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Cesarean Section in a Parturient With Severe Functional Mitral Stenosis Secondary to "Repaired" Mitral Dysplasia
Abstract Number: SAT-73
Abstract Type: Case Report/Case Series
Cardiac disease is one of the leading causes of maternal morbidity and mortality in the USA (1). Pregnancy is associated with multiple changes in cardiac physiology that begin in the first trimester including increases in cardiac output and blood volume along with decreases in systemic vascular resistance and blood pressure. These hemodynamic changes are considered to be adaptations for normal pregnancy, but these changes may provoke cardiac complications in parturients with congenital heart disease (2). A multidisciplinary approach involving maternal-fetal-medicine, anesthesiology, cardiology, cardiothoracic surgery, and critical care is required for these patients. We present a 23yo G2P0010 with a history of congenital mitral dysplasia who was scheduled for a primary cesarean section (CS) at 35wks. The patient underwent mechanical mitral valve (MMV) placement at age 4yr, which had never been replaced, and she remained on life-long anticoagulation. The patient had no cardiac complications until she reached 11wk gestational age at which time she was hospitalized for significant volume overload and NYHA class IV symptoms. Her treatment involved aggressive diuresis and she was discharged home with a diuretic regimen in preparation for a planned CS. She was found to have severe functional mitral stenosis of her MMV that was significantly undersized for her current body surface area. Serial transthoracic echocardiograms revealed worsening mitral stenosis with a mean gradient of 25mmHg, moderate pulmonary hypertension (RVSP 40-45mmHg) and NYHA class II-III symptoms with preserved left ventricular ejection fraction 55-60%. She was readmitted for her CS at 34wks. Anesthesia for her CS was provided using a dural puncture epidural (DPE), invasive hemodynamic monitoring, and targeted vasopressor/fluid therapy. During DPE dosing, after a T10 level was obtained, cardiothoracic surgery performed a cut-down with wire placement in the femoral vessels in case there was a need to transition to ECMO emergently. Upon obtaining a T4 level of anesthesia, an uneventful CS, requiring minimal vasopressor support, resulted in delivery of a male infant with Apgars of 8 and 9. Uterine atony was prevented through the use of carefully titrated doses of methylergonovine maleate rather than an oxytocin infusion. She was admitted to the CICU for post-op observation, but was discharged to the postpartum floor 24hr later. We will discuss the anesthetic technique, the use of uterotonics, the consequences of prolonged maternal and fetal exposure to anticoagulation, and other peripartum considerations in this type of patient.
1. Yildirim, Erkan, Murat Çelik, and Yaşam Kemal Akpak. "Mitral Stenosis and Pregnancy." Open Science Journal of Clinical Medicine 3.6 (2015): 220-223.
2. Elkayam, Uri, and Fahed Bitar. "Valvular heart disease and pregnancy: part II: prosthetic valves." Journal of the American College of Cardiology 46.3 (2005): 403-410.