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Management of Parturient with Hypertrophic Obstructive Cardiomyopathy
Abstract Number: RF3AC-386
Abstract Type: Case Report Case Series
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant genetic disease caused by mutations in sarcomere genes resulting in defective contractile components within cardiac myocytes. It is characterized by asymmetric hypertrophy of left ventricle, resulting in left ventricular outflow tract (LVOT) obstruction that is exacerbated by decreases in preload. Given the hemodynamic changes that occur during pregnancy and labor, parturients with HOCM must be carefully medically managed to minimize morbidity and mortality to the mother and fetus .
A 37 year-old G5P2 patient with a history of chronic hypertension treated with metoprolol, and echocardiogram findings concerning for HOCM presented to L&D at 37w5d for planned vaginal delivery. Physical exam notable for 3/6 systolic ejection murmur at right sternal border. Cardiology following for HCOM management who recommended forceps assisted vaginal delivery with epidural to decrease straining which would worsen LVOT obstruction, continuing home metoprolol, and treating episodes of hypotension with fluid boluses and phenylephrine while avoiding inotropes.
At 38w, an epidural catheter was placed and labor was induced with oxytocin. Shortly after induction, patient began complaining of SOB with contractions, associated with episodes of tachycardia with HR in 110s and SBPs of 170s. EKG revealed signs of LVH with strain/ischemia and inverted T-waves in inferior leads. Decision was made to take patient to OR for urgent cesarean section.
An arterial line and central line were placed, and a continuous epidural with bupivacaine and fentanyl provided adequate analgesia. Normal cesarean section followed. Epidural was kept in place for an additional 24 hours to minimize episodes of tachycardia secondary to pain. Patient transferred from ECU to floor on POD#1 and was discharged home on POD#4 with instructions to follow up with cardiology.
Expectant mothers with hypertrophic obstructive cardiomyopathy have a higher risk of perinatal morbidity and mortality compared to the general population . However, the risks to the mother and fetus can be minimized with appropriate medical management, particularly with the use of negative inotropic agents (e.g. beta blockers or nondihydropyridine calcium channel blockers), avoiding vasodilators, using neuraxial anesthetics to minimize tachycardia and straining secondary to pain, and phenylephrine to maintain SVR [2,3].
 Autore, C., et al (2003). Risk associated with pregnancy in hypertrophic cardiomyopathy. ACC Current Journal Review, 12(2), 101.
 Hensley, N. B., et al (2014). Evaluation and Management of Hypertrophic Cardiomyopathic Patients Through Noncardiac Surgery and Pregnancy. Hypertrophic Cardiomyopathy, 269-278.
 Wigle, E. D., et al. Hypertrophic Cardiomyopathy with Latent (Provocable) Obstruction: Pathophysiology and Management. Diagnosis and Management of Hypertrophic Cardiomyopathy, 95-104.