We report the case of a 25-year-old woman (164cm, 84kg, G2 P1). She was referred to the tertiary care level delivery unit of Farhat Hached University Hospital for a scheduled c-section at 37 weeks of gestation. The medical history of the parturient notes a hypertrophic cardiomyopathy diagnosed at the age of 12 in a context of a repeated shortness of breath. She has been put under bisprolol 2.5 mg/day. The evolution of the illness was marked by the occurrence of two episodes of syncope at the age of twenty. The rhythmologic exploration has highlighted severe and paroxysmal ventricular rhythm disorders indicating the placement of a double room implantable cardioverter defibrillator (ICD). Afterwards, the evolution was uneventful. The current pregnancy was spontaneous and well followed by the obstetrician and the cardiologist (monthly consultation). No cardiovascular or obstetric complication was noted. Bisprolol dose was doubled throughout the pregnancy. The patient presented for an elective cesarean section at 39 SA. Clinical examination showed 86 heartbeats per minute, blood pressure of 110/80 mm Hg and a respiratory rate of 18 cycles/min. A transthoracic ultrasonography showed an asymmetrically overdeveloped left ventricle (LV), an inter ventricular septum at 28 mm, a Left ventricular ejection fraction of 80%, an intra LV gradient of 10 mm Hg, a disorder of the compliance of the LV with high filling pressures of the LV, a non-dilated left atrium, and not distended right cavities with normal systolic function of the right ventricle (Figure 1). Anesthetic examination shows a good venous capital and no evidence for oral intubation difficulty.
The patient was sent on the eve of the caesarean section to her cardiologist who decided the deactivation of the defibrillator given the risk of inadvertent activation during the scheduled surgery. In the operating room, the patient received invasive monitoring of her blood pressure, her electrocardiogram, her pulse oxygen saturation measurement and her expired CO2 pressure. The venous infusion during the surgery was established with a 16 G peripheral branule in the back of the left hand prefilled with 500ml of saline. The patient had a rachi-analgesia at the level of L4 - L5 with 200mug of morphine. The induction was with a rapid sequence with 3 mg/kg propofol, 1 mg/kg of suxamethonium and 0.5mug/kg of remifentanil. Oral intubation was performed without incident. The anesthesia was performed by of sevoflurane and of remifentanil at a dose of 0.05g/kg/min. An antibiotic prophylaxis with 2g of Cefazolin was administered after the clamping of the umbilical cord. Ten minutes after the anesthetic induction occurred the fetal extraction of a female newborn of 2900 g weight and an Apgar score of 8/9/10. Five IU of oxytocin were slowly intravenously injected then, followed after the delivery by a dose of 20 IU of oxytocin for 4 hours. During the surgery the hemodynamic parameters were stable (no heart arhythmia) authorizing the awakening and extubation of the patient on the operating table. The patient was transferred in the resuscitation care unit. She received a multimodal analgesia. The ICD has been reactivated 6 hours after the end of the intervention. Postoperative outcomes were simple: in particular, no cardiac rhythm disorder, or heart failure. The patient was released 3 days after her delivery. She was referred to her cardiologist for a further adjustment of her drugs.