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Table of Contents  
CASE REPORT
Year : 2010  |  Volume : 4  |  Issue : 2  |  Page : 115-118  

Cardiac arrest in a case of undiagnosed dilated cardiomyopathy patient presenting for emergency cesarean section


1 Department of Obstetrics and Gynaecology, Gian Sagar Medical College & Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Anaesthesiology & Intensive Care, Gian Sagar Medical College & Hospital, Ram Nagar, Banur, Punjab, India

Date of Web Publication3-Dec-2010

Correspondence Address:
Sukhwinder Kaur Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.73520

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   Abstract 

Cardiac diseases in the pregnancy pose a multitude of challenges to the obstetricians as well as anesthesiologists. Cardiac pregnant patients presenting for emergency cesarean section do not give time for cardiac optimization and stabilization if they come to the hospital for the first time without any antenatal check-up. The situation can get worse if there is no history related to the decompensated cardiac tissue with asymptomatic gestation and also if the relatives hide all the facts from the doctor about any past cardiac history. We report a case of term pregnancy for emergency cesarean section with asymptomatic dilated cardiomyopathy, which developed severe ventricular arrhythmias and cardiac arrest during the surgical procedure. She was resuscitated successfully on the operation table and was shifted to Intensive Care Unit for further management. The diagnosis of dilated cardiomyopathy was made only after carrying out echocardiography in the postoperative period. The history of previous cardiac complaints was not revealed purposefully by the relatives to avoid the expenses which they would have incurred on investigations and treatment of cardiac ailment.

Keywords: Cardiac diseases, dilated cardiomyopathy, lignocaine, ventricular tachycardia


How to cite this article:
Bajwa SK, Bajwa SJ, Sood A. Cardiac arrest in a case of undiagnosed dilated cardiomyopathy patient presenting for emergency cesarean section. Anesth Essays Res 2010;4:115-8

How to cite this URL:
Bajwa SK, Bajwa SJ, Sood A. Cardiac arrest in a case of undiagnosed dilated cardiomyopathy patient presenting for emergency cesarean section. Anesth Essays Res [serial online] 2010 [cited 2019 Dec 7];4:115-8. Available from: http://www.aeronline.org/text.asp?2010/4/2/115/73520


   Introduction Top


The level of literacy, sociocultural behavior and lack of awareness regarding medical health hazards in developing countries like India lead to ignorance of the impact of pre-existing heart diseases on becoming pregnant and its outcome. As a result, in spite of the safe motherhood policies formed by the government, it fails to elicit a large-scale response in adoption of contraceptive practices and adequate safety during pregnancy. We are reporting an asymptomatic and undiagnosed case of peripartum dilated cardiomyopathy, which presented to our institute for emergency caesarean section and developed ventricular arrhythmias and cardiac arrest during surgery.


   Case Report Top


A 24-year-old lady belonging to low socioeconomic strata, presented to the antenatal outpatient department with history of decreased fetal movements since 3-4 days and productive cough with mucoid sputum since 2-3 days. Her period of gestation (POG) came up to be 38 weeks + 2 days. Detailed history did not reveal any significant medical disease. Patient had a regular antenatal check-up with a private practitioner and her 1 st and 2 nd trimesters were uneventful. She had been immunized against tetanus and had taken regular hematinics during the present pregnancy. She had undergone one previous lower segment cesarean section (LSCS) 4 years back under subarachnoid block at term for meconium stained liquor with fetal distress, at a private nursing home. She did not give history of any postoperative complication after the previous LSCS and was immunized with immunoglobulin-D. A detailed, but quick, pre-anesthetic examination was conducted by the anesthesiologist and the following parameters were recorded on examination.

  • general physical examination: no significant finding;
  • fasting status: since last 4 hours;
  • pulse: 88/minute with regular rhythm;
  • blood pressure: 120/70 mm of Hg;
  • cardiovascular system: Normal first and second heart sounds heard with no added sound;
  • respiratory system: B/L occasional rhonchi were heard; and
  • per abdomen: uterus was term size, relaxed with cephalic presentation, fetal heart rate was 110/minute with regular rhythm.
Her provisional diagnosis was established as Gravida 2 and Para 1 having POG 38 wks + with previous LSCS and Rh negative pregnancy. Immediate ultrasonography with biophysical profile (BPP) was done which revealed decreased liquor and no active fetal movement, decreased fetal tone and non stress test revealed non-reassuring fetal heart pattern. The decision for immediate LSCS was taken in view of deranged BPP with the consent of relatives after explaining to them about the surgical and anesthetic implications. Patient was shifted to the operation theater and a good intravenous access was secured. Monitoring gadgets were attached for pulse rate, non-invasive blood pressure, pulse oximetry and electrocardiogram. She was administered intrathecal anesthesia with 26-G quincke spinal needle, and 2.2 ml of 0.5% of hyperbaric bupivacaine was injected into subarachnoid space after establishing a clear flow of cerebrospinal fluid. Surgery commenced after the sensory analgesia was established at T8 dermatome. Live term female baby was delivered as vertex, and during uterine closure, the patient developed bizarre ventricular complexes immediately after administration of injection oxytocin as infusion. She developed ventricular tachycardia with a rate of 140/minute and was administered preservative free injection xylocaine 80 mg as bolus dose. The ventricular tachycardia did not revert even after administration of additional 80 mg dose of xylocaine and progressed to ventricular fibrillation. Patient developed cardiac arrest and surgery was stopped. We applied 200 J of asynchronized direct current with defibrillator and were ready with injection adrenaline but fortunately she regained cardiac activity and sinus rhythm. We had intubated the patient with 7.5-mm sized cuffed endotracheal tube during this episode and mechanical ventilation with Bains circuit was initiated. The whole episode lasted for about 2.5-3 minutes. Rest of the surgical period was uneventful, and after the surgery, she was shifted to Intensive Care Unit (ICU) for further management in an intubated state. She was extubated in ICU after 2 hours and her whole treatment was reviewed by the cardiologist. She was advised chest X-ray and echocardiography (ECHO). X-ray chest showed cardiomegaly with no gross pathology in either lung but ECHO showed dilated cardiomyopathy with a decreased left ventricular ejection fraction of 31.8%. After the first postoperative day, she showed marked improvement, breast feeding was started and she was shifted to cardiology ward for further conservative management.

