Help! She's a 33 Week Multip...Breech...Fully Dilated...and by the Way She Has a Cardiomyopathy!
- Describe the effects of pregnancy on the heart.
- Identify the signs and symptoms of cardiomyopathy.
- Describe the impact of cardiomyopathy on pregnancy.
Case: Cardiomyopathy was diagnosed 6 years prior, and she was counseled not to get pregnant again. Her ejection fraction was 10-15%. She had mild shortness of breath, but no chest pain. She had pulmonary hypertension, chronic hypertension and type 2 diabetes. An anesthesiology consult, cardiology consult and neonatology consult were ordered. She denied discomfort, but contractions were noted every one to three minutes, so tocolysis was ordered.
Later, she spontaneously ruptured membranes and was visually unchanged on speculum exam (2 cms). An hour later, she became uncomfortable, found to be fully dilated with a frank breech presentation. The fetal heart rate was nonreassuring and a stat c-section was called. The patient was on the OR table one minute later, but she would not stop pushing, and delivered a baby weighing 2600 grams vaginally. The apgars were 7/9 and the newborn was transferred to the Neonatal Intensive Care Unit.
BPs in the OR spiked to 200s/100s, and the patient was started on a nitroglycerin drip by the anesthesia team. She was taken to the ICU to recover. The patient had expressed a desire to breastfeed and had a lactation consult, but it was determined that the medications she would require would be contraindicated.
Four days later she had an ICD (implantable cardioverter defibrillator) placed. The ICD had been recommended because of her risk of sudden cardiac death when she was in her first trimester, but she had elected to wait until after she delivered. The following day, she had an IUD placed and was discharged to home.
Conclusion: Cardiomyopathy is rare and can be life-threatening. (She had been warned that her mortality rate would be greater than 50%). Cardiomyopathies are classified as dilated, hypertrophic or restrictive. Dilated cardiomyopathy was her diagnosis, the most commonly diagnosed and also the most common cardiomyopathy associated with pregnancy. The left ventricle is dilated and weakened in dilated cardiomyopathy resulting in a decrease in the heart’s ability to pump blood.
An assisted second stage would be planned for these patients in order to decrease the work load on her heart, so she was fortunate not to have pushed long. Patients such as this would benefit from a multidisciplinary plan communicated by viability at the latest.
Keywords: cardiomyopathy, dilated cardiomyopathy, heart disease
