Successful, High-Risk Delivery to a Mom With a Complex Congenital Heart Condition
Alyssa Simela was born with tricuspid atresia, a congenital heart defect that prevents blood from flowing normally through the heart and lungs. She underwent several surgical procedures as a baby, but her condition makes her completely dependent on her veins being able to get blood from her body to the lungs via a Fontan operation. This allows oxygenated blood to reach the left side of the heart, where blood pumps to the rest of the body. Patients with this heart defect only have a small chance of successfully carrying a child to term and have a high risk of developing heart problems during pregnancy and delivery.
Alyssa had already defied these odds with the birth of her first child in 2019. However, after she became pregnant again in February 2022, she began to experience palpitations and shortness of breath. She went to see Ali Zaidi, MD, Director of Mount Sinai’s Adult Congenital Heart Disease Center. Dr. Zaidi made changes to her medications to help control the palpitations and followed her very closely during her pregnancy.
“It is possible to be pregnant and have a successful birth after having a Fontan operation like Alyssa,” Dr. Zaidi explains. “However, it may be too risky for some women with such complex heart conditions. It is important to discuss any potential pregnancy with your adult congenital heart disease (ACHD) specialist.”
Arrhythmias and heart failure are the most frequent cardiac complications, and miscarriages are also common in these patients. Successful pregnancies can be frequently complicated with premature deliveries. “Such patients need ongoing multidisciplinary care involving specialists from the Adult Congenital Heart Disease, Maternal Fetal Medicine and Obstetric Anesthesia teams—which we are able to provide at Mount Sinai,” says Dr. Zaidi, Associate Professor of Medicine (Cardiology) and Pediatrics, at the Icahn School of Medicine at Mount Sinai.
Alyssa’s care was also overseen by Lauren Ferrara, MD, Assistant Professor of Obstetrics, Gynecology and Reproductive Science, and a member of the Mount Sinai's Maternal Fetal Medicine team—which specializes in high-risk pregnancy. With Alyssa, Dr. Ferrara and Dr. Zaidi decided on a plan to induce in November 2022, to avoid the stress that labor would exert on her heart.
“Alyssa was more symptomatic than she had been with the first pregnancy,” Dr. Ferrara says. “This of course was more worrisome to both myself and Dr. Zaidi, causing us to watch her more closely. Our plan was for an earlier delivery. Although our goal is to prolong pregnancy to as close to 39 weeks as possible for fetal well-being, the mother’s safety has to take priority.”
However, on October 22, and at 35 weeks, Alyssa went into voluntary labor. When she arrived at The Mount Sinai Hospital she was in extreme pain, but there was no time to administer an epidural. Luciana Vieira, MD, Assistant Clinical Professor of Obstetrics, Gynecology and Reproductive Science and member of the Maternal Fetal Medicine team, oversaw her delivery. After 45 minutes, they delivered a baby girl weighing 4 pounds, 6 ounces. The baby was in good health, and despite her prematurity did not need admission to the Neonatal Intensive Care Unit.
“Alyssa came in to the hospital in active labor, so was having a lot of pain from contractions, but she didn't have to push for very long,” Dr. Vieira says. “But it became much more complicated due to her underlying heart condition after the delivery.”
Her placenta had not naturally separated after the delivery, and Alyssa began to bleed very heavily. She was rushed into surgery. In this situation, Alyssa’s heart condition put her in grave danger—bleeding or a fast irregular heart rate can potentially prevent blood from getting to the pumping chamber of her heart and, therefore, to her vital organs. Her heart had already been put under enormous strain during the birth, and her heart rate was becoming dangerously slow.
A team of specialists were brought in to stabilize Alyssa’s heart and blood pressure. Eric Franz, MD, Assistant Professor of Anesthesiology, Perioperative and Pain Medicine, administered the general anesthetic, carefully adjusting the dosage with support and insights from Kali Hopkins, MD, fellow in adult congenital heart disease.
“Alyssa’s blood loss and administration of anesthesia put significant strain on her heart given her underlying anatomy,” Dr. Hopkins says. “Though a tenuous situation, the anesthesia and OB teams worked skillfully and rapidly to administer blood and strong medications to raise her blood pressure.”
Once Alyssa stabilized, Dr. Vieira and the Maternal Fetal Medicine team successfully removed the placenta.
“This is the advantage of getting care at a world class health center like Mount Sinai,” Dr. Franz says. “We are able to quickly bring in all the interdisciplinary expertise needed for complex cases such as Alyssa’s.”
“The most incredible moment was when Dr. Franz removed the breathing tube and Alyssa immediately asked how her heart and her baby are,” Dr. Hopkins says.
Alyssa spent several days in the Cardiac Intensive Care Unit before she was finally reunited with her daughter, and months later, they are both doing well. She feels that the expertise of Dr. Zaidi and Dr. Hopkins and the fast response of the Maternal Fetal Medicine team were crucial for this positive outcome, especially given the severity of her case.
Alyssa is back to following her pre-pregnancy care with ongoing monitoring of her heart rhythm and function. She says growing up with her heart condition has made her very aware of her heart health. She has always been careful to eat healthily, maintain her physical activity and to keep up regular visits to her cardiologist.
“I put my heart through the ultimate stress test with delivering my second child,” Alyssa says. “But I believe because I stayed healthy and active before and during my pregnancy that I was able to endure that. Now I’m getting back into my workout routine and continuing to eat a heart healthy diet.”
Dr. Zaidi credits this dedication to her being able to have children, and surviving this frightening experience. “Alyssa is truly incredible! She has severely complex CHD and despite multiple operations she wants to live a full life, have a family and enjoy taking care of her children. There is no better outcome than to see a young woman with congenital heart disease reach her goals and dreams, to see her smile when she sees her kids. This would not happen without the multidisciplinary care at Mount Sinai, but mostly because of Alyssa’s own determination, desire, and inner strength.”