After repeated counseling sessions with the relatives, they revealed that the patient had undergone similar problem in the last pregnancy and they had not revealed these facts this time as they feared heavy expenses on investigations and treatment. Patient was discharged from the hospital on the eighth postoperative day with the instructions not to bear any more pregnancy as well as to carry the treatment card of our institution to wherever she goes for the treatment of any other ailment.


   Discussion Top


The lack of information regarding the increased risks of maternal and fetal health during pregnancy in cardiac diseases leads to a much higher incidence of maternal mortality and morbidity in such patients. The diagnosis of heart diseases in majority of pregnant women in the rural health set-up is very difficult considering the lack of advanced cardiac diagnostic facilities as well as shortage of heart specialists in such peripheral health centers. To our knowledge, there is hardly any risk factor assessment or a scale followed in the entire rural health set-up which should at least measure the potential possibilities leading to increased complications and adverse outcome in pregnant cardiac patients. Though the recent health programs have laid stress on regular antenatal visits and thorough clinical examination, still a lot has to be done from the public side, and the one-sided efforts of government are not going to bear fruitful results. In our case, what could have been done had she delivered outside the tertiary care center? Her entire pregnancy was uneventful and she developed complications only during the surgical procedure and the back-up of intensive care services proved to be a blessing for this patient. The exact incidence of maternal mortality and morbidity due to pre-existing cardiac diseases is very difficult to establish as majority of deliveries occur in the disintegrated health set-up. Pregnant females with asymptomatic cardiac diseases are difficult to diagnose even at the tertiary care level when such patients present for emergency cesarean section. Their clinical condition and the pathophysiologic impact of emergency obstetrical indication warrant immediate cesarean section, and thus give a very short time for pre-anesthetic assessment and relevant investigations. The attending anesthesiologist has to depend upon his clinical acumen and skills to diagnose any subclinical disease entity in these patients and to manage them accordingly.

Peripartum cardiomyopathy is defined as the development of idiopathic left ventricular systolic dysfunction during the last trimester up to 5 months of the postpartum period, with an approximate incidence of 1 in 4000 live births. [1] The diagnosis can be established by echocardiography findings indicating a left ventricular ejection fraction of less than 45%, fractional shortening of less than 30% and a left ventricular end diastolic dimension of more than 2.6 cm/m 2 of body surface area. [2] Patients may present to an obstetrician with a total asymptomatic gestation period or with gradual progressive complaints. Occasionally, the hypertrophy disappears, the ventricular walls become thinner and through a phase of mistaken improvement, congestive heart failure develops. There is a possibility of sudden death in some cases due to onset of ventricular arrhythmia as was the scenario in our case. Although the etiology remains unknown, endomyocardial biopsies in women with peripartum cardiomyopathy have demonstrated myocarditis in many patients. The highest incidence of myocarditis reported was 76%, but one of the most recent series found myocarditis in only 8.8% of the patients. [3],[4] The possible associated risk factors include pregnancy induced hypertension, multiple pregnancy, obesity, multigravida and older age at conception. [5],[6] Medical therapy should be initiated as soon as diagnosis is established, keeping in consideration the safety profile of pregnancy, postpartum period and breast feeding. Drug regimens considered safe during pregnancy include digoxin, diuretics and hydralazine, while beta blockers can be started after delivery to improve the cardiac function. The failure of these drug regimens warrants aggressive and intensive intravenous medications for the sake of maternal safety. Most of the women recover completely with optimal cardiac function during the first 6 months of postpartum period while a few persist with dysfunction of the left ventricle. There is general consensus among cardiologists and the obstetricians that pregnancy should best be avoided and if it continues till term, cesarean section should be the priority over normal trial of labor. Vasodilator agents such as nitroglycerine or nitroprusside for preload and afterload reduction, and dopamine, dobutamine and milrinone for ionotropic support may be used. There is scanty information in the literature regarding anesthetic management of peripartum cardiomyopathy. Some authors have argued the case for general anesthesia in severe cases, as "cardiac reserve" is considered so limited that any reduction in systemic vascular resistance due to epidural blockade could be catastrophic. [7] Others have argued the case for regional anesthesia on the basis that reduction in afterload may be beneficial in a situation of poor ventricular function, where no outflow tract obstruction is present. [8] The choice for combined spinal epidural seems appropriate as this technique has lower failure rate, reduced anxiety, prolonged postoperative analgesia, lower incidence of hemodynamic derangements, fetal and maternal safety and added advantage of regional over general anesthesia. [9],[10],[11]

