P035: ANESTHETIC MANAGEMENT OF A PARTURIENT WITH PERIPARTUM CARDIOMYOPATHY FOR CESAREAN DELIVERY
Karan Verma, MD, Zahira Zahid, MD; JMH
Background: Peripartum cardiomyopathy is a type of dilated cardiomyopathy that results in heart failure in the last month of pregnancy or within five months of delivery. There is an absence of identifiable cause for the heart failure and there is no recognizable heart disease prior to the diagnosis. The left ventricular systolic function is reduced as evidenced by an ejection fraction of less than 45%. This condition affects 1 in 1300 to 4000 live births and the survival rate is 98% with appropriate management. We describe the management of a parturient scheduled for cesarean section with peripartum cardiomyopathy after medical optimization.
Clinical Features: A 33 year old Hispanic lady G3P2002 at 34 weeks gestation presents with acute congestive heart failure. She is diagnosed with dilated peripartum cardiomyopathy (EF 20%, NYHA class 4) and is started on medical management in the cardiac intensive unit with improvements in symptoms and ejection fraction on ECHO. Her past medical history is significant for obesity (BMI 50). At a multidisciplinary conference, a decision is made to proceed with cesarean delivery at 34.3 weeks as there is a potential for deterioration from a cardiac standpoint. After placement of an arterial line and obtaining central IV access with invasive monitoring (Swan Ganz), a modified CSE with reduced spinal dose is performed. The patient remains hemodynamically stable. In addition, the groin is cannulated should the patient decompensate and need to be placed emergently on ECMO. The Cardiac Surgery team is present at bedside. Intra-op course is uneventful. A baby girl is born with APGARS of 9/9/9. Blood loss is 700cc. Initial postoperative care is in the cardiac intensive unit. The ECMO line is removed 48 hours post-op. She is observed for 7 days in the cardiac intensive unit and discharged home on POD # 8.
Conclusion: The management of patients with peripartum cardiomyopathy is complex and requires a multidisciplinary approach and a coordinated plan of action. Anesthetic goals for cesarean delivery include preserving cardiac contractility, and avoiding large increase in preload and afterload. A modified CSE with invasive blood pressure monitoring is a safe alternative to general anesthesia in these patients. Lastly, prophylactic ECMO cannulation is a feasible option in patients with peripartum cardiomyopathy with high risk features.