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Severe Mitral Stenosis in Pregnancy: A Success Story
Abstract Number: SU-17
Abstract Type: Case Report/Case Series
Approximately 1% of pregnancies are complicated by cardiac disease with rheumatic heart disease being one of the most common etiologies. This can lead to mitral stenosis, which is the most common clinically significant valvular abnormality in pregnancy (1). Parturients with severe mitral stenosis often do not tolerate the increased cardiovascular demands of pregnancy, and outcomes correlate with New York Heart Association functional classification and severity of the mitral stenosis (2,3). In this case report, we describe successful management of a parturient complicated by severe mitral stenosis with NYHA class III/IV symptomatology by early use of invasive monitoring and an intentional intrathecal catheter.
Our patient is a 33y/o G2P1000 who presented at 35w1d for induction of labor secondary to history of a term intrauterine fetal demise and worsening heart failure symptoms. She had a bioprosthetic valve replacement 5 years prior due to rheumatic heart disease and now presents with acute on chronic valvular heart failure with restenosis. A recent transthoracic echo showed a mean gradient of 17 mmHg, severely dilated LA, and pulmonary hypertension (RVSP 42 mmHg). On presentation, she exhibited class III NYHA symptomatology with JVD present above the ear, distention of the scalp veins, a 2/6 systolic murmur, and mild pitting edema of the lower extremities. She was hemodynamically stable and on room-air.
An arterial line and intentional intrathecal catheter were placed prior to induction of labor. A sufentanil infusion was maintained throughout the first stage of labor, and the patient remained comfortable. A forceps-assisted second stage was successfully completed by creating a saddle block with hyperbaric bupivacaine. The patient was hemodynamically stable throughout. She was transferred to the cardiac ICU for post-delivery optimization, where she had an uneventful course until her discharge.
Mitral stenosis is challenging to manage due to the hemodynamic changes of pregnancy. Epidurals are often cited as the regional technique of choice due to the ability to titrate incremental doses coupled with a slower onset that allows the maternal cardiovascular system to compensate for the sympathetic blockade. However, by placing an intrathecal catheter, we were able to ensure proper position and adequate analgesia for the assisted stage II, while maintaining hemodynamic stability. We were able to maintain an acceptable heart rate, adequate venous return, and adequate SVR, while preventing pain, hypoxemia, hypercarbia and acidosis, as well as avoid any Valsalva attempts with our technique, which was tailored to our patient’s cardiovascular status.
1. Madazli R et al. Archives of Gynecology and Obstetrics. 2010; 281:29-34.
2. Kannan M and Vijayanand G. Indian Journal of Anaesthesia. 2010; Sep-Oct; 54(5): 439-444.
3. Reimold S and Rutherford JD. The New England Journal of Medicine. 2003; 349:52-59.