Sudden death during pregnancy in hypertrophic cardiomyopathy

Sudden death of a pregnant woman because of massive aspiration-case report and review of literature

INTRODUCTION

Massive aspiration of gastric contents as a cause of death in pregnancy without anesthesia is possible, but is not documented in the available literature as a separate case report.

AIM

To describe sudden death of a pregnant woman because of massive aspiration of gastric contents.

CASE REPORT

The presence of a valvular anomaly in a 26-year-old woman had been known since childhood: the prolapse of both mitral cusps. In the 34th week of her second pregnancy, after dinner, she went to take a shower when she collapsed with abundant vomiting of stomach contents. The ambulance came in 20 min and started a resuscitation procedure which was unsuccessful, and the death of the pregnant woman was established in the 34th week of pregnancy. Autopsy revealed massive aspiration of gastric contents into the trachea and bronchi, pulmonary edema, and generalized cyanosis. Left ventricular dilatation was found in the heart, with prolapse of both mitral valve cusps.

CONCLUSION

Sudden deaths in pregnancy are rare and dramatic conditions in emergency medicine. Cardiac checkups are very important for pregnant women with heart failures or heart anomalies, and must be recommended by gynecologists.

Pregnancy-induced severe left ventricular systolic dysfunction in a patient with hypertrophic cardiomyopathy

This paper reports the first case of hypertrophic cardiomyopathy (HCM) that developed postpartum congestive heart failure (CHF) and severe left ventricular (LV) systolic dysfunction. Review of the literature and clinical implications are discussed.

Cardiomyopathy in pregnancy and caesarean section: Four case reports

We present the clinical details of four women with cardiomyopathy who required caesarean section. Two women had peripartum cardiomyopathy and two had hypertrophic obstructive cardiomyopathy, one of whom has had two caesarean sections. Those with peripartum cardiomyopathy were more compromised than those with hypertrophic obstructive cardiomyopathy. Co-operation between obstetric and cardiac anaesthetists ensured optimum experience was available. An incremental combined spinal-epidural technique with invasive monitoring was used for three women and one received general anaesthesia. The risks and benefits of different anaesthetic techniques are discussed.

Pregnancy related complications in women with hypertrophic cardiomyopathy

OBJECTIVES

To determine whether pregnancy is well tolerated in hypertrophic cardiomyopathy.

SETTING

Referral clinic.

DESIGN

The study cohort comprised 127 consecutively referred women with hypertrophic cardiomyopathy. Forty (31.5%) underwent clinical evaluation before pregnancy. The remaining 87 (68.5%) were referred after their first pregnancy. All underwent history, examination, electrocardiography, and echocardiography. Pregnancy related symptoms and complications were determined by questionnaire and review of medical and obstetric records where available.

RESULTS

There were 271 pregnancies in total. Thirty six (28.3%) women reported cardiac symptoms in pregnancy. Over 90% of these women had been symptomatic before pregnancy. Symptoms deteriorated during pregnancy in fewer than 10%. Of the 36 women with symptoms during pregnancy, 30 had further pregnancies. Symptoms reoccurred in 18 (60%); symptomatic deterioration was not reported. Heart failure occurred postnatally in two women (1.6%). No complications were reported in 19 (15%) women who underwent general anaesthesia and in 22 (17.4%) women who received epidural anaesthesia, three of whom had a significant left ventricular outflow tract gradient at diagnosis after pregnancy. Three unexplained intrauterine deaths occurred in women taking cardiac medication throughout pregnancy. No echocardiographic or clinical feature was a useful indicator of pregnancy related complications.

CONCLUSIONS

Most women with hypertrophic cardiomyopathy tolerate pregnancy well. However, rare complications can occur and therefore planned delivery and fetal monitoring are still required for some patients.

UK registry of high-risk obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan’s syndrome

The UK registry of high-risk obstetric anaesthesia was set up in late 1996 to collect reports of high-risk pregnancy, pool them into a central database and disseminate the results. At the time of analysis for this paper (December 31, 2001) 308 cardiorespiratory reports had been received. The five most common conditions, occurring in 125 cases (41% of the total), were arrhythmias (43 cases), cardiomyopathy (26 cases), aortic stenosis (24 cases), transposition of the great arteries (18 cases) and Marfan's syndrome (14 cases). We describe the features and management of these cases.

Risk associated with pregnancy in hypertrophic cardiomyopathy

OBJECTIVES

We sought to assess mortality and morbidity in pregnant women with hypertrophic cardiomyopathy (HCM).

BACKGROUND

The risk associated with pregnancy in women with HCM is an important and increasingly frequent clinical issue for which systematic data are not available and a large measure of uncertainty persists.

METHODS

Maternal mortality in 91 consecutively evaluated families with HCM was compared with that reported in the general population. The study cohort included 100 women with HCM with one or more live births, for a total of 199 live births. Morbidity related to HCM during pregnancy was investigated in 40 women evaluated within five years of their pregnancy.

RESULTS

Two pregnancy-related deaths occurred, both in patients at a particularly high risk. The maternal mortality rate was 10 per 1,000 live births (95% confidence interval [CI] 1.1 to 36.2/1,000) and was in excess of the expected mortality in the general Italian population (relative risk 17.1, 95% CI 2.0 to 61.8). In the 40 patients evaluated within close proximity of their pregnancy, 1 (4%) of the 28 who were previously asymptomatic and 5 (42%) of the 12 with symptoms progressed to functional class III or IV during pregnancy (p < 0.01). One patient had atrial fibrillation and one had syncope, both of whom had already experienced similar and recurrent events before their pregnancy.

CONCLUSIONS

Maternal mortality is increased in patients with HCM compared with the general population. However, absolute maternal mortality is low and appears to be principally confined to women at a particularly high risk. In the presence of a favorable clinical profile, the progression of symptoms, atrial fibrillation, and syncope are also uncommon during pregnancy.

Epidural analgesia for labour and delivery in a parturient with congenital hypertrophic obstructive cardiomyopathy

We report a parturient delivering vaginally at term with symptomatic congenital hypertrophic obstructive cardiomyopathy. Epidural analgesia was used during labour and delivery and is likely to have made a useful contribution to the successful outcome. Although controversial, reported use of epidural analgesia during labour for hypertrophic obstructive cardiomyopathy parturients has been generally positive. A multi-disciplinary team approach, early anaesthetic assessment and a carefully managed epidural catheter inserted in early labour can optimize analgesia and minimize the stresses of labour and vaginal delivery provided the risks of reduced preload and afterload are minimized.

Hypertrophic cardiomyopathy and pregnancy

The case of a young primiparous woman with defibrillator-assisted familial hypertrophic cardiomyopathy (HCM) has led us to review the literature on this pathology, which is exceptional because of its scarcity and the originality of the problems encountered. To our knowledge, this is the first observation ever reported of defibrillator-assisted activation during pregnancy in a woman with HCM. Several questions raised from this particular case, e.g. what are the risks caused by pregnancy in these patients, what is the impact of therapeutics, does the activation of an internal defibrillator involve particular risks, what is the best disposition for delivery and what are the risks for fetuses? We have tried to ask all of these questions, using as exhaustive a literature review as possible.