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Epidural Analgesia for a Parturient with Hypertrophic Obstructive Cardiomyopathy
Abstract Number: SU-51
Abstract Type: Case Report/Case Series
Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by asymmetric hypertrophy of the interventricular septum resulting in dynamic left ventricular outflow tract obstruction. Prevalence is 1 in 500 and inheritance is autosomal dominant (1). Management of the parturient with HOCM can be challenging as sympathetic stimulation leading to tachycardia and decreases in preload or afterload can worsen LVOT obstruction leading to morbidity or fatal outcomes.
Case: 18 y/o G1P0 at 38+2 weeks gestational age was transferred to our institution from an OSH due to a history of HOCM. Her vitals were within normal limits and she denied cardiopulmonary complaints. An echocardiogram showed a small LV cavity with severe asymmetric LVH, hyperdynamic systolic function with an EF >75%, systolic anterior motion of the mitral valve, late peaking LVOT velocity up to 3.4 m/sec, and a peak gradient up to 55 mmHg.
An interdisciplinary meeting consisting of maternal fetal medicine, OB anesthesia, and cardiology was held to coordinate care. She was previously non-compliant with beta blockade and presented with HRs in the 90s. Metoprolol and IV fluids were started, and she was placed on telemetry. She was induced at 39+0 weeks for HOCM and AC lag <2.5%.
During labor, an arterial line was placed for hemodynamic monitoring. An epidural catheter was placed via a CSE technique to confirm midline placement, although no intrathecal dose was administered to prevent sudden hypotension. The test dose, lidocaine with epinephrine, was not used to avoid tachycardia in the event of intravascular placement. An alternative test dose of 2ml 2% lidocaine to check for intrathecal placement was followed 3 min later by fentanyl 100mcg to check for intravascular placement. The epidural was slowly titrated in 3ml increments with 0.125% bupivacaine until a T10 level was achieved. An infusion of 0.125% with fentanyl 2mcg/ml was begun at 8ml/hr. The patient remained hemodynamically stable during epidural titration and labor. A planned vacuum assisted second stage delivery was performed to reduce maternal Valsalva expulsive effort.
The patient was monitored on L&D with an arterial line and telemetry for 24 hours postpartum for signs of heart failure. She was then transferred to postpartum and discharged home on PPD#2 without complication.
Discussion: No standards exist for anesthetic management of parturients with HOCM. Prior case series have demonstrated that neuraxial anesthesia can be performed safely and is well tolerated with minimal hemodynamic lability when slowly titrated (2). Goals of care should include avoiding tachycardia and acute decreases in preload/afterload, adequate analgesia, and maintenance of euvolemia. An interdisciplinary team approach can help formulate a safe and effective plan to improve care in high risk patients.
1) Gersh, B. et al. (2011) J Am Coll Cardiol 58: e212-60
2) Ashikhmina, E. et al. (2015) Int J Obstet Anesth 24: 344-355