Background:
This case details a patient with dilated cardiomyopathy and heart failure, who had a vaginal delivery in the third trimester.
Method: Review of clinical course.
Details:
A 33-year-old female has a background of heart failure with reduced ejection fraction (HFrEF), secondary to idiopathic dilated cardiomyopathy. This was diagnosed in 2021 with a left ventricle ejection fraction (LVEF) of 11%. Her condition improved with medications, with a stable LVEF of 35% since 2023. She had an unplanned pregnancy diagnosed at 28 weeks while taking teratogenic medications, (1) including sacubitril with valsartan, ivabradine and dapagliflozin. She was largely asymptomatic of heart failure symptoms during pregnancy, with New York Heart Association Functional class one. (2)
Multiple fetal anomalies were detected at 31 weeks; large echogenic kidneys, cardiomegaly, fetal hydrops, abnormal dopplers and anhydramnios. A fetal death in utero was diagnosed at 32 weeks. Labour was induced with mifepristone and misoprostol, and the baby was delivered vaginally. She remained well in the post-partum period.
Conclusion:
This case illustrates a vaginal delivery in an HFrEF patient that was well tolerated in the third trimester, likely due to stable heart function without decompensation. Misoprostol was chosen over oxytocin for induction, as it was predicted to cause less fluid shift. This is consistent with literature highlighting that oxytocin may cause fluid retention with prolonged infusion in cardiac disease. (3) This report emphasises the importance of optimising cardiac function prior to delivery, and the serious adverse effect of teratogenic medications on a developing fetus.