33 – Cardioversion in a Pregnant Patient with Corrected Tetralogy of Fallot

33 Cardioversion in a Pregnant Patient with Corrected Tetralogy of Fallot

Kailash Bhatia

Scenario in a Nutshell

Patient with known repaired Tetralogy of Fallot (ToF) suffers new-onset, regular, narrow complex tachycardia which is unresponsive to medical management requiring DC cardioversion under general anaesthesia.

Stage 1: Initial assessment of narrow complex tachycardia in labouring parturient with adult congenital heart disease (ACHD).

Stage 2: Correction of electrolytes, perform vagal manoeuvres, administer adenosine for continued tachyarrhythmia.

Stage 3: Medical management for tachyarrhythmia unsuccessful, adverse features now present.

Stage 4: DC cardioversion and caesarean section.

Target Learner Groups

All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, operating department practitioners and cardiologists.

Specific learning opportunities
Assessment of narrow complex tachycardia in adult congenital heart disease (ACHD) patients
Knowledge of algorithm for management of tachyarrhythmia
Consideration of anaesthetic plan for DC cardioversion in pregnancy
Importance of senior MDT obstetric and cardiology input in ACHD parturients

Suggested learners (to represent their normal roles) In the room from the start Available when requested
Anaesthetic ST3+
Obstetric ST3+
Midwife Coordinator
Midwife in room
Operating Department Practitioner (ODP)/anaesthetic nurse
Cardiology ST
Suggested facilitators
Faculty to play role of student midwife giving handover at time of emergency buzzer

Details for Facilitators

Patient Demographics

Name: Michelle

Age: 29

Gestation: 36

Booking weight: 64 kg

Parity: P0

Scenario Summary for Facilitators

29-year-old 36-week primipara woman, with history of repaired Tetralogy of Fallot, attends delivery suite in spontaneous labour. She has been complaining of sudden onset of palpitations and feels her heart is racing. She has a confirmed narrow complex tachyarrhythmia on the monitor.

Her past surgical history is repaired TOF with Waterston shunt, followed by a repair of pulmonary valve and closure of VSD. Recent echo shows signs of moderate pulmonary regurgitation and mild RV dysfunction. She attended the joint obstetric, cardiac, anaesthetic clinic 6 weeks ago. (For the Anaesthetic letter see Figure 33.1. For the echocardiogram report see Figure 33.2.)

Figure 33.1 Anaesthetic Clinic Letter.

Figure 33.2 Patient’s echocardiogram report.

On arrival on the delivery suite, she is reviewed by the team. All investigations performed and bloods taken. Potassium and magnesium corrected.

Although initially stable with tachyarrhythmia, it does not respond to vagal manoeuvres, adenosine or beta blockers.

Patient then becomes hypotensive and complains of chest pain. Decision made for DC cardioversion in theatre.

The patient is intubated and cardioverted successfully.

CTG remains suspicious, the obstetric team proceed to perform an emergency LSCS.

Set-up Overview for Facilitators

  • Clinical setting

  • In a delivery room, on a delivery bed

  • Patient position

  • Semi-recumbent

  • Initial monitoring in place

  • No monitoring – has just arrived on delivery suite

  • Other equipment

  • No IV access or maternal/fetal monitoring but all equipment available

  • Useful manikin features

  • Intubation

  • Defibrillation and cardioversion

Medical Equipment

For core equipment checklist, see Chapter 9.

Additional equipment specific to scenario
Arterial line Resuscitation trolley with defibrillator Pads for defibrillation

  • Adenosine

  • Beta blockers – Metoprolol

  • Digoxin

  • Diltiazem

  • Magnesium

  • Potassium

  • Drugs for intubation

Information Given to the Learner

SBAR Handover by faculty (playing the role of midwife) to the obstetric and anaesthetic on-call team
Time: Midday
Situation: 29 years old. 36 weeks primipara in spontaneous labour. She has a past history of adult congenital heart disease and is now complaining of palpitations.
Background: She was diagnosed with Tetralogy of Fallot in childhood and has had surgical repair. She has been seen in obstetric anaesthetic clinic (see Figure 33.1). She has been symptom-free in pregnancy until yesterday, when she started suffering with palpitations. She has just arrived in hospital and is in spontaneous labour, which commenced about 3–4 hours ago.
Assessment: I was just about to perform some observations but thought it best to get you immediately.
Recommendations: Would you like me to get the clinic letter while you meet Michelle?

Oct 24, 2020 | Posted by in OBSTETRICS | Comments Off on 33 – Cardioversion in a Pregnant Patient with Corrected Tetralogy of Fallot
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