Management of Secundum ASD with NYHA II at Term in Labor
Proceed with vaginal delivery with continuous cardiac monitoring, epidural analgesia, and assisted second stage to minimize maternal pushing effort. 1
Immediate Delivery Management
Vaginal delivery is the preferred mode in almost all cases of atrial septal defect, including those with NYHA class II symptoms and preserved ventricular function. 2, 1 The European Society of Cardiology explicitly states this preference due to lower blood loss, reduced infection risk, and decreased venous thrombosis/thromboembolism risk compared to cesarean delivery. 1
Intrapartum Protocol
Position the patient in left lateral decubitus during labor to optimize venous return and cardiac output while minimizing aortocaval compression. 1
Provide epidural analgesia early to reduce catecholamine surge and hemodynamic stress, avoiding the profound blood pressure effects of dinoprostone if labor induction is needed. 1
Allow passive descent of the fetal head and use assisted delivery (forceps or vacuum) to shorten the second stage and minimize Valsalva maneuvers, which can worsen right-to-left shunting if present. 1
Avoid methylergonovine for postpartum hemorrhage prophylaxis as it causes vasoconstriction and hypertension; use oxytocin instead. 1
Cardiac Monitoring Requirements
Continuous hemodynamic monitoring is essential during labor and for at least 24 hours postpartum as fluid shifts can precipitate heart failure even in previously stable patients. 1 With NYHA class II symptoms and an ejection fraction of 65%, this patient has preserved ventricular function, which is favorable for vaginal delivery. 2
Key Monitoring Parameters
Monitor for arrhythmias continuously, as atrial fibrillation and other tachyarrhythmias are the most common cardiac complications during labor in ASD patients, occurring in 4-5% of cases. 3
Assess for signs of paradoxical emboli (sudden neurological changes, chest pain), which occur in 2-5% of pregnancies with ASD. 3
Watch for shunt reversal and cyanosis, particularly during periods of increased right heart pressure such as pushing or fluid shifts. 2
Contraindications to Vaginal Delivery (Not Present in This Case)
Cesarean delivery would be indicated only if: 1, 4
- Severe pulmonary arterial hypertension or Eisenmenger syndrome (mortality 20-50%)
- Clinical signs of acute right heart failure unresponsive to medical management
- Acute deterioration in ventricular function during labor
This patient's NYHA class II status with preserved ejection fraction (65%) does not meet these criteria. 2
Postpartum Management
Continue intensive monitoring for 24-48 hours postpartum as this is a critical period for hemodynamic instability due to autotransfusion from uterine involution and mobilization of extravascular fluid. 1 The risk of heart failure paradoxically increases in the immediate postpartum period despite successful delivery. 1
Medical Management
Diuretics may be needed if signs of volume overload develop, though they should be used judiciously to avoid hypotension. 2
Consider thromboprophylaxis given the increased risk of paradoxical emboli in patients with interatrial shunting, particularly in the postpartum hypercoagulable state. 2
Critical Pitfalls to Avoid
Do not perform cesarean section based solely on the ASD diagnosis without assessing current functional status and hemodynamics. 1
Do not underestimate postpartum risk—the majority of cardiac complications occur in the first 24-48 hours after delivery when fluid shifts are maximal. 1
Do not allow prolonged maternal pushing as Valsalva maneuvers increase right atrial pressure and can precipitate shunt reversal. 1
Delivery Location
This delivery must occur in a tertiary center with cardiology backup and immediate access to echocardiography. 1 While vaginal delivery is appropriate, the presence of congenital heart disease with NYHA class II symptoms requires specialized monitoring capabilities and rapid response capacity for potential complications such as arrhythmias or acute heart failure. 1, 4