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Just a C/S in a morbidly obese patient, What about her strokes, heparin and bad heart valve?
Abstract Number: RF5AH-196
Abstract Type: Case Report Case Series
A 35-year-old morbidly obese (177 kg) woman, G1P0, at 26 weeks gestation, presented to triage after an ultrasound showed absent end diastolic flow. A repeat ultrasound confirmed this diagnosis and the patient was admitted to L&D where magnesium and antenatal corticosteroids were started. The patient’s medical history was complex. In 2004 the patient was diagnosed with rheumatic heart disease and underwent a mechanical mitral valve replacement. In the following years, she had multiple ischemic strokes resulting from non-compliance with anticoagulation. In October of 2018, a large thrombus was found on her mitral valve which caused critical mitral stenosis, acute diastolic heart failure and a new stroke. It was deemed necessary at this time for the patient to undergo a redo-mitral mechanical valve replacement at 12 weeks gestation. The patient was admitted again in November 2018 for atrial flutter which required multiple cardioversions and initiation of metoprolol and flecainide. On admission to L&D cardiology was consulted for management of anticoagulation and a heparin drip was started. She reported good fetal movement and her fetal tracings were category 1. Over the following week, fetal tracings worsened with multiple prolonged decelerations. A multidisciplinary meeting was held, and it was agreed that the safest plan for the patient and baby would be a primary cesarean delivery under general anesthesia. Anticoagulation was discontinued for 6 hours and anti-Xa and PTT laboratory values returned to normal. On hospital day six the patient was taken to the operating room where an awake arterial line, central line and pulmonary artery catheter were inserted. A cardiac anesthesiologist was present during insertion of lines and induction of anesthesia and a cardiothoracic surgeon was available in case advance circulatory support was needed. The patient was started on a norepinephrine drip and the patient was induced with propofol, ketamine and etomidate. She received succinylcholine and a secure airway was obtained by way of video laryngoscopy. The patient tolerated induction and incision well, with no hemodynamic issues. The obstetricians were able to dissect down to the uterus with little bleeding and a viable baby boy was delivered. On delivery of the placenta, the patient became hypertensive and her pulmonary artery pressures became severely elevated. The patient was given a dose of milrinone and over the next 10 minutes her pulmonary pressures equalized to baseline. The obstetricians were able to control hemostasis quickly and closed the uterus and abdomen with no significant complications. At the end of the case, she was reversed with glycopyrrolate and neostigmine and was transitioned to pressure support ventilation. The patient was found to meet extubation criteria and was extubated in the OR with no pulmonary complications. The patient was taken to the CVICU for further monitoring and was able to leave the ICU the following day.