Introduction: Management of pregnancy and delivery in women with complex cardiac conditions presents a challenge in which care must be carefully evaluated and individualised.
Clinical Case:
A 33 year-old woman presented to the maternity department desiring pregnancy. She had a history of congenital heart disease with bicuspid aortic valve, aortic coarctation and atrial and ventricular septal defects requiring five previous cardiac surgeries with subsequent severe, symptomatic mechanical aortic valve stenosis. Preconception counselling had identified a high risk of adverse outcome (modified WHO Class IV) and pregnancy was advised against, however on conception a shared decision was made to proceed. The expected clinical deterioration required frequent antenatal monitoring and eventually prolonged hospitalisation for management of progressive heart failure and anticoagulation. Due to worsening maternal status, a difficult decision was made to perform an elective classical caesarean section under general anaesthesia at 24 weeks gestation, with multidisciplinary discussions involving obstetrics, obstetric medicine, cardiology, anaesthetics, neonatology and intensive care. Mechanical circulatory support was available but not required. The patient was managed on the intensive care unit for 48 hours following delivery. Her baby was born at 508g, required 25 days intubation for neonatal lung disease, spent 80 days in NICU and was discharged home after a total 107-day admission.
Conclusion:
This case highlights the medical and ethical challenges in the management of extreme high-risk pregnancy at peri-viable gestation in a woman with severe cardiac disease. The complex multidisciplinary collaboration required to optimise outcomes for both mother and baby are illustrated.