Syncopal episodes for pregnant pt

[9D4]

I had a pt yesterday that I've been trying to find the answer for a question that I've had with no luck.
Pt is a 29 year old that is 34 weeks pregnant and has been having syncopal episodes since she was a teenager. They diagnosed them at that time as a vasovagal response to severe menstrual cramps as that was the only time they would occur in the pt.
Pt has continued having them throughout pregnancy and obviously has not had her menstrual cycle. Pt does state she has been having Braxton Hicks contractions since week 22, continuing until about 3 weeks prior to pt admittance to OB unit yesterday.
I asked the pt if she has noticed any correlation between when she has the Braxton Hicks contractions and her syncopal episodes and she states she cannot truthfully remember if there was a pattern between them occurring at the same time. Pt state's there is not a correlation on if she is active or not, only that she always has them while standing, never sitting or lying. States she has not had an episode in about a week and a half (typically averages about 3-4 weeks in between episodes).
So I started to think that maybe the contractions caused the pt bear down a bit and stimulate a vagal response and cause the syncopal episode.
Then the doc came in. He got a 12 lead (I don't have a copy unfortunately). He states that in his experience syncopal episodes typically is related to the pt's PR interval (which I have never heard). He states the pt's PR interval was shortened and that will lead to a pt having syncopal episodes. I tried to ask the reasoning and he didn't really provide a clear reason. Pt's PR interval was 0.12 consistently.
Only thing I can find is that the PR interval can be shortened due to hypertrophic cardiomyopathy, but in that case the pt would likely have chest pain, SOB, etc...? From what I remember, HCM also normally has biphasic T waves in the 12 lead, which the pt did not have.
Any opinions? I know it's hard to say without the strip, but I didn't have time to grab one.

 

[joshrunkle35]

If they were in relation to vasovagal response, it would make sense she would have them when pregnant if lying on her back, etc.

 

[Handsome Robb]

Even just being pregnant knowing the physiological response to pregnancy when it comes to the relationship between the two.

With that said repetitive syncope and pregnancy isn't a good thing. Not only is mom starving her brain of blood but also the fetus although, admittedly, I don't know what the effects of a vasovagal episode would have on a fetus since it's much lower than the mother's head...

 

[OnceAnEMT]

With that said repetitive syncope and pregnancy isn't a good thing. Not only is mom starving her brain of blood but also the fetus although, admittedly, I don't know what the effects of a vasovagal episode would have on a fetus since it's much lower than the mother's head...

A good point. I would bet that their is no effect. That said, of course the potential secondary trauma is a threat to mom and fetus.

 

[Handsome Robb]

A good point. I would bet that their is no effect. That said, of course the potential secondary trauma is a threat to mom and fetus.

I wouldn't necessarily say it has no effect since syncopals are generally a generalized hypotensive episode. I just don't know how compromised the blood flow would be or if the body would shunt blood to the placenta.

Yes I just said generally generalized...haha

 

[Brandon O]

What's the question? It sounds like she's having the same problem she's had her whole life.

I suppose the PR thing might be in reference to WPW.

 

[9D4]

What's the question? It sounds like she's having the same problem she's had her whole life.

I suppose the PR thing might be in reference to WPW.

Well, the doc basically said that my theory was "good, but it's much more likely to be due to HCM."
So basically just asking second opinions on whether you all think it sounds like it was due to HCM or not since I'm not familiar with it really.

 

[Brandon O]

Well, the doc basically said that my theory was "good, but it's much more likely to be due to HCM."
So basically just asking second opinions on whether you all think it sounds like it was due to HCM or not since I'm not familiar with it really.

It could be, but we don't have much to go on. Was she worked up when she was younger? An echo for instance?

 

[Ewok Jerky]

I doubt you the answers but I would wonder how much blood she is losing during menstruation. Also if she is getting enough fluid replacement during her period. Syncopal episodes only when standing during a period of acute blood loss ....

Physiologic reaction to pregnancy is also hypo volemia.

