Management of a Parturient with Symptomatic Severe Aortic Stenosis and Unstable Mood Disorder
•The physiologic changes of pregnancy can increase cardiac complications in patients with history of stenotic valve repair or replacement.
•The mean pressure gradient across a prosthetic valve increases throughout gestation, due to the increase in cardiac output, leading to worsening symptoms as pregnancy progresses1.
•This can be further challenging to manage in the setting of unstable mood disorder.
•We present a parturient with symptomatic severe stenosis of her bioprosthetic aortic valve and the challenges associated with her mental health.
A 38 yo G4P2 with history of thoracic aortic aneurysm s/p aortic root replacement with bioprosthesis in 2004, presented at 32 weeks gestation to the labor and delivery unit after a witnessed syncopal episode in a lobby of the hospital. She reported worsening chest pain and intermittent shortness of breath since her third trimester. She also had a history of bipolar/schizoaffective disorder, and had self-discontinued her monthly Haldol injections early in the pregnancy. Transthoracic echo revealed severe stenosis of her bioprosthetic aortic valve with peak velocity of 6.1m/s and aortic valve area of 0.6cm2.
•Given the severity of her symptoms and stenosis, cardiology recommended urgent aortic balloon valvuloplasty. Initially, she was very tearful, with intermittent screaming outbursts and expressed hopelessness for her and baby’s life. She refused all forms of care including IV access and any cardiac intervention. She left the labor unit several times, and her capacity was assessed by psychiatry as she expressed no concern about the mortality of her condition without emergent intervention. After much counseling, she eventually agreed to plan of care.
•Due to the concern of maternal mortality and unpredictable nature of delivery, our multidisciplinary team planned for C-section and bilateral tubal ligation with cardiopulmonary bypass and cardiac surgeons on standby. In the event of acute decompensation, an emergent aortic valve replacement would take place. In the OR, an awake arterial line and right IJ central line were placed with a low dose dexmedetomidine infusion in the background. A dural puncture epidural was placed, slowly dosed with 2% lidocaine until a T6 level was obtained. CVTS placed sheaths in the right common femoral artery and vein. Once, baby was delivered, a remifentanil infusion was initiated and she received morphine through her epidural. Hemodynamics remained stable throughout and she was transported to CVICU for monitoring. Two days later, she returned to the OR for an aortic valve replacement and was discharged home 5 days later.
•In 10% of maternal severe aortic stenosis, cardiac complications during pregnancy are reported1.
•Further studies are needed to identify and evaluate normal echocardiographic parameters to assess prosthetic valve function in pregnancy1.
•Risk of complications can significantly increase in the setting of untreated mood disorders, potentially impacting treatment and exposing the patient and fetus to harm2.
•Studies have shown peripartum depression as a risk factor for pre-eclampsia and cardiovascular disease in general however, further studies needed to determine whether it is a risk factor for cardiovascular complications of pregnancy3.
•Treatment and delivery planning should include integration of mental health services in the perinatal management of patients with severe cardiac disease and poor mental health.