Clinical Case 075: a CTG, a VE and a distant ECHO
This is a rare case. One where I was at a bit of a loss as to which was the best option. So keen to get your input!
A 23 yo. woman G?1, P0 – was flown in from a remote community in “threatened premature labour”, she was estimated to be about 34 weeks (but unclear on dates / late scans / possible IUGR). She had not had much antenatal care, however her old notes were pulled….
She had a history of pretty bad rheumatic heart disease in her teens and had previously been diagnosed by the visiting Cardiologist as having severe mitral regurgitation and moderate aortic valve incompetence. We didn’t have a recent ECHo but one from 2 years ago showed the same picture – severe MR, mod AR and preserved LV function. Of course 2 years and a pregnancy can change a lot of things – so we were unsure as to her current cardiac function. On history she did complain of mild exertional dyspnoea, though no chest pain. Never had an episode of APO.
OK – so once she arrived it was clear that she was in fact in labour. She was having 5 – 10 minutely, moderate contractions. Her VE revealed a 4 cm cervix. The CTG was looking OK though a baseline tachycardia was evident.
Now – the mantra of premature labour in remote Australia is “in utero transfer” – we know that keeping the fetus in the uterus and delivering in a tertiary centre improves outcomes. So we opt for tocolytics in TPL wherever viable.
Back to the case: we want to stop the contractions – our usual drugs are nifedipine, salbutamol and a prayer! So, can we use these agents in a woman with a potentially fragile cardiac output? What are the potential issues for this lady?
An hour later the labour was slowing but…. the CTG was not looking good. She had had a few decelerations, and just now a long, low decel to 60/min. OK – now this bub needs to come out.
She will need an anaesthetic – the tradition is a spinal / subarachnoid block with some vasopressor support. We don’t want to do a GA if at all possible. So what do we need to think about in a woman with relatively severe MR / AR? What are the potential pitfalls?
Just for fun – what would change if she has mitral stenosis or aortic stenosis as a result of her rheumatic disease?
Let me know
OK this is not an obstetric problem, this is an anaesthetic one. So I’ll shut up and read the pearls from people who know what they are talking about!
For tocolysis may I suggest an Indomethacin suppository?