Corrected Transposition of the Great Vessels and Scoliosis in an Obstetric Patient
Abstract Number: T-76
Abstract Type: Case Report/Case Series
Corrected transposition of the great vessels places pregnant women at higher risk of premature delivery, spontaneous miscarriage, fetal mortality, as well as right ventricular (RV) dysfunction and tricuspid regurgitation (TR) while pregnant without return to baseline.
A 26 year old G20010 at 30 and 3/7 weeks with corrected transposition of the great vessels and scoliosis presented for primary Cesarean section and bilateral tubal ligation. Previously she had a balloon atrial septoplasty at 1 day and Sennig procedure at 6 months old. Prior to and during her pregnancy she was followed regularly by cardiology. A pre-partum echo showed mild pulmonary stenosis and TR with low normal to mildly depressed RV (systemic) function normal left ventricular (pulmonary) function. At 10 weeks the patient developed mild dyspnea but unchanged echo. ECG showed sinus rhythm and right axis deviation. At 23 weeks, mild MVP with mild MR developed and RV function was moderate to severely depressed. She was now a NYHA class 2-3 and furesomide was started. Holter monitor findings were insignificant. At 26 weeks she had mild improvement in dyspnea with unchanged echo. At 28 weeks she had increasing fatigue but again the echo was unchanged. A multidisciplinary plan was developed with early scheduled delivery at 30 weeks or earlier, early epidural placement, CVICU recovery, adult cardiology follow-up, and cardiac anesthesia availability. The plan was modified to include delivery via Cesarean section to avoid prolonged labor. Prior to the procedure, two large bore IVs and an epidural were placed without difficulty. A radial arterial line was placed with ultrasound. Chloroprocaine 3% was given in divided doses to a T5 sensory level. MAP was maintained >75 mmHg with ephedrine and phenylephrine as deemed necessary. APGARs were 7 and 8. Oxytocin was given after placental delivery. Chloroprocaine was redosed and IV fentanyl and epidural morphine were given post-delivery. The patient was transported to the CVICU, had an uneventful hospital course, and was discharged POD 2.
Hemodynamic changes in pregnancy include a 40-50% increase in blood volume, 30-50% increase in cardiac output, a decrease in SVR and PVR, and 10-20 beat increase in heart rate. These changes may increase RV size and result in worsening of RV function in women with corrected transposition of the great vessels. Asymptomatic women with normal or near normal right ventricular function, good functional class, and good exercise capacity at baseline can successfully navigate pregnancy albeit at higher risk. Anesthetic management plays an important role and should include consideration of early neuraxial techniques with titration of dosing, hemodynamic monitoring, and avoidance of increased demand on the myocardium.
S. Cataldo, et al. "Pregnancy following Mustard or Senning correction of transposition of the great arteries: a retrospective study." BJOG 3 July 2015.