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A CASE SERIES: MANAGEMENT OF A PREGNANT CARDIAC PATIENT
Abstract Number: 208
Abstract Type: Case Report/Case Series
INTRODUCTION: With an increase in the number of older age parturient as well as improvements in medical therapy, those with coexisting cardiac disease are becoming more common. We report a case series of management of pregnant patients with differing cardiac co-morbidities.
CASE 1: A 36 year old pregnant female was scheduled for elective repeat C-Section.
The patient's medical history is significant for Severe Dilated Cardiomyopathy and HTN, multiple admissions with shortness of breath and signs of CHF. She was on Digoxin, furosemide and Hydralazine. On examination, Height: 5' 2", Weight: 212 lbs, Airway-MP-3, BP 144/77 mm of Hg, HR 84/min, RR 16/min. Echocardiogram showed severe LV dilation, Global hypokinesis, and LV diastolic dysfunction, Mild MR and mild pulmonary HTN, EF- 35%.
Two large bore intravenous and right Radial A-line catheters were placed. Rapid sequence induction was done with Remifentanil, 2% Lidocaine, Etomidate, and Succinylcholine. CVP catheter and TEE probe were introduced. The patient was extubated at the end of the procedure and transferred to ICU for further management.
CASE 2: A 32 year old pregnant female, G2P1, at 35 weeks gestation and low lying placenta was scheduled for C-Section. She had history of severe HOCM, s/p IVS reduction and MVR in 2004. Recent echocardiography showed HOCM with left ventricular EF 75%, left ventricular outflow tract gradient of 60 mm Hg, mild MS, mild to moderate MR and pulmonary artery systolic pressures of 45. Physical examination showed Class II Mallampati airway, BP 109/73 mmHg, and heart rate 97 beats/min. Two large bore intravenous and arterial catheters were placed and prehydrated. The total fluids given were 1000 ml Hextend, 2000 ml Lactated Ringers and 2 units of PRBCs. The estimated blood loss was 1200 ml.
CASE 3: 28 years, G5P1 female with anemia and rheumatic heart disease was scheduled for repeat C/S and tubal ligation. A transthoracic echo showed moderate mitral stenosis, mild mitral regurgitation, moderate to severe aortic stenosis, moderate aortic insufficiency, moderate triscuspid stenosis, severe tricuspid regurgitation, and normal LV function. On Lopressor 25 mg PO bid. Large bore intravenous and arterial lines, Right IJ Cordis, and Swan-Ganz catheter were inserted prior to induction. RSI was with Etomidate, Remifentanil, and Succinylcholine. TEE was monitored intraoperatively. She was extubated in the OR, hemodynamically stable.
DISCUSSION: Understanding the underlying cardiovascular pathology, its interaction with the physiologic changes of pregnancy, the impact on the hemodynamic parameters is of vital importance in the optimal management of the pregnant cardiac patients. The effect of anesthetic agents on the cardiovascular system and its impact on the particular cardiac lesion is more important than any particular type of anesthetic management. TEE is a very useful tool to monitor and guide the therapy in select group of patients.