Also, did this just come up during your history or was her CC syncope?

 

[Carlos Danger]

Well, the doc basically said that my theory was "good, but it's much more likely to be due to HCM."
So basically just asking second opinions on whether you all think it sounds like it was due to HCM or not since I'm not familiar with it really.

Just a couple random thoughts here:

• A shortened PR is a normal finding in pregnancy. And I don't see how a shortened PR can lead to syncope, anyway.

• The ECG of someone with HCM is ugly and not subtle, to my understanding.

• HCM is a serious condition that she would likely already know she had because it would/should have been discovered on the workup for her syncopal episodes.

• Cardiomyopathy of pregnancy is probably what the MD was referring to, but it doesn't usually manifest itself until very late in the pregnancy

 

[Brandon O]

• A shortened PR is a normal finding in pregnancy. And I don't see how a shortened PR can lead to syncope, anyway.

WPW has a short PR and is associated with palpitations/syncope/deadness.

• The ECG of someone with HCM is ugly and not subtle, to my understanding.

Not really, just suggestive. Kinda have to know what to look for. It's not like Brugada or the other electrical abnormalities that can be largely diagnosed from the ECG alone. Hopefully she's been worked up already, but not necessarily.

 

[Carlos Danger]

WPW has a short PR and is associated with palpitations/syncope/deadness.

Not really, just suggestive. Kinda have to know what to look for. It's not like Brugada or the other electrical abnormalities that can be largely diagnosed from the ECG alone. Hopefully she's been worked up already, but not necessarily.

The point is that if a PRI of 0.12 was the only "abnormal" EKG finding, it would be considered a normal EKG, especially in the third trimester of pregnancy.

One would assume that she's been worked up sufficiently to reveal a cardiac EP, valvular, or myopathic origin for her syncope and is being followed by someone. Let's take a closer look at her 12-lead and find her records. If it turns out she's never been worked up, then let's start with an echo.

CM of pregnancy seems unlikely given she's only 34 weeks and has been having these symptoms for years. WPW seems equally unlikely if the EKG is normal and if she only has these episodes when menstruating.

If she's falling at 34 weeks, I would assume OB is gonna order bedrest if they haven't already.

 

[Brandon O]

Sounds about right to me!

 

[9D4]

I doubt you the answers but I would wonder how much blood she is losing during menstruation. Also if she is getting enough fluid replacement during her period. Syncopal episodes only when standing during a period of acute blood loss ....

Physiologic reaction to pregnancy is also hypo volemia.

Also, did this just come up during your history or was her CC syncope?

I actual did ask an approx volume and she said it "wasn't anything extreme, just normal spotting". Now that I think about I shoulda asked her to be more specific.
It actually came up during the hx. The pt had started to have contractions, so she came in. They started a mag drip to slow the labor process, but this all came about during my questioning.
Brandon, pt stated that she had been in for a lot of tests as a teenager when she originally had them when they came up with the dx of vasovagal syncope. I would imagine that an echo would've been indicated at the time, but honestly I can't say I asked.

 

[Rick Tresnak]

I think they need to go back to the beginning. The EKG doesn't sound impressive. The cardiomegaly is easy enough to diagnose via echo. The symptoms are odd with menstration. Even more so with pregnancy.

Endocrine issues perhaps. But I would start with an EEG

 

[Nova1300]

Blood supply to the placenta is not autoregulated, meaning the vessels don't contract and relax to maintain flow. So, if mom's perfusion drops, so too does baby's. Unlikely it is clinically significant assuming the episodes are brief and the pressure recovers.

Pregnant women can have 'supine hypotensive syndrome' which is from baby laying on the great vessels, compromising filling of the heart and can lead to syncope. But, if this happens when she is standing it is unlikely the culprit.

Pregnancy is not a hypovolemic state. In fact, there is a dilutional anemia which is normal in pregnancy from increase in plasma volume.

