Maternal Heart Strain: Navigating Peripartum Cardiomyopathy in Crisis

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?

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