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Paying it forward: Anesthetic management of the parturient post heart transplant
Abstract Number: RF1AA-81
Abstract Type: Case Report Case Series
Pregnancy after heart transplantation is becoming increasingly common due to advances in heart disease and transplant medicine. However, anesthetic reports of such cases are exceedingly rare. The pathophysiological changes in the heart transplant parturient pose maternal, fetal and neonatal risks that the anesthesiologist must consider.
A 17-year-old G1P0A0 with history of dilated cardiomyopathy eleven years status post heart transplant, was admitted at 30w1d to the antepartum unit after endomyocardial biopsy indicated acute cellular and antibody mediated rejection. Immunosuppressive therapy consisted of azathioprine and tacrolimus after a history of rejection six years prior. Most recent echocardiogram revealed a new pericardial effusion and depressed left ventricular ejection fraction (LVEF) of 37%. Cardiology recommended intravenous immunoglobulin (IVIG) in addition to immunosuppression. After completion of IVIG, routine labs and observation demonstrated elevated 24-hour total protein and hypertension, consistent with preeclampsia without severe features. Continued in-house management included biweekly IVIG, weekly echocardiogram and serial brain natriuretic peptide (BNP). Three weeks after admission, patient developed new onset headache and elevated creatinine with mild weight gain, despite improved heart function. Thus, induction of labor (IOL) was favored due to concern for preeclampsia with severe features. Given her preserved LVEF, patient was cleared for spontaneous vaginal delivery (SVD) per cardiology. Following initiation of oxytocin and prophylactic magnesium infusion, dural puncture epidural was performed and initiated at a programmed intermittent bolus infusion of 0.0625% bupivacaine with 2 ug/cc fentanyl. Patient progressed to complete with artificial rupture of membranes (AROM) and was transported to the operating room for delivery. After spontaneous vaginal delivery (SVD) of infant with Apgars 8/8, the initial 24-hour postpartum period was complicated by postpartum hemorrhage and acute kidney injury (AKI) requiring fluids, one unit packed red blood cells (pRBC) and diuresis. Remainder of postoperative course remained uneventful, including postpartum echocardiogram and blood pressure control.
With appropriate multidisciplinary care including transplant physician, maternal fetal medicine and obstetric anesthesiologist, pregnancy post heart transplantation is a viable and reasonably safe option. Risk of graft rejection, hypertension, infection, and other fetal and maternal complications are real and should be carefully monitored to optimize outcomes.
1. Macera F, Occhi L, and Masciocco G. et al. “A new life: motherhood after heart transplantation. A single-center experience and review of literature.” Transplant. 2018; 102(9):1538-1544.
2. Abdalla M. and Mancini, D. “Management of pregnancy in the post-cardiac transplant patient.” Semin Perinatol. 2014; 38(5): 318-325.