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Levels of maternal care: timely transport and management for a parturient with severe heart failure
Abstract Number: FCH-552
Abstract Type: Case Report Case Series
Cardiovascular disease is a leading cause of maternal mortality. A system to classify and access centers that are prepared to provide specialized care is necessary to minimize maternal morbidity and mortality. Moreover, a system that defines how the care can be delivered is essential.
38-year-old G5P3 at 37wks was transferred to our institution with severe heart failure (HF). She had a history of HF after her 2nd child and was intermittently on vasodilator and diuretic before and after delivery of her third, all born at the high-risk (HR) maternal hospital near her home.
This current pregnancy was significant for a 2 wk history of worsening symptomatic HF. She was admitted to the cardiac care unit (CCU) in the same regional medical center for medical management. The HR maternity/neonatal area is near but not on the main campus. With an untested system for providing immediate obstetric coverage and delivery at one site (or escalation of cardiac services at the OB site), she was transferred to our regional center.
With worsening HF, she was admitted to our CCU, critically ill with an EF of 10%. With ongoing medical therapy a multidisciplinary delivery plan was made. Cesarean delivery (CD) took place in a cardiac hybrid operating room. Femoral cannulation was performed with access that would allow ECMO or Impella insertion if necessary. General anesthesia was induced. A transesophageal echo probe was placed. The CD proceeded uneventfully. Post-delivery diuresis and inotropic support were adequate to maintain perfusion, and femoral access was left in place on transfer to the ICU. She was extubated POD1, maintained on diuretic and vasodilator, and discharged POD8 with her baseline EF of 23%. All care took place in our regional center with all services on site.
This case highlights the importance of prenatal planning and counselling for women with high risk cardiac disease, and the pathway to escalation of care when necessary. Patients may have hesitance in transferring care distant from their base, but proper expectations must be set early for women with severe disease. Transfer of care to a facility with Level IV maternal care is essential (Table); however, consideration on how to deliver that care effectively is an important factor. Coordination with multiple specialists, nurses and operating room leaders is vital. Prompt multidisciplinary planning with in-house specialty teams was contributory to a good outcome.