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A Case of Congenital Heart Disease Requiring Aggressive Fluid Management
Abstract Number: T3C-8
Abstract Type: Case Report/Case Series
Pregnancy in women with pulmonary hypertension, despite advances in medical therapies, is associated with a high maternal mortality and complication rate. Preoperative optimization along with point of care monitoring may be necessary to improve outcomes.
Presentation: Our patient is a 18 year old G1P0 @ 21 wks with PMHx of congenital heart disease s/p AV canal repair with mechanical MVR (requiring anticoagulation), abdominally placed dual chamber pacemaker, history of cor pulmonale, and new onset seizure at 14 wga. For predelivery workup, the pacemaker was interrogated and noted functional. A treadmill stress test at 22wks was aborted due to RBBB with 42% predicted mx HR achieved. TTE demonstrated preserved EF 55-60% but elevated right ventricular pressure (65mmHg). A right heart cath showed PAP = 79mmHg. Furosemide and sildenafil therapy was initiated.
Preoperative: At 33+6 wga, one week prior to planned CD, pt was admitted to MICU for anticoagulation bridging from warfarin to heparin drip and epoprostenol initiation. Betamethasone x2 was administered.
Intraoperative: Awake central line was placed. L and R radial arterial lines were attempted, but unsuccessful. Magnet was placed on abdominal pacemaker. A dural puncture epidural was performed with slow administration of epidural medication (test dose + 100mg Lidocaine + 100mg fentanyl). Delivery was uneventful with EBL 800mL and IVF 750mL.
Postoperative: Pt c/o acute dyspnea and chest pain with hypoxemia (O2 sats 70s). Per auscultation, pulmonary edema suspected. Bedside TTE showed right atrial dilation with poor contraction suggestive of hypervolemia. Patient was given furosemide, started on dobutamine infusion, inhaled nitric oxide and 100 mg lidocaine via epidural for vasodilation. 30 min later, TTE was performed with improvement in exam. Pt was transferred to ICU and dobutamine and inhaled nitric oxide discontinued after 48 hours. Pt discharged home on POD # 7.
Patients with congenital heart disease with severe pHTN are at risk for complications during pregnancy. Prior to delivery, it is important to medically optimize the patients and utilize a multidisciplinary approach to care. Our patient’s medical management was complicated and required pulmonary vasodilation, diuresis and anticoagulation prior to cesarean delivery. Despite a successful delivery, postoperatively, our patient required further intervention with ionotropic support, pulmonary artery vasodilation, diuresis and peripheral vasodilation which was guided by bedside TTE evaluation. Providers should be aware of the risks of postoperative fluid overload in patients with CHD and pulmonary hypertension.
Thomas E, Yang J, Xu J, Lima FV, Stergiopoulos K. . J Am Heart Assoc. 2017;6(10)
Hemnes AR, Kiely DG, Cockrill BA, et al. Pulm Circ. 2015;5(3):435-65.