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Simultaneous Cesarean Delivery and Coronary Artery Bypass Grafting (CABG)
CASE STUDIES
Banner, S. and Harvey, D.
Proceedings of the 2010 AWHONN Annual Convention
Simultaneous Cesarean Delivery and Coronary Artery Bypass Grafting (CABG) Poster Presentation Sheryl Banner, RNC, BSN, Labor & Delivery, Christiana Care Health System, Newark, DE
Deborah Harvey, RNC, Labor and Delivery, Christiana Care Health System, Boothwyn, PA
Childbearing
ur case study reports the multidisciplinary management of a patient with ST-elevation myocardial infarction (STEMI) and spontaneous coronary artery dissection. The patient presented to the obstetric (OB) triage area at 34 weeks gestation complaining of chest pain, shortness of breath, nausea, and diaphoresis. She reported having a history of myocardial infarction 6 years prior so she was immediately given aspirin, IV access was established, and cardiac enzymes were drawn. A stat EKG showed ST elevation so the patient was transferred immediately to the main emergency department. An OB nurse accompanied her to continue fetal monitoring. Nitroglycerine therapy was initiated, and she was sent for an emergency cardiac catheterization.
O
Prior to the cardiac catheterization, our OB operating room (OR) team sta¡ed by Labor and Delivery nurses was noti¢ed that this patient may need a Cesarean delivery in the emergency room. The decision was made to delay the delivery until after the cardiac catheterization was completed. Continuous electronic fetal monitoring continued during this period. The cardiac catheterization showed a dissection of the left main coronary artery that extended to the left anterior descending artery and the left circum£ex artery. The patient was then transferred to the Cardiovascular Intensive Care Unit (CVICU) where she underwent a transesophageal echocardiogram that ruled out aortic dissection. The OB team was on stand-by in the event of a stat Cesarean delivery.
After much deliberation between the obstetricians, the cardiologist, the cardiac surgeon, the anesthesiologist, and the nurses, the decision was made to deliver the patient by Cesarean in the main OR. All of the equipment normally necessary for Cesarean delivery and newborn resuscitation was transported to the cardiac surgery operating room. The OB team and the cardiac surgery team prepared for the case simultaneously. The OB team performed a primary Cesarean section and a live female was delivered. As soon as the abdominal incision was closed, the OB team stepped back from the OR table and the cardiac team stepped forward to perform the coronary artery bypass grafting. The patient recovered well postoperatively and was discharged after 5 days. The newborn was discharged from the Neonatal Intensive Care Unit (NICU) 23 days after birth. Myocardial infarction, spontaneous coronary artery dissection, and coronary artery bypass grafting are all very rare in pregnancy. There are no published statistics for perinatal survival of all three. The maternal mortality rate associated with myocardial infarction alone is estimated to be as high as 37%. We present a di⁄cult case with a successful outcome that was achieved through careful consideration of the unique needs of mother and fetus by a multidisciplinary team that worked very well together.
Changing the Clinical Situation from PPROM to HELLP Poster Presentation reterm premature rupture of membranes (PPROM) is associated with signi¢cant risk to the mother and her unborn child. With PPROM remote from term, close clinical observation for
P
JOGNN 2010; Vol. 39, Supplement 1
infection, placental abruption, onset of labor, and fetal compromise is necessary. A case study is presented of a 23-year-old G1P0 who presented at 24 weeks with PPROM. Her fetus was breech. At 31 weeks she developed preeclampsia and was treated with magnesium sulfate. Her lab values were
S127
Banner, S. and Harvey, D.
Proceedings of the 2010 AWHONN Annual Convention
Simultaneous Cesarean Delivery and Coronary Artery Bypass Grafting (CABG) Poster Presentation Sheryl Banner, RNC, BSN, Labor & Delivery, Christiana Care Health System, Newark, DE
Deborah Harvey, RNC, Labor and Delivery, Christiana Care Health System, Boothwyn, PA
Childbearing
ur case study reports the multidisciplinary management of a patient with ST-elevation myocardial infarction (STEMI) and spontaneous coronary artery dissection. The patient presented to the obstetric (OB) triage area at 34 weeks gestation complaining of chest pain, shortness of breath, nausea, and diaphoresis. She reported having a history of myocardial infarction 6 years prior so she was immediately given aspirin, IV access was established, and cardiac enzymes were drawn. A stat EKG showed ST elevation so the patient was transferred immediately to the main emergency department. An OB nurse accompanied her to continue fetal monitoring. Nitroglycerine therapy was initiated, and she was sent for an emergency cardiac catheterization.
O
Prior to the cardiac catheterization, our OB operating room (OR) team sta¡ed by Labor and Delivery nurses was noti¢ed that this patient may need a Cesarean delivery in the emergency room. The decision was made to delay the delivery until after the cardiac catheterization was completed. Continuous electronic fetal monitoring continued during this period. The cardiac catheterization showed a dissection of the left main coronary artery that extended to the left anterior descending artery and the left circum£ex artery. The patient was then transferred to the Cardiovascular Intensive Care Unit (CVICU) where she underwent a transesophageal echocardiogram that ruled out aortic dissection. The OB team was on stand-by in the event of a stat Cesarean delivery.
After much deliberation between the obstetricians, the cardiologist, the cardiac surgeon, the anesthesiologist, and the nurses, the decision was made to deliver the patient by Cesarean in the main OR. All of the equipment normally necessary for Cesarean delivery and newborn resuscitation was transported to the cardiac surgery operating room. The OB team and the cardiac surgery team prepared for the case simultaneously. The OB team performed a primary Cesarean section and a live female was delivered. As soon as the abdominal incision was closed, the OB team stepped back from the OR table and the cardiac team stepped forward to perform the coronary artery bypass grafting. The patient recovered well postoperatively and was discharged after 5 days. The newborn was discharged from the Neonatal Intensive Care Unit (NICU) 23 days after birth. Myocardial infarction, spontaneous coronary artery dissection, and coronary artery bypass grafting are all very rare in pregnancy. There are no published statistics for perinatal survival of all three. The maternal mortality rate associated with myocardial infarction alone is estimated to be as high as 37%. We present a di⁄cult case with a successful outcome that was achieved through careful consideration of the unique needs of mother and fetus by a multidisciplinary team that worked very well together.
Changing the Clinical Situation from PPROM to HELLP Poster Presentation reterm premature rupture of membranes (PPROM) is associated with signi¢cant risk to the mother and her unborn child. With PPROM remote from term, close clinical observation for
P
JOGNN 2010; Vol. 39, Supplement 1
infection, placental abruption, onset of labor, and fetal compromise is necessary. A case study is presented of a 23-year-old G1P0 who presented at 24 weeks with PPROM. Her fetus was breech. At 31 weeks she developed preeclampsia and was treated with magnesium sulfate. Her lab values were
S127