P058: EVOLVING CARE OF A PARTURIENT WITH NEWLY DIAGNOSED HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY, CHRONIC HYPERTENSION AND MYOCARDITIS
Lida Esfandiary, MD; Adam L Wendling, MD; University of Florida
Introduction: The leading cause of maternal mortality in the US is cardiovascular disease. We present the evolving care of a parturient with newly diagnosed hypertrophic cardiomyopathy (HOCM), chronic hypertension (cHTN), and myocarditis.
Methods: A 26-year-old G2P1 parturient with cHTN presented with a two-day history of shortness of breath at 23 weeks estimated gestational age. Of note, the patient had discontinued her previously prescribed labetalol due to intolerance. Upon presentation with severely elevated blood pressures and elevated liver function enzymes, she was given hydralazine due to her intolerance of labetalol. Shortly thereafter, she had a precipitous decline in blood pressure, tachycardia and concerns for atrial fibrillation with rapid ventricular response. She was resuscitated and stabilized with phenylephrine and fluids. Subsequent transthoracic echocardiogram (TTE) found left ventricular ejection fraction (LVEF) of 60% with severely asymmetric septal hypertrophy without obstruction at the time. Other pertinent findings included electrocardiogram with left ventricular hypertrophy and right bundle branch block, elevated B-type natriuretic peptide, and severely elevated, upward-trending troponins. She was stabilized with esmolol infusion which was eventually transitioned to twice daily metoprolol. Fetal assessments were generally favorable aside from stable fetal growth restriction. Later, a second TTE revealed persistent severe septal hypertrophy without obstruction, but with decreased LVEF to 40% followed by a third TTE which demonstrated normal septal thickness but further decrease in LVEF to 30%.
Results: Throughout the remainder of her hospitalization, her blood pressure remained controlled, and she was largely asymptomatic. Troponins eventually returned to baseline as well. Due to her prolonged hospitalization with a possible episode of unstable atrial fibrillation during her initial presentation and declining LVEF, she was anticoagulated with low molecular weight heparin. Since her symptoms and fetal status were largely stable, her delivery is planned for 37 weeks EGA via cesarean delivery.
Discussion: For her CD, we plan a left radial arterial line and continuous ECG prior to a high lumbar epidural catheter. Intravenous midazolam will be available if needed for anxiolysis. Surgical anesthesia will be achieved with incremental doses of 2% lidocaine and epidural fentanyl to improve block quality. Phenylephrine infusion will maintain mean arterial pressure within 10% of baseline. Uterine tone will be achieved with controlled infusion of intravenous oxytocin and, if needed, carboprost. Quantitative blood loss and urine output will be followed with judicious volume replacement with crystalloid since she has demonstrated declining LVEF. She will recover with ongoing invasive blood pressure and continuous ECG monitoring for 24h. Postoperative analgesia will be with epidural morphine 3mg, scheduled ketorolac and acetaminophen with oral oxycodone 5mg as needed. She will have enoxaparin restarted no sooner than 24h after epidural catheter is removed. We plan on follow up with heart failure clinic for her evolving condition.
Conclusion: This is a unique case illustrating care of a parturient with cHTN and newly diagnosed HOCM with depressed heart function that continues to decline and the evolving plans to best manage her condition.