Neuraxial blockade may actually improve myocardial performance by reducing the afterload on the left ventricle without impairing contractility. [12] The anesthetic management of such patients poses a multitude of challenges to the attending anesthesiologists. The choice of anesthesia is governed by the pathophysiologic parameters, and any technique employed should avoid increases in afterload and use of negative ionotropic agents. The availability of invasive monitoring, ionotropic support and vasodilator therapy is mandatory during anesthesia and surgical procedure as the behavior of such patients is very unpredictable. [13] The rapid establishment of subarachnoid block may lead to sudden onset of hemodynamic instability leading to heart failure and ventricular arrhythmias. Graded epidural anesthesia is a better option and one can use adjuvants along with local anesthetics. [13] The decrease in systemic vascular resistance with gradual and controlled induction of anesthesia reduces the afterload without impairing left ventricular contractility, which improves the myocardial performance and the cardiac output. [7]

The main question still remains unanswered! What will an anesthesiologist do if he or she encounters such a case at rural health set-up with only meager facilities available? While dealing with similar cases, presence of intensive care facilities is very important to deal with any type of such complication. We suggest that the training of the anesthesia residents must include 3-4 months of cardiology posting as a part of their post-graduate course curriculum as we are encountering increasing number of cardiac patients for elective or emergency surgeries on day-to-day basis. The efforts should be on the part of the government agencies also to strengthen the national program which aims at decreasing the maternal and infant mortality rates by recruiting more specialists for rural health services and screening of every parturient for possible presence of cardiac ailment. This will be possible only if doctors are given more incentives for rendering their services in such backward areas in our country.

 
   References Top

1.Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, et al. Peripartum cardiomyopathy. National Heart, Lungs and Blood Institute and Office of Rare Diseases; Workshop recommendations and Review. JAMA 2000;283:1183-8.  Back to cited text no. 1
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2.Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol 1999;94:311-6.  Back to cited text no. 2
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3.Rizeq MN, Rickenbacher PR, Fowler MB, Billingham ME. Incidence of myocarditis in peripartum cardiomyopathy. Am J Cardiol 1994;74:474-7.  Back to cited text no. 3
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4.Hilfiker-Kleiner D, Kaminski K, Podewski E, Bonda T, Schaefer A, Sliwa K, et al. A cathepsin-D cleaved 16-kD form of prolactin mediates postpartum cardiomyopathy. Cell 2007;128:589-600.  Back to cited text no. 4
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5.Julian DG, Szekely P. Peripartum cardiomyopathy. Prog Cardiovasc Dis 1985;27:223-40.  Back to cited text no. 5
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6.Heider AI, Kulla JA, Strauss RA, Wells SR. Focus on primary care: Peripartum cardiomyopathy; a review of the literature. Obstet Gynecol Surv 1999;54:526-31.  Back to cited text no. 6
    
7.Brown G, O'Leary M, Douglas I, Herkes R. Perioperative management of a case of severe peripartum cardiomyopathy. Anaesth Intensive Care 1992;20:80-3.  Back to cited text no. 7
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8.Hutchison RC, Ross AW. Severe peripartum cardiomyopathy. Anaesth Intensive Care 1992;20:398.  Back to cited text no. 8
    
9.Rawad N, Schollin J, Wesstron G. Epidural versus combined spinal epidural block for cesarean section. Acta Anaesthesiol Scand 1988;32:61-6.  Back to cited text no. 9
    
10.Davies SJ, Paech MJ, Welch H, Evans SF, Pavy TJ. Maternal experience during epidural or combined spinal epidural anaesthesia for cesarean section: A prospective, randomized trial. Anesth Analg 1997;85:607-13.  Back to cited text no. 10
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11.George LM, Gatt SP, Lowe S. Peripartum cardiomyopathy: Four case histories and commentary on anaesthetic management. Anaesth Intensive Care 1997;25:292-6.  Back to cited text no. 11
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12.Swan DA, Bell B, Oakley CM, Goodwin J. Analysis of the symptomatic course, prognosis and treatment of hypertrophic obstructive cardiomyopathy. Br Heart J 1971;33:671-85.  Back to cited text no. 12
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13.Hawthorne L, Lyons G. Cardiac arrest complicating spinal anesthesia for caesarian section. Int J Obstet Anesth 1997;6:126-9.  Back to cited text no. 13
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