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Pregnancy in Adults with Corrected Congenital Heart Disease (CHD) - An Anesthesiologist’s Specter
Abstract Number: T3C-5
Abstract Type: Case Report/Case Series
Background: There is an increasing number of adults with corrected CHD reaching childbearing age. The prevalence of cardiac events in these patients during pregnancy is as high as 20%. The leading cause of maternal death is related to cardiac complications. A multidisciplinary approach to a care plan of a mother with repaired CHD is a necessity.
Case 1: A 27 year-old G3 P0111, at 33w2d with di/di twin gestation was seen for increased shortness of breath and chest pain. A perimembranous ventricular septal defect was repaired at age 2 for pulmonary hypertension. She had persistent pulmonary artery branch stenosis from hypoplasia, however had no established prenatal care until 32 weeks at which point the echo showed peak right ventricular (RV) pressure of 36 mm Hg and moderate tricuspid regurgitation. The findings were stable from prior examinations.
Case 2: A 23 year-old G2P1, status post Ross procedure presented for induction of trial of labor after prior cesarean delivery. Her cardiac history was significant for dilated aortic root, pulmonic valve stenosis, peak right ventricular pressures of 72 mm Hg, and moderate right ventricular hypertrophy and dilatation.
Management: A multidisciplinary team developed a plan for both emergent and non-emergent delivery for both. Both patients were recommended an early epidural and abbreviated second stage labor. Invasive monitoring was available for both but was not required. Intensive care teams were notified of possible admissions for instability.
Case 1: At 33 weeks she was diagnosed with preeclampsia with severe features. Magnesium prophylaxis was established. She had a forceps assisted second stage and delivered two live infants (1690 g) and (1520 g). The postpartum course was uneventful.
Case 2: She underwent induction of labor with oxytocin, received an early epidural and had an uneventful forceps assisted delivery.
Case 1: The patient had a corrected ventricular septal defect with pulmonary artery stenosis complicated by no antenatal care until 32 weeks and preeclampsia with severe features. Physical exam and echo did not suggest acute decompensation or evidence of RV strain. We planned to maintain euvolemia and early establishment of labor analgesia with slow onset sympathectomy. Uterine atony and postpartum hemorrhage were concerns with twin gestation and preeclampsia. Since Ergot and Prostaglandin F2α therapy have significant risks, we planned for a prostaglandin E1 suppository and early Bakri balloon placement.
Case 2: Pulmonic stenosis of the graft valve led to elevated RV pressures without pulmonary shunting and pulmonary hypertension. Ideally, the valve replacement should have occurred pre conception. The goals were euvolemia and preventing increases in RV strain.
Both these patients highlight the complex residual cardiac pathology that develops over time in adults with corrected CHD and the unique considerations for anesthetic management.