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Worsening Severe Pulmonary Stenosis in Pregnancy: A Case Report
Abstract Number: F-65
Abstract Type: Case Report/Case Series
Women with repaired Tetralogy of Fallot (TOF) can present with significant residual cardiac anomalies such as pulmonary stenosis (PS), pulmonary regurgitation (PR), tricuspid regurgitation and right ventricular (RV) dysfunction. The hemodynamic changes of pregnancy can complicate such cases leading to heart failure and arrhythmias. We present a case of a 24 y/o woman with history of TOF whose pregnancy was challenged by worsening PS and PR.
A 24 y/o G1P0 with history of TOF presented to our institution at 35 weeks EGA for evaluation of non-reassuring fetal heart rate. Her TOF was repaired shortly after birth and she underwent replacement of her pulmonary valve in 2005. Her cardiac disease was complicated by ventricular tachycardia (VT) after which an implantable cardioverter defibrillator was placed.
She had been evaluated by cardiology 4 months prior and was found to have worsening PS and PR. Her transthoracic echo (TTE) at the time showed severe PS and moderate PR with a pulmonic valve gradient of 103mmHg and a mean of 50mmHg. She had signs of right atrial hypertension and an increasing number of premature ventricular complexes (PVCs) putting her at risk for sustained VT.
On admission, she presented with hypertension (HTN) but workup for preeclampsia was negative. On hospital day 2 arterial and central venous lines were placed for monitoring and better-quality access, respectively. A repeat TTE showed normal LVSF (EF 60-65%), right ventricular failure, severe PS and moderate PR with increased CVP. Subsequently, the patient had SROM with late decelerations. She was taken to the OR for cesarean delivery, an epidural catheter was placed and a milrinone intravenous infusion was started. Epidural anesthesia was inadequate and the fetus continued to have recurrent late decelerations, hence general endotracheal anesthesia was induced. Her intraoperative course was complicated by an episode of desaturation, frequent PVCs, and one episode of nonsustained VT. A female newborn with Apgars of 3/9 was delivered. The patient was transported to the ICU after surgery and continued to required vasopressor support for hemodynamic stability. She was extubated on POD 1. Pressor support was weaned and patient was transitioned to beta-blocker therapy for ectopic beats. She was discharged home on POD 5.
Cardio circulatory changes associated with pregnancy may result in a significant hemodynamic burden and can lead to morbidity and even mortality in women with cardiac disease(2). Despite being asymptomatic before pregnancy, women with moderate to severe PS can present with serious complications as was seen in our patient (right heart failure and arrhythmias)(1). These patients may require additional hemodynamic monitoring during delivery and should have coordinated care between a congenital cardiac specialist, a high-risk obstetrician and an anesthesiologist.
1. Drenthen 2007
2. Hameed 2007
3. Silversides 2010