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STAT Cesarean Section in a Woman with Symptomatic Heart Murmur
Abstract Number: S4D-2
Abstract Type: Case Report/Case Series
Introduction: Heart murmurs can represent a variety of cardiac anomalies, which can range from benign to lethal. Currently, most females born with congenital heart diseases reach childbearing age. Prior unidentified cardiac lesions can first present during pregnancy or even labor. Limited healthcare access can further complicate matters as they might not be recognized and managed appropriately.
Case: A 32 year-old Hispanic female G5P3 at 35w2d presented to the labor and delivery unit with uterine contractions. Her medical history included 3 prior C-sections, gestational diabetes, and the mention of pulmonary hypertension, documented in the outside records. The patient had a limited understanding of her cardiac history, but reported symptoms of angina and shortness of breath. She was last evaluated for this 14 years ago in her native country. Physical examination was significant for a BMI of 24, a Mallampati Class II, and a grade 3/6 crescendo-decrescendo systolic murmur heard best at left upper sternal border. The lumbar region was unremarkable. Intravenous access was obtained with a left forearm 18 Ga. catheter. On review of her prior anesthetics, a spinal had been employed 3 years prior. Anesthetic records had referenced a 2006 echocardiogram which showed mild pulmonic stenosis, but no report was available. Within an hour, the patient progressed to active labor. Decision was made to proceed with an urgent C-section. An echocardiogram had been performed, but surgery had to proceed before it was interpreted. Given the patient’s stable symptoms, decision was made to proceed with a slow load epidural. This was placed at L4-5, and a T4 level was reached with a total dose of 15 mL of 2% lidocaine given over 15 minutes. Invasive hemodynamic monitoring was deferred at this time but tight hemodynamic control was maintained with IV fluids and a phenylephrine drip. The procedure went forward without any intra or perioperative complications.
Discussion:Congenital heart diseases (CHD) can be lethal if appropriate care and caution isn’t taken. This patient had an unclear history of pulmonary stenosis or pulmonary hypertension, or both. Given these constraints, the worst case and best case scenarios were weighed. Consideration was to presume pulmonary hypertension, which can present a 50% mortality risk in the parturient. Neuraxial and general anesthesia have both been used safely in these cases. The most important choice is the anesthetic that allows tight hemodynamic control with complete analgesia. The echocardiogram showed moderate pulmonic stenosis without pulmonary hypertension. Postpartum, cardiology recommended follow-up echo in 6 months.
References: 1. Rex S, Devroe S. Anesthesia for pregnant women with pulmonary hypertension. Curr Opin Anaesthesiol. 2016;29(3):273-281. 2. Hameed AB, Goodwin TM, Elkayam U. Effect of pulmonary stenosis on pregnancy outcomes--a case-control study. American heart journal. 2007;154(5):852-854.