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A MULTIDISCIPLINARY TEAM APPROACH ENSURES THE SAFE DELIVERY OF A PREGNANT WOMAN WITH PERIPARTUM CARDIOMYOPATHY
Abstract Number: RF3AC-271
Abstract Type: Case Report Case Series
A 30-year-old G5P4004 at 37w0d with PMH of peripartum cardiomyopathy (PPCM) was admitted for scheduled induction of labor (IOL) for her fifth pregnancy. At three months postpartum after her third pregnancy an echocardiogram (echo) showed her EF 20%. Heart failure (HF) medication and a LifeVest was prescribed for primary prevention of sudden cardiac death. Seven months postpartum, LV systolic function recovered and LifeVest and medications were discontinued. The following year, a preoperative evaluation for a bilateral partial salpingectomy (BPS) revealed an unintended pregnancy and EF 35%. Metoprolol was restarted. Her fourth vaginal delivery was without complication. Nine months postpartum and in the first trimester of her fifth pregnancy, EF remained 40%. EF decreased to 25% in the third trimester, resulting in a referral to MFM and anesthesiology. For scheduled IOL, she was admitted to the cardiac ICU and titrated up on dobutamine. Echo showed EF 45%. Intrapartum monitoring included an arterial line with cardiac output monitoring, pulse oximetry, and continuous telemetry. A labor epidural was placed and dosed to prevent significant hypotension. She underwent an uneventful vaginal delivery and BPS. Dobutamine was continued to augment EF during expected fluid shifts. She was transitioned to standard HF medications and bromocriptine to prevent prolactin induced cardiac remodeling. EF was 30% after dobutamine cessation. Patient was sent home with a LifeVest and plans for ICD placement.
Although PPCM is rare in the United States, cardiac disease remains the most common cause of death in pregnant women in the developed world (1). Management of a pregnant woman with PPCM is focused on treating the patient’s HF symptoms, while avoiding teratogenic medications. If the HF is stable, then medications are used to optimize LV function while a safe plan for delivery is made (2). Furosemide, digoxin, hydralazine and amlodipine (substituted for ACE inhibitors/ARBs which are known teratogens), and beta-blockers (excluding atenolol) are all safe during pregnancy (1, 2). Dobutamine, dopamine, and milrinone have not shown evidence of risk during pregnancy (2). Lastly, some studies have reported bromocriptine as beneficial in PPCM when added to HF regimen (1, 2, 3). A multidisciplinary team approach is needed to develop a safe delivery plan (1, 2, 3). Neuraxial anesthesia is the technique of choice in patients with PPCM as it provides afterload reduction and blunts the hemodynamics response to labor and delivery (2, 3). General anesthesia is used only in emergent situations as volatile agents can decrease SVR, RSI can lead to hemodynamic instability, and the highest risk of mortality occurs during induction and intubation (2). HF medications and monitoring are continued postpartum, and if EF <35%, a LifeVest is warranted (3).
1. Curr Opin Obstet Gynecol (2018); 30:378-38
2. Trends in CV Med (2018); 5:8
3. Curr Treat Options Cardio Med (2018); 20:66