrected transposition of great arteries
Abstract Number: S-34
Abstract Type: Case Report/Case Series
Case report: A 28-year-old primigravida presented with a diagnosis of congenitally corrected transposition of great vessels and dextrocardia. She had good exercise tolerance and stable vital signs. Echo showed 50% ejection fraction (EF) and mildly reduced systemic (morphologic right) ventricle. A multidisciplinary meeting between Obstetrics, Cardiology, Anaesthesia and Intensive care unit (ICU) team was held to decide on optimal obstetric management. Induction of labour was planned.
At 37 weeks she developed palpitations, increasing shortness of breath and peripheral edema. Repeat echo showed moderate ventricular dysfunction with EF 40%, severe systemic atrioventricular regurgitation and severely enlarged left atrium.
Prior to labour induction, an arterial line was inserted and continuous cardiac output monitoring was performed using arterial pressure waveform analysis with the FloTracTM monitor. Haemodynamic optimization was guided by stroke volume variation and goal directed fluid therapy. A lumbar epidural was then inserted followed by rupture of membranes and oxytocin infusion. Fluid balance was closely monitored continuously using FloTracTM system. First stage of labour was uneventful and 2nd stage was shortened using vacuum assisted delivery of a healthy baby. Cardiac condition was stable apart from persistent tachycardia throughout labour. Postpartum, she spent 24 hours in ICU with similar monitoring. Her tachycardia settled spontaneously. She was discharged home on day 4.
Discussion: Patients with congenitally corrected transposition have a thin-walled right ventricle as the systemic circulatory pump. The stress of increased cardiac output can cause failure, atrioventricular regurgitation and arrhythmias. We used minimally invasive continuous cardiac output monitoring using FloTracTM system, fluid balance optimization and good maternal pain control to prevent decompensation and achieve vaginal delivery with a good foeto-maternal outcome.
Continuous CO measurement is probably most beneficial in patients with structural cardiac disease. Women with transposition complexes carry extra risk during pregnancy and delivery. We used minimally invasive continuous cardiac output monitoring, fluid balance optimization and good maternal pain control to prevent decompensation and achieve vaginal delivery with a good foeto-maternal outcome.