What is the recommended management for a 26-week pregnant woman with intermittent shortness of breath, diastolic dysfunction of the right ventricle, and abnormal septal motion?

Management of Pregnant Woman with RV Diastolic Dysfunction and Abnormal Septal Motion

Monthly cardiac evaluations with echocardiography are strongly recommended for pregnant women with right ventricular diastolic dysfunction and abnormal septal motion to monitor for deterioration of cardiac function and prevent heart failure. 1

Diagnostic Evaluation

For a 26-week pregnant woman presenting with intermittent shortness of breath, diastolic dysfunction of the right ventricle, and abnormal septal motion, the following diagnostic approach is essential:

• Comprehensive echocardiography to assess:

  • Severity of RV diastolic dysfunction
  • Degree of abnormal septal motion
  • Presence of associated lesions (ASD, VSD)
  • Estimation of pulmonary pressures
  • Assessment of tricuspid regurgitation

• Oxygen saturation monitoring to rule out hypoxemia which may indicate right-to-left shunting

Risk Stratification

This patient's presentation suggests potential cardiac conditions that require careful monitoring:

1. Possible pulmonary hypertension - Abnormal septal motion with RV dysfunction may indicate elevated pulmonary pressures
2. Potential congenital heart defect - Abnormal septal motion could be associated with ASD or other septal defects
3. Risk of heart failure - RV diastolic dysfunction can progress to heart failure during pregnancy

Management Protocol

Immediate Management

1. Referral to tertiary center with expertise in cardiac disease in pregnancy 2
2. Multidisciplinary team involvement including:
   • Maternal-fetal medicine specialist
   • Cardiologist with expertise in pregnancy
   • Cardiac anesthesiologist
   • Neonatologist

Ongoing Management

1. Regular cardiac monitoring:

   • Monthly echocardiography to assess RV function and septal motion 1
   • More frequent monitoring (every 2-4 weeks) if symptoms worsen

2. Symptom management:

   • Left lateral positioning to prevent IVC compression
   • Supplemental oxygen if saturation falls below 95%
   • Careful fluid management to avoid volume overload

3. Medication considerations:

   • Beta-blockers may be considered if tachyarrhythmias develop, but must be used with caution in RV dysfunction 1
   • Diuretics for volume overload if needed

Delivery Planning

1. Timing: Consider planned delivery at 37-38 weeks after fetal lung maturity

2. Mode of delivery:

   • Vaginal delivery is appropriate in most cases with adequate cardiac function 1
   • Consider cesarean delivery if cardiac function deteriorates

3. Anesthesia:

   • Regional anesthesia with careful hemodynamic monitoring
   • Avoid sudden hemodynamic changes

4. Peripartum monitoring:

   • Continuous cardiac monitoring during labor and delivery
   • ICU observation for 24-48 hours postpartum

Special Considerations

Warning Signs Requiring Urgent Intervention

• Worsening shortness of breath
• Decreased exercise tolerance
• New onset arrhythmias
• Signs of right heart failure (increasing peripheral edema, JVD)
• Syncope or pre-syncope

Postpartum Care

• Close monitoring for 72 hours post-delivery
• Echocardiographic assessment prior to discharge
• Follow-up within 2 weeks of delivery

Pitfalls and Caveats

1. Do not dismiss shortness of breath as normal in pregnancy - Research shows that significant SOB during pregnancy may be associated with subtle cardiac involvement requiring investigation 3

2. Avoid misattributing symptoms to normal pregnancy changes - Dyspnea and peripheral edema are common in normal pregnancy but can mask early signs of heart failure 4

3. Watch for peripartum cardiomyopathy - While the current presentation suggests RV dysfunction, be vigilant for development of LV dysfunction as pregnancy progresses 5, 6

4. Beware of hemodynamic stress during delivery - The greatest hemodynamic stress occurs during labor and immediately postpartum, requiring close monitoring during this period

By following this management approach with regular cardiac monitoring and appropriate multidisciplinary care, the risks of maternal and fetal complications can be minimized in this pregnant woman with RV diastolic dysfunction and abnormal septal motion.