///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Prophylactic intraaortic balloon pump placement prior to induction of labor in a patient with peripartum cardiomyopathy and severe mitral regurgitation

Abstract Number: RF4BD-457
Abstract Type: Case Report Case Series

David E Arnolds Md, PhD1 ; Richa Dhawan MD2; Jennifer Banayan MD3

A 30 yo G7P6 patient of unknown gestational age (GA) but approximately in the third trimester presented with chest and abdominal pain. She had a history of peripartum cardiomyopathy (PPCM) diagnosed after her most recent delivery. She did not seek prenatal care and continued her heart failure medications, including lisinopril, during this pregnancy. Ultrasound was consistent with GA of 32-35 weeks and revealed anhydramnios. Transthoracic echocardiography demonstrated dilated cardiomyopathy with a left ventricular ejection fraction (EF) of 38% and severe mitral regurgitation (MR). She was recognized as being at high high risk of peripartum decompensation due to her severe MR and low EF. Cardiology was consulted and recommended prophylactic placement of an intraaortic balloon pump (IABP). After multidisciplinary discussion, a subclavian IABP was placed and the patient underwent induction of labor with a transcervical catheter and oxytocin. The patient was managed on labor and delivery with a cardiac intensive care unit (ICU) nurse to manage the IABP. A dural puncture epidural was placed for labor analgesia, as well as to minimize cardiac stress during delivery and further reduce afterload. The patient remained hemodynamically stable throughout labor and delivered a vigorous infant. After postpartum tubal ligation, the patient was transferred to the cardiac ICU. On postpartum day 1 her intraaortic balloon ruptured. She remained hemodynamically stable and the IABP was removed. On postpartum day 2 she was transferred to the floor and was subsequently discharged on postpartum day 4.

Cardiac disease is the leading cause of pregnancy-related mortality in the United States (1). Pregnancy is particularly high risk in women with severe mitral or aortic valve disease, history of PPCM, EF < 40%, aortopathy, cyanotic congenital heart disease, or pulmonary hypertension (2). Late prenatal care is additionally associated with poor cardiac outcomes (3). IABPs are primarily used as mechanical support for patients in cardiogenic shock, but have also been used prior to high-risk procedures. Case reports describe IABP use in pregnancy for patients with peripartum cardiomyopathy (4, 5), although we are unaware of prior reports of prophylactic IABP placement prior to labor and vaginal delivery. Our patient suffered rupture of her intraaortic balloon, which is a rare but recognized complication of IABPs (6). The overall major complication rate associated with IABPs is approximately 3% (6). Our case highlights the challenges of caring for parturients with severe cardiac disease as well as the need to balance risks and possible benefits of mechanical circulatory support for vaginal delivery.

1.Creanga et al 2015

2. Elkayam et al 2016

3. Silversides et al 2018

4. Samalvavicius et al 2018

5. Gevaert et al Crit Care 2011

6. Ferguson et al JACC 2001

SOAP 2019