A 36-year-old female G7P4034 (7 pregnancies; 4 full-term deliveries; 0 preterm; 3 abortions; 4 living children) at 31 weeks gestation presented with preterm contractions, orthopnea, and worsening dyspnea. Notably, she had a history of peripartum cardiomyopathy with persistent left ventricular dysfunction (LVEF) of 20%. The patient had previously been advised against pregnancy due to non-recovered ventricular function (World Health Organization Class IV).1 She declined admission for cardiac optimization earlier in pregnancy due to complex social circumstances. Laboratory studies revealed abnormalities in creatinine, liver function tests, lactate, and N-terminal B-type natriuretic peptide levels.
Due to concerns of impending cardiac decompensation, the patient was transferred to the cardiac intensive care unit (CICU) for closer monitoring. Upon repeat cervical examination in the CICU, the patient was found to be in early preterm labor, cephalic presenting, with reassuring fetal heart monitoring. Hemodynamic assessment with pulmonary artery catheterization confirmed cardiogenic shock. Dobutamine was initiated, resulting in improved systemic oxygenation and cardiac performance. A multidisciplinary team involving obstetrics, maternal-fetal medicine, cardiology, advanced heart failure (HF), obstetric anesthesia, cardiac anesthesia, cardiothoracic surgery, neonatology, and cardiac intensive care discussed the patient's case for delivery planning.
Which one of the below is the best delivery strategy for this patient?
Show Answer
The correct answer is: B. Immediate augmentation of labor with planned vaginal delivery.
Augmentation of labor with planned vaginal delivery is generally the preferred method of delivery in this population and is considered safe in pregnant patients with HF when hemodynamically stable or stabilized with inotropic support.1–3 Cesarean delivery (A) is associated with increased maternal risk (e.g., infection, hemorrhage with or without blood transfusion, and surgical complications including intraoperative injury, thromboembolism, and hemodynamic stress) and should be reserved for urgent or emergent cases.4 Cesarean delivery may have been appropriate had the patient's hemodynamic status not improved with dobutamine. Cesarean delivery may also be indicated in situations where expediting delivery is necessary due to acute decompensation in cardiac function or clinical status, where the risks of continuing with a trial of labor outweigh the benefits of vaginal delivery.4 Delaying delivery for medical optimization (C) is often not clinically feasible; worsening decompensation due to ongoing pregnancy physiology makes expedited delivery necessary.1,5 Post-delivery, additional interventions can optimize cardiac function and hasten the resolution of pregnancy-related cardiovascular changes.1,5
In this scenario, the patient's parity and early gestational age increased the chances of achieving a prompt vaginal delivery in the second stage with minimal maternal exertion. After hemodynamic improvement with dobutamine, augmentation of labor with continued invasive hemodynamic monitoring was recommended. Labor occurred in a cardiac operating room to allow for ongoing multidisciplinary cardiac and obstetric care and to facilitate prompt intervention (e.g., mechanical support, extracorporeal membrane oxygenation [ECMO], cesarean delivery) in case of further clinical deterioration.1,3,5 The patient was preemptively cannulated for potential escalation to an intra-aortic balloon pump or ECMO. The patient had a spontaneous vaginal delivery without maternal or fetal complication. Postpartum, an immediate post-placental levonorgestrel-releasing intrauterine device was inserted.1 Dobutamine was continued, along with nitroglycerin drip for afterload reduction and intravenous diuresis for biventricular volume overload. The patient was successfully weaned off nitroglycerin and dobutamine by post-delivery day 2 and transitioned to oral guideline-directed medical therapy. The patient chose not to breastfeed, therefore upon discharge, the patient was prescribed empagliflozin, sacubitril/valsartan, spironolactone, carvedilol, and anticoagulation given pro-thrombotic risk with post-delivery LVEF of 15%.3 Avoidance of future pregnancy was advised.1,3
Mehta LS, Warnes CA, Bradley E, et al; American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Cardiovascular considerations in caring for pregnant patients: a scientific statement from the American Heart Association. Circulation 2020;141:e884-e903.
Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum cardiomyopathy. J Am Coll Cardiol 2020;75:207-21.
Ecker JL, Frigoletto FD Jr. Cesarean delivery and the risk–benefit calculus. N Engl J Med 2007;356:885-88.
Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary management of cardiogenic shock during pregnancy. J Card Fail 2023;29:193-209.
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