Pregnant with a failing heart: an obstetrician’s nightmare: a case report

¹Department of Medicine and Therapeutics, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana, ²Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana, ³Tamale Teaching Hospital, Tamale, Ghana, ⁴Department of Obstetrics and Gynecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana, ⁵Department of Obstetrics and Gynecology, Korle-Bu Teaching Hospital, Accra, Ghana, ⁶Department of Anesthesia, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana

^&Corresponding author
Alfred Doku, Department of Medicine and Therapeutics, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana

Introduction    

There are several medical conditions which can adversely affect pregnancy outcomes for women and their offspring and for which preconception care can make a difference. Some patients, despite counseling by their physician, may get pregnant or choose to continue with their pregnancy and would require care by experienced physicians at tertiary care centers. Approximately 1% of pregnancies are complicated by cardiac disease [1]. Some of these women may not have been known to have an underlying cardiovascular problem and may die from an acute event during pregnancy. Others have an underlying, pre-existing heart condition, which deteriorates with the increased demands of pregnancy. Pregnancy with symptomatic heart failure is associated with high perinatal and maternal mortality rates in sub-Saharan Africa and poses a challenge to the cardiologist, obstetrician, anesthesiologist and neonatologist [2]. Late booking for antenatal care is common in sub-Saharan Africa and is influenced by several factors including maternal education, husband's education, marital status, household income, and having a history of obstetric complications [3]. Cultural beliefs and ideas about pregnancy as well as autonomy and gender role in the decision-making process play an important role [4]. These factors, together with a lack of a clearly documented plan and poor communication between relevant subspecialties can result in significant maternal and fetal complications for women presenting late in pregnancy with medical conditions. The following case presentation highlights how a combination of factors including those affecting treatment adherence, continuity of care in the healthcare system and late presentation can complicate the management of a pre-existing medical condition in pregnancy.

Patient and observation     

Patient information: we present a 29-year-old female, Gravida 5 Para 4 (3 alive + 1 Intrauterine fetal demise(IUFD)) who was diagnosed with peripartum cardiomyopathy 20 months ago following her 4^th delivery. The diagnosis was made 3 months after delivery. Her echocardiography finding at the time was that of a dilated cardiomyopathy with an ejection fraction of 20%. She was started on standard guideline-directed medical therapy (GDMT) for heart failure (angiotensin-receptor blocker [ARB], beta-blockers [BB] and mineralocorticoid antagonists [MRA]) at the Cardiac clinic of the Korle Bu Teaching hospital.

Clinical findings: she was lost to follow-up for several months and presented pregnant with a twin gestation at 22 weeks despite receiving counselling on the need for effective contraception. She presented with worsening pedal swelling, orthopnoea and cough, all compatible with decompensated heart failure. She had fine bilateral basal lung crepitations and required intravenous diuretics for decongestion.

Diagnostic assessments: the echocardiogram done during this index presentation showed dilated cardiac chambers with global hypokinesia, severe functional mitral and tricuspid regurgitation and a left ventricular ejection fraction (EF) of 15%. The pulmonary artery systolic pressure was elevated at 65mmHg. Electrocardiography showed sinus tachycardia.

Therapeutic interventions: her heart failure medications were modified to include hydralazine, isosorbide dinitrate and bisoprolol whilst her ARB (losartan) and MRA (spironolactone) were withheld. She presented a unique and particularly difficult situation to the cardiologist, obstetrician, neonatologist and anaesthesiologist mainly because of concerns of poor maternal outcomes with continuation of the pregnancy on one hand, and the problems and challenges associated with the care of extremely premature babies in a resource-limited setting, on the other hand. Following a multidisciplinary team meeting, the decision was made to proceed with termination of the pregnancy (by caesarean delivery) after a brief period of inpatient observation during which she deteriorated clinically with worsening heart failure. She under went a caesarean section with bilateral tubal ligation under low dose combined spinal- epidural anaesthesia in the third week of her admission (at 24 weeks gestation). Two live babies weighing 0.59kg and 0.66kg with low Apgar scores were delivered who did not survive in the neonatal intensive care unit on account of severe prematurity.

Follow-up and outcomes: her post-op course was complicated by a large right-sided pleural effusion that required needle thoracocentesis and an acute pulmonary embolism which required management in the intensive care unit with mechanical ventilation and ionotropic support for ten days. She made a slow recovery and was gradually transitioned onto her oral heart failure medications plus oral anticoagulation with warfarin. She was discharged in stable condition with mild dyspnoea at rest after about eight weeks of admission.

