Twin pregnancy, dyspnea, cyanosis, and a heart murmur

Omar K. Hallak, MD, Frederick R. Helmcke, MD, Marshall St. Amant, MD, Daniel Bayhi, MD, Lisa Diethelm, MD, Glenn P. Kelley, MD, and D. Luke Glancy, MD

From Louisiana State University Health Sciences Center and the Medical Center of Louisiana, New Orleans, Louisiana.

Corresponding author: D. Luke Glancy, MD, Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Room 441, New Orleans, Louisiana 70112.

A 32-year-old woman presented at 14 weeks gestation with a twin pregnancy. Her chief complaints were exertional dyspnea and orthopnea. She had a history of 2 spontaneous abortions followed by delivery of a live term infant 14 years previously. Two years previously she had suffered a cerebrovascular accident with eventual complete recovery.

Cardiovascular examination revealed mild cyanosis, 2+/4+ symmetrical clubbing of fingers and toes, jugular venous distention with large CV waves with an estimated mean right atrial pressure of 15 mm Hg, and a prominent left parasternal lift. The second heart sound was moderately and fixedly split with a loud second component. A grade 2/6 systolic ejection murmur was heard in the pulmonic area, and a grade 3/6 blowing pansystolic murmur was heard at the apex.

Electrocardiographic findings were a long P-R interval, left anterior fascicular block, and right ventricular enlargement, all typical of an atrioventricular septal defect (Figure 1). In addition, there were frequent ventricular premature complexes and P waves indicating left atrial enlargement and having a frontal plane axis of –5?. This much left axis deviation of the P wave is unusual in atrioventricular septal defect limited to the lowermost portion of the atrial septum, so-called ostium primum atrial septal defect (1, 2), but often is found when the entire atrial septum is missing (3, 4). (BUMC Proceedings 2002;15:221-223)