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Cardioversion of Parturient with Congenital Heart Disease, Alcohol Abuse, and Preeclampsia with Severe Features: A Case Report
Abstract Number: F1C-9
Abstract Type: Case Report/Case Series
Cardiac arrhythmias occur in about 1% of pregnancies(1). Some, such as atrial fibrillation (AF) increase maternal and fetal morbidity and mortality if not treated with medication or direct current cardioversion (DCCV)2. Although first report of DCCV in pregnancy was in 1965(3), as of 2012, fewer than 20 cases have been reported(4). We report successful DCCV in parturient with third trimester twin pregnancy complicated by congenital heart disease (CHD), alcohol abuse, and severe preeclampsia receiving magnesium.
A 34-year-old, Gravida 5, Para 1, female with dichorionic, diamniotic twins at 31/2 weeks gestation was admitted for expectant management of preeclampsia with severe features including headache. Her past medical history was significant for congenital aortic coarctation status-post repair, chronic hypertension, heart failure with preserved ejection fraction, insulin-dependent type 2 diabetes, and ongoing alcohol abuse. Magnesium (4gm bolus, 2gm/hr infusion IV) and betamethasone (12mg IM) were given for seizure prophylaxis and fetal lung maturity, respectively. Exam on admission revealed an irregularly-irregular pulse with rate of 120, BP 129/84. EKG revealed AF. Telemetry was instituted. Cardiology recommended metoprolol (100mg PO TID) for rate control and planned for elective DCCV later that day.
Following rapid sequence induction of anesthesia (propofol 200mg, succinylcholine 100mg IV), intubation (6.5 ETT), and maintenance with sevoflurane (0.9% inspired), a transesophageal echo (TEE) was performed since the onset of AF was uncertain by history. Given the absence of thrombus on TEE, DCCV (biphasic, 200J x 1) was performed with conversion to normal sinus rhythm. Fetal heart rate (FHR) was monitored throughout the procedure and recovery period. The obstetrician and OB nurses were present throughout and prepared for emergent cesarean delivery (CD). FHR remained reassuring throughout. All care was provided in our main OR and PACU, respectively, as opposed to labor and delivery.
Two days after DCCV, the decision was made to proceed with delivery due to worsening preeclampsia. CD was performed under spinal anesthesia (bupivacaine 10.5mg, fentanyl 15mcg, morphine 0.15mcg). Apgars were baby A 4/3/5/7, baby B 3/1/1/6/7, and both transferred to the neonatal ICU. The remainder of the mother’s hospital course was uneventful with discharge to home 5 days after delivery.
This is a noteworthy case of successful DCCV for AF in a high risk parturient with CHD, alcohol abuse, and preeclampsia. We will discuss measures taken to coordinate safe treatment of this patient, as well as role of preeclampsia and magnesium treatment on maternal arrhythmia.
1Singth V, Bhakta P, et al. Acta Anaesth. Belg. 2014;65:105-7
2Vasiliki K, Georgiopoulous G, et al. Current Medical Research and Opinion. 2017. 33:8, 1497-504
3Brown O, Davidson N, Palmer J. J Obstet Gynaecol 2001; 41: 2: 241-2
4Moore JS, Teefey P, et al. Obstet & Gynecol. 2012: 67(5): 298-312