Discussion     

Cardiac disease in pregnancy is a common problem in under-resourced countries and a common significant cause of maternal and fetal morbidity and mortality [1]. Peripartum cardiomyopathy (PPCM) is a life-threatening cardiomyopathy that affects women late in pregnancy or in the early puerperium and occurs more commonly in women of African descent [5]. The diagnostic criteria require the development of cardiac failure in the last month of pregnancy or within 5 months after delivery, left ventricular (LV) systolic dysfunction with no identifiable cause for cardiac failure, and no recognized heart disease before the last month of pregnancy [6]. There can be a delay in the diagnosis of PPCM due to the overlap of symptoms and signs of normal late pregnancy and those of early heart failure. Severe systolic dysfunction, marked LV dilatation and right ventricular involvement are associated with worse outcomes [5]. Patients with PPCM are often young, have just started their families and may wish to get pregnant again. With expert interdisciplinary management, successful subsequent pregnancies have been reported particularly in patients with recovered EF but the outlook for those with persistent LV dysfunction remains dire especially in resource-limited settings [7]. Poor follow-up, late presentation and lack of interdisciplinary team management approach has been associated with poor maternal and foetal outcomes of PPCM in sub-Saharan Africa (SSA) [7]. Rheumatic heart disease (RHD) is the major cause of acquired cardiac disease in poor countries and may manifest for the first time in pregnancy because of the hemodynamic demands of that physiologic stage. A study of women presenting in pregnancy with valvular heart disease in SSA showed that maternal morbidity and mortality was high especially in those with symptomatic heart failure and poorly tolerated arrhythmias [8].

A proportion of these patients may be treated with warfarin, a Coumadin derivative that can produce a characteristic embryopathy as well as fetal and maternal bleeding. Prophylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses in resource-limited settings can be associated with high rates of maternal and neonatal complication [8]. Cultural, educational and socio-economic factors have been suggested to influence the decision to get pregnant as well as late booking for maternity care after pregnancy in women with cardiac diseases [9]. Mazibuko et al. showed that the majority (61%) of pregnant women with cardiac disease who had prosthetic heart valves attended antenatal care in the second trimester of pregnancy [8]. Preconception assessment by an experienced team of specialists is essential in order to minimize the risk of adverse pregnancy outcome in women who present late in pregnancy with other medical conditions. Late booking for antenatal care in these women may be contributed to by cultural beliefs and ideas about pregnancy, gender role in the decision-making process including reproductive issues and influenced by maternal education, husband's education, marital status, household income, and a history of obstetric complications [3]. In managing cardiac disease in pregnancy, early delivery should be considered with deteriorating cardiac function and if frank heart failure ensues. In more stable patients, the ideal target would be to reach 37 weeks of gestation but the best compromise will be achieved by discussion with the multi-disciplinary team to balance maternal health and foetal maturity [10]. There is no consensus about the choice of anesthesia for cesarean delivery in PPCM. Both general and regional anesthesia can be chosen so long as sudden hemodynamic variations are avoided. In our patient, we chose low dose combined spinal-epidural anesthesia. Low dose combined spinal-epidural anesthesia has been reported to be a reliable choice, in which low-dose spinal provides dense blockade and epidural can be utilized to extend the block level if required [11]. Counseling with effective contraception is required due to potential recurrence and when the EF has not recovered to >50-55%, subsequent pregnancy should be discouraged. For the majority of women, a long-acting reversible form such as an intrauterine contraceptive device will be the most favorable if sterilization (e.g. bilateral tubal ligation) is unacceptable.

All women of childbearing age with chronic medical diseases should receive counseling on the implications of pregnancy for their health, risks of their condition on pregnancy-related outcomes, genetic counseling for those with congenital diseases and discussion on what modifications to drug therapy would be necessary. Because a high proportion of pregnancies are unintended or unplanned in Africa, healthcare providers must be proactive in discussing reproductive planning and preconception care with their patients to ensure that those with chronic medical conditions are knowledgeable enough to make informed decisions around reproductive issues. Contraceptive considerations is central to this process because of the need to avoid, delay, or optimally time pregnancy as part of preconception care of women with these medical conditions [12]. The choice of contraception for such women should be individualized with considerations for efficacy, safety and personal preference [13]. Methods associated with high failure rates such as barrier methods or natural family planning should not be recommended. Combined hormonal contraceptive should be avoided as they increase the risk for venous thromboembolism [13].

Conclusion     

Medical emergencies in pregnancy in Africa carry a high risk to both mother and unborn child in Africa. Hence, women with chronic medical conditions need to be knowledgeable enough to make informed decisions around reproductive issues. The healthcare system in Africa must be equipped to adequately and appropriately manage medical emergencies presenting in pregnancy and the puerperium and effective pathways to ensure that physicians and obstetricians can communicate properly to treat pregnant women as this has been demonstrated to produce more favorable outcomes.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Alfred Dokuconceptualized the article and directed how content should be drafted. Abdul-Subulr Yakubu wrote the article. Theodore Kobla Boafor, Winfred Baah, David Kwame Asare, zifa Ahadzi, Perez Sepenu, eff Osei Agyapong and Ebenezer Owusu Darkwa reviewed the article and made important changes and recommendations. All the authors have read and agreed to the final manuscript.

Acknowledgments     

The authors are grateful to the patient and her family as well as the multidisciplinary team (obstetricians, cardiologists, obstetric medicine specialists, anesthetists and neonatologists) for the care.

References