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Cyclic Tachycardia During Labor
Abstract Number: T4D-7
Abstract Type: Case Report/Case Series
Introduction: Continuous fetal heart rate monitoring and tocometry are the standard of care at most medical centers in the US for laboring women. However, maternal heart rate is often an overlooked hemodynamic parameter during labor, and the pathophysiology of the hemodynamic changes during labor with each uterine contraction are not well-investigated.
Case: A 36-yr-old G2P1 at 40w1d presented for an induction of labor due to a history of postpartum cardiomyopathy (CM). She was diagnosed three years prior, when she developed a left bundle branch block and mild systolic dysfunction (EF 45%). Subsequently, her CM resolved and during this pregnancy, she was asymptomatic and not on any cardiac medications. As her induction progressed, she underwent an uneventful epidural placement. A 3mL test dose of lidocaine 1.5% with epinephrine 1:200,000 and a 10mL mixture of fentanyl 2mcg/mL and bupivacaine 0.125% was given through the epidural. She was on continuous pulse oximetry and when in the right lateral position, she developed tachycardia to the 160s prior to each uterine contraction. Her blood pressure was normal and she was completely asymptomatic. The maternal heart rate was continuously traced by the maternal/fetal monitor, so the pattern could be observed with tocometry. The attached image is her cardiotocography.
Discussion: We present a case of severe maternal tachycardia coincidental with uterine contractions. Similar hemodynamics were documented in a 21-yr-old parturient with severe aortic stenosis, (1), suggesting that patients with severe LV outflow tract obstructions are more sensitive to changes in intravascular volume. We hypothesize that in this patient, there was a decreased stroke volume and cardiac output, which led to compensatory tachycardia. The increased preload from uterine contractions augments maternal cardiac output and stroke volume leading to a decrease in maternal heart rate. These changes may be exaggerated by vasodilation associated with neuraxial analgesia and the aortocaval compression from positioning. Identifying this pattern throughout labor could help providers optimize maternal volume status during labor. More studies need to be performed to analyze the change in maternal hemodynamics associated with uterine contractions.
1. Baird E, et al. Hemodynamic Effects of Aortocaval Compression and Uterine Contractions in a Parturient with Left Ventricular Outflow Tract Obstruction. Anesthesiology. 2012;117(4): 879