HCM - so usually HCM presents as heart failure. The usual CHF syndrome. They can have syncope, but that is a result of lack of blood flow to the brain from the worsening obstruction and resulting heart failure (meaning, I would suspect her to have syncope once her heart failure was bad enough that it was compromising flow to the brain). Pregnancy is a huge physiologic stress on the body. It requires ever-increasing cardiac output, something HCM patients cant really supply because of their obstruction. So, they decompensate, and usually well before 34 weeks. The process should be progressively worsening as the fetus grows and demands greater and greater amounts of cardiac output. I think if this syncope was from HCM, you would have a much sicker patient.

I would give this young lady a holter monitor for a few days. And an echo.

 

[Nova1300]

Let me add one thing. Believe it or not, most patients with a diagnosis of HCM that have minimal symptoms at baseline can get through pregnancy ok. But, if this girl has had syncope from HCM prior to pregnancy, it is very likely she would be much sicker once pregnant.

 

[9D4]

Blood supply to the placenta is not autoregulated, meaning the vessels don't contract and relax to maintain flow. So, if mom's perfusion drops, so too does baby's. Unlikely it is clinically significant assuming the episodes are brief and the pressure recovers.

Pregnant women can have 'supine hypotensive syndrome' which is from baby laying on the great vessels, compromising filling of the heart and can lead to syncope. But, if this happens when she is standing it is unlikely the culprit.

Pregnancy is not a hypovolemic state. In fact, there is a dilutional anemia which is normal in pregnancy from increase in plasma volume.

HCM - so usually HCM presents as heart failure. The usual CHF syndrome. They can have syncope, but that is a result of lack of blood flow to the brain from the worsening obstruction and resulting heart failure (meaning, I would suspect her to have syncope once her heart failure was bad enough that it was compromising flow to the brain). Pregnancy is a huge physiologic stress on the body. It requires ever-increasing cardiac output, something HCM patients cant really supply because of their obstruction. So, they decompensate, and usually well before 34 weeks. The process should be progressively worsening as the fetus grows and demands greater and greater amounts of cardiac output. I think if this syncope was from HCM, you would have a much sicker patient.

I would give this young lady a holter monitor for a few days. And an echo.

Good info, I appreciate that. I can't say that I understood HCM well enough to comment before, but I'm getting a better grasp of it now.
Still, now I just wonder what the actual cause was and if the vasovagal response was the actual cause, as her previous doc dx'd. It just seems strange to me that cramps/ contractions would be strong enough to stimulate that kind of reaction out of her.

 

[mycrofft]

1. Was the syncope hx with menstruation strictly from the pt? Or verified by a parent or such? If unverified, give it a lighter consideration or think of what can occur during menstruation which causes syncope…and hypovolemia is not one in most people. A study about vasovagal syncope and menstrual cycle= not much difference with or without periods, period.
http://www.ncbi.nlm.nih.gov/pubmed/23467969

2. Hypovolemia with menstruation? Maybe it isn't plain menstruation. Endometriosis? Any acute abd ℅ with menstruation not helped by OTC pain meds? Need labs, including iron, electrolytes, CBC with differential, vital signs and ekg while affected.

3. Treat what you see, don't try to link everything (pregnancy does not equal menses; pretty much the opposite except it is in the lower female abdomen). Keep asking other docs for their input and study it yourself.

 

[Brandon O]

HCM - so usually HCM presents as heart failure. The usual CHF syndrome. They can have syncope, but that is a result of lack of blood flow to the brain from the worsening obstruction and resulting heart failure (meaning, I would suspect her to have syncope once her heart failure was bad enough that it was compromising flow to the brain).

No offense meant, but this is not at all what I've heard, taught, or been taught.

The textbook answer -- in my understanding -- is that while hypertrophic cardiomyopathy can present with heart failure, the most important manifestation is palpitations, syncope, and death from arrhythmia. Not so much from the structural obstruction as from the histological irregularities that predispose to abnormal conduction. Most importantly, young folks who do have syncope are exactly the ones waving a flag that they're high risk for sudden death.

But I've been wrong before and am open to correction if you have a lot of experience with peds cardiology.