2019 FSA Posters

P016: NON-ISCHEMIC CARDIOMYOPATHY IN PREGNANCY
Tyler Haskell, DO, Matthew Andoniadis, MD, Adam Wendling, Michael (Tony) Cometa, MD; University of Florida

Introduction/Background: Pregnancy results in significant physiologic changes to the parturient.  Comorbidities such as severe non-ischemic cardiomyopathy (NICM) and pulmonary hypertension present an additional challenge to the anesthesiologist.  We discuss the coordination of care between multiple disciplines and the use of an intra-aortic balloon pump to facilitate a safe delivery plan for both the mother and infant.

We present the case of a 38-year-old G7P4024 morbidly obese female with NICM who presented with decompensated systolic heart failure at 24 weeks gestation. The patient’s ejection fraction (EF) was noted to be 20-25%.  Due to the patient's tenuous state, she was kept in cardiac intensive care unit (CICU) until 28 weeks gestation while being optimized with dopamine, bumetanide, and metoprolol.  The original plan was to have the obstetrical team induce labor in the cardiac intensive care unit (CICU).  The anesthesiology service was to be consulted for labor analgesia and the cardiology service would place an intra-aortic balloon pump (IABP) to assist cardiac function in the immediate postpartum period.  Additionally, a femoral central venous line (CVL) and femoral arterial line were to be placed in case extracorporeal membrane oxygenation (ECMO) became necessary.  On hospital day 28, however, the patient decompensated becoming tachycardic, tachypneic, and more orthopneic[M1] [M2] .  She emergently underwent insertion of an IABP and pulmonary artery catheter (PAC).  A milrinone infusion was initiated secondary to PAP of 50/30 and PCWP of 30 mmHg.  Dopamine and bumetanide infusions were continued and magnesium was added for fetal neural protection.  The following day a cesarean delivery under general anesthesia was provided by an anesthesiology team experienced in both obstetrical and cardiac anesthesia.

Methods: In the operating room anesthesia was induced via a rapid sequence induction with 50mg lidocaine, 20mg etomidate, 100mcg fentanyl, 100mg succinylcholine. Pulmonary artery pressures remained stable throughout case. Intraoperative transesophageal echocardiography demonstrated severe global hypokinesis, dilated left ventricle, EF 20%, tricuspid annular plane systolic excursion of 11.3mm indicating severe right ventricular systolic dysfunction, and severe mitral and tricuspid regurgitation. Epinephrine and norepinephrine infusions were initiated secondary to decreasing cardiac index and blood pressure.  At the conclusion of surgery for post op analgesia, ultrasound guided bilateral transverse abdominis plane blocks were performed and then the patient was extubated.

Results: Low transverse cesarean delivery. Infant female was double footling breech presentation, weighing 1275g. APGARS 6 and 9 at 1 and 5 minutes.

Discussion/Conclusion: Physiologic changes of pregnancy result in increased maternal blood volume and cardiac output which would present significant challenges for our patient. The anticipated use of IABP optimizes the cardiac function during the critical postpartum period when increases in blood volume from uterine autotransfusion can cause acute hemodynamic compromise.  Despite appropriate multidisciplinary peripartum planning, the patient required more immediate intervention via IABP due to acute cardiogenic decompensation.  With a femoral IABP optimal positioning for neuraxial blockade was not possible and proceeding under general anesthesia allowed for improved oxygenation and ventilation, intraoperative TEE monitoring, and decreased labor-associated hemodynamic alterations which may have occurred with vaginal delivery.