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Multi-Disciplinary Team Approach to Parturient with Significant Cardiac Failure
Abstract Number: SU-97
Abstract Type: Case Report/Case Series
The incidence of heart disease in pregnant women is an important cause of maternal mortality and morbidity.
Case Report: A 31-year-old woman, G6P2032, with history of intravenous drug use leading to two bicuspid and tricuspid valve replacement and repair after MSSA endocarditis, stroke, hepatitis C, cirrhosis, pulmonary hypertension with pulmonary artery systolic pressure of 70+ mmHg, deep vein thrombosis, thrombocytopenia, bipolar disorder, and methadone maintenance was transferred to our hospital because of worsening cardiac status, NYHA class IV heart failure. Echocardiograph demonstrated severe mitral regurgitation, moderate tricuspid regurgitation and suspected perforation of posterior mitral leaflet. Patient was admitted to the cardiac surgery intensive care unit. A multi-disciplinary team consisting of maternal fetal medicine, cardiac surgery, thoracic surgery, cardiology, interventional radiology (IR), anesthesia and psychiatry were assembled. Given her complicated cardiac conditions, prophylactic accesses for potential venous arterial extracorporeal membrane oxygenation (ECMO) were placed which will be activated should she go into congestive heart failure. Given the need for anticoagulation in this setting, IR has been contacted for potential uterine artery embolization via left femoral access (right femoral access for ECMO) if excessive bleeding is encountered. Because of maternal request of non-dismemberment of the demised fetus, induction of labor was initiated after placement of labor epidural. Daily communication and frequent updates of the patient’s conditions were communicated among the team. Two days later, after the successful delivery of the fetus, placenta failed to decent. Manual attempt to extract the placenta was unsuccessful. Patient continued to complain of pain despite of multiple top-ups through the lumbar epidural. An urgent dilation and evacuation procedure was conducted for the retained placenta with ECMO and IR standby. A combined spinal epidural anesthesia was placed and level was brought up slowly until patient has adequate level for surgical coverage for the procedure. Patient tolerated the procedure very well with continuous cardiac output monitoring. The total EBL was 1000 ml. She got replacement of the similar amount of the fluid with a mixture of crystalloid and colloid. The femoral line was removed on the second day post-operation. There were no intraoperative or postoperative complications.
Discussion: This is a report of multi-disciplinary team care approach to a complicated patient. The leading role for anesthesiologist is obviously important in such a procedure-centered operation and should be strongly advocated for safety.
1. Grewal J, et al. Heart Fail Clin. 2014;10(1):117-29.
2. Pieper PG, et al. Best Pract Res Clin Obstet Gynaecol. 2014;28(4):579-91.
3. Gei A, et al. Clin Obstet Gynecol. 2014;57(4):806-26.