///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Management of a Parturient Undergoing Vaginal Delivery s/p VSD Repair

Abstract Number: 209
Abstract Type: Case Report/Case Series

Chawla L Mason M.D.1 ; Maya S. Suresh M.D.2

Introduction:

Significant advancements have been made in surgical correction of congenital heart lesions resulting in a growing population of parturients with a history of congenital heart disease (CHD). Therefore, it remains important that anesthesia providers understand their management. This case report illustrates the successful anesthetic management of a parturient s/p repair of a ventricular septal defect (VSD) undergoing vaginal delivery.

Case:

A 30-year-old G3P2 patient at 36 4/7 weeks gestation presented to labor and delivery unit for induction of labor. Her medical history was remarkable for a VSD in childhood requiring surgical correction. She reported good exertional tolerance and had a history of two recent, uneventful vaginal deliveries without an epidural.

On examination, her weight and height were 68.9 kg and 63 inches respectively. Baseline vital signs were as follows: blood pressure 114/56, pulse 66, respiratory rate 16, oxygen saturation 100% on room air. On auscultation, a soft systolic murmur was heard. A recent echocardiogram revealed normal left ventricular function with an ejection fraction of 65-69%. Pulmonary artery systolic pressures were 30 mmHg and minimal left to right shunting was reported. With the exception of the presence of anti-Kell antibodies, all laboratory studies were within normal limits.

After the patients consent was obtained, gastrointestinal and subacute endocarditis prophylaxis medications were administered. The patient was preloaded with 500 ml. Maintaining strict aseptic technique, the patients ~L3L4 epidural space was uneventfully engaged via loss of resistance technique using saline at a depth of 5cm. An epidural catheter was easily threaded 4cm and secured. A negative test dose was confirmed, and the patient received a total of 12ml of 0.125% bupivicaine with 2 mcg/ml of fentanyl in incremental doses over a 20-minute period. A T10-level bilaterally was achieved and a maintenance infusion was initiated at 10 ml/hr. The patient remained comfortable and hemodynamically stable throughout the labor course and vaginally delivered a healthy 2560g female.

Discussion:

Parturients with CHD now account for roughly 80% of the 0.2%-4% of pregnancies complicated by cardiac disease. VSD affects 7% of adults with CHD. Patients may be asymptomatic and pregnancy uneventful if the VSD is small or surgically corrected. With larger uncorrected VSDs, left-to-right shunting can markedly increase pulmonary blood flow resulting in pulmonary hypertension and/or right ventricular failure. Those conditions that may increase PVR and heart rate (i.e. hypoxemia, acidosis, hypercarbia, and pain) should be avoided.

It may be possible to administer either regional or general anesthesia. Regardless of anesthetic technique, optimal management requires extensive preparation, effective communication amongst caregivers, and thorough understanding of the patients disease process.

SOAP 2009