Importance of history and physical; HOCM in pregnancy

Manuscript type : Brief Report | Article Date : 2015/03/16

  • Autors

    1. Bhardwaj Rahul
    2. Singh Sarabjeet
    3. Singh Harpreet
  • Abstract

    Hypertrophic (Obstructive) Cardiomyopathy is typically well tolerated in pregnancy but patients may become symptomatic if given epidural anesthesia. Therefore it is very important to collect to do a through history and physical prior to any anesthetic procedure. We will discuss a patient who was 34 weeks pregnant and received epidural anesthesia which resulted in sudden drop in her blood pressure and development of chest pain. Learning Objective The learning objective of this case report is the importance of through history and physical before any and all procedures. We are physician should not simple rely on the history and physical of other because what if the pervious person failed to get important details. So each medical provider should get their own information from the patients as a way of confirming detailed medical history.
  • Description

    INTRODUCTION

    Hypertrophic (Obstructive) Cardiomyopathy is usually well-tolerated throughout pregnancy. It is the increase in cardiac output and plasma volume which helps increase the left ventricle cavity size helping offset the common symptoms of hypertrophy. The risk of developing symptoms is higher in women who are symptomatic before pregnancy or in those with a history of severe left ventricular outflow tract obstruction. However, in patients with moderate to severe disease with no documented history of hypertrophic cardiomyopathy or no previous cardiology work-up, administering epidural anesthesia can result in a pooling of blood [and with HOCM] causing an exaggerated drop in blood pressure manifesting with symptoms such as dyspnea and chest pain.

    CASE REPORT

    A 33-year-old Gravida 8 Para 4 female at 34 weeks gestation with a past medical history of a heart murmur and anemia since 2010 presented with diarrhea, vomiting and abdominal pain. Patient was initially admitted under Obstetrics service for Premature Rupture of Membrane (PROM). Initial vital signs were Temperature 36.8 C, Blood Pressure- 113/68, Respiratory Rate-19, Heart Rate- 110/min. Initial physical exam was focused on obstetrics complaints and pelvic exam was highly suspicious for PROM and decision for urgent delivery was made. Patient was prepped with epidural anesthesia and within 15 minutes of administration, the blood pressure dropped to 80/50, tachycardic and the patient started complaining of chest pain and shortness of breath. An electrocardiogram (EKG) done at this time showed sinus tachycardia with inverted T waves in lead 1 and AVL and flattening of T waves in lead V5 and V6. Following this event Medicine was consulted and further history revealed that patient was told she had a murmur diagnosed several years ago but was not worked up. Patient gave a history prior to the admission saying she did not have any dyspnea, chest pain, palpitation, decreased exercise tolerance but did reveal lower extremity swelling. Family history reviled a murmur in her mother and son but was patient was unware of diagnosis or type. Initial vital signs during medicine evaluation were Temp. 36.8, Pulse. 104, Resp. 19, BP. 106/77. Physical exam revealed no carotid bruits, normal s1 s2 with a 4/6 holo-systolic murmur with equal intensity in all four regions without radiation and no change in position, maneuvers or respirations. Lung exam reveal clear breath sounds heard bilaterally with equal air entry. Abdominal girth was appropriate for gestational age, and 2+ pitting edema. Labs revealed microcytic anemia with hemoglobin of 8.4 and hematocrit of 26.4, all other values were within normal limit. Complete metabolic panel (CMP) and cardiac enzymes within normal limits, chest x-ray was differed due to patient being pregnant. 2D transthoracic echocardiogram was performed to evaluate her murmur which revealed intra-ventricular septum thickness to be 1.5cm (reference range 0.6-0.9) with ejection fraction of 55-60% and dynamic outlet obstruction with peak gradient of 150 mmhg. Systolic Anterior Motion of mitral valve also present in the echo with mild/moderate mitral regurgitation. Secondary to the above findings patient was started on metoprolol which was tolerated well with no further symptoms. Patient had a uneventful deliver with epidural, delivering a healthy baby. Patient was discharged on metoprolol and followed closely by cardiology.

    DISCUSSION

    Hypertrophic Obstructive Cardiomyopathy (HOCM) is a unique cardiovascular disease caused by a mutation in genes encoding cardiac sarcomere proteins which is inherited as an autosomal dominant pattern. According to Genetics Home Reference, Hypertrophic cardiomyopathy is the most common genetic heart disease in the United States.[1] According Approximately 70% of patients who have HOCM report a positive family history with at least one member affected.[2] According to Dr. Autore and colleagues maternal mortality in HOCM is 10 per 1000 live births which are greater compared to general population. However, the absolute maternal morality in HOCM patient was equivalent to general population but it was higher in those patients who had symptoms prior to pregnancy.[3] Pregnancy is accompanied by major physiological changes, which place extra demands on the cardiovascular system. Therefore, the importance of taking a good history and doing an extensive pre-conception evaluation is extremely important. In our patient a through exam would have revealed a systolic murmur and history would have revealed a diagnosis of a “murmur”. It has been noted that women with pre-existing HOCM the use of epidural/spinal anesthesia can result in hypotension as a result of venous pooling and decreased systemic vascular resistance.[4] Pregnant women who have HOCM usually tolerate pregnancy well. However, since mortality is higher compared to the general population, a detailed history and physical exam in early stages of pregnancy can help determine an increased risk of complications during labor. A strong family history with the presence of audible murmur should raise suspicion of the disease requiring further work to confirm the diagnosis. The women should be made aware of the risks and benefits of epidural anesthesia and administration should be done cautiously in such patients.

  • Reference

    1. 1.1. Familial hypertrophic cardiomyopathy.2015. Available: http://ghr.nlm.nih.gov/condition/familial-hypertrophic-cardiomyopathy. Last accessed 02/25/2015.
    2. 2.2. Pieper P, Walker F. Pregnancy in women with hypertrophic cardiomyopathy. Neth Heart J. 2013; 21: 14-18.
    3. 3.3. Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P, Spirito P. Risk associated with pregnancy in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002;40: 1864-9
    4. 4.4. Dolbeau JB, Hebert T, Espitalier F, Fusciardi J, Laffon M. Obstructive hypertrophic cardiomyopathy and caesarean section under combined spinal and epidural anaesthesia with prophylactic vascular ligation: regarding a case. Ann Fr Anesth Reanim. 2001;30: 64-6.