Preterm Cesarean Delivery in a Parturient with Idiopathic Pulmonary Hypertension
Abstract Number: 112
Abstract Type: Case Report/Case Series
The patient is a 37-year-old G2P1 parturient with a 5-year history of idiopathic pulmonary hypertension and previous eclampsia who presented at 24 weeks gestational age for worsening dyspnea. She was admitted to the cardiology service and continued on her usual nifedipine regimen. Right heart catheterization (RHC) exposed pulmonary artery pressure (PAP) 85/34 mm Hg, mean 53 mm Hg. An epoprostenol infusion was begun. Thorough discussion with the patient revealed her desire to continue the pregnancy, and the departments of Maternal Fetal Medicine (MFM) and Anesthesiology were consulted. A multispecialty case management conference was held to discuss management plans, specifically emphasizing care at the time of delivery.
The patient remained in the hospital for monitoring and titration of therapy. She was anticoagulated with LMWH and symptoms controlled on epoprostenol, nifedipine, and metoprolol. At 31 weeks GA, the patient became more dyspneic, and RHC revealed PAP: 104/38 mm Hg, mean 67 mm Hg. A pulmonary artery catheter (PAC) was placed, and inhaled nitric oxide (iNO) therapy was started after transfer to the ICU. The decision was made to proceed with scheduled operative delivery in the main operating room.
On the morning of surgery, a lumbar epidural catheter was placed and an infusion of 0.125% bupivacaine and 2mcg/ml fentanyl was begun at 4ml/hour. On arrival to the OR for Cesarean delivery and BTL with GETA and low-dose epidural, a femoral arterial line was placed pre-induction. Remifentanil was used during a modified RSI with etomidate and succinylcholine. iNO and epoprostenol IV were continued throughout surgery. Maintenance of anesthesia was achieved with sevoflurane and remifentanil with high FiO2. Monitoring included TEE and PAC. The obstetricians delivered the infant, Apgars 7/7. Oxytocin was given for uterine atony, followed by misoprostol with good effect. With 800 ml blood loss, the patient became hypotensive with near equalization of pulmonary and systemic pressures, and sodium bicarbonate, albumin, and phenylephrine were given with improved hemodynamics. BTL and abdominal closure were performed with no complications. PAP on arrival to the ICU was 81/38 mm Hg, mean 57 mm Hg. Epidural PCA provided postoperative analgesia.
The patient was extubated on the evening of surgery. No major complications occurred, although she remained hospitalized for one month for optimization of home therapy, which included coumadin, metoprolol, sildenafil, and epoprostenol.
Pulmonary hypertension in pregnancy is known to be associated with increased maternal mortality. Despite advances in management, women with pulmonary hypertension are still advised to avoid pregnancy. The literature consists of case studies and series, and as such, debate continues over the optimal management of parturition. A multidisciplinary approach to the care of these complex patients is advocated to optimize outcomes for mother and child.