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

Management of A Parturient with Aortic Coarctation Undergoing Vaginal Delivery

Abstract Number: 224
Abstract Type: Case Report/Case Series

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

Introduction:

Parturients with congenital heart disease account for roughly 80% of the 0.2-4% of pregnancies complicated by cardiac disease. Therefore, it is important that anesthesia providers understand their management. This case report illustrates the successful anesthetic management of a parturient with aortic coarctation undergoing vaginal delivery.

Case:

A 33-year-old G3P2 patient at 39 1/7 weeks gestation presented to labor and delivery unit for induction of labor. Her medical history was remarkable for hypertension and aortic coarctation diagnosed just four months prior. She reported an exertional tolerance consistent with >4METS and had a history of two uneventful vaginal deliveries without an epidural.

On examination, her weight and height were 73.5 kg and 62 inches respectively. Baseline vital signs were as follows: blood pressure in left arm 153/66, blood pressure in right arm 160/68, pulse 71, respiratory rate 18, oxygen saturation 100% on room air. On auscultation, no murmur was heard. Echocardiography demonstrated aortic coarctation with a peak gradient of 32 mmHg and an ejection fraction of 55-59%. Angiography of the chest illustrated focal narrowing of the superior descending thoracic aorta. No regions of aneurysmal dilatation were noted. All laboratory data were within normal limits.

After obtaining patient consent and administering an appropriate preload, 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 patients epidural was incrementally dosed with a solution containing 0.125% bupivicaine with 2 mcg/ml of fentanyl. A T8-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 underwent successful vacuum-assisted delivery of a healthy 3500g female.

Discussion:

Coarctation of the aorta accounts for 5-8% of congenital heart lesions. It refers to narrowing in part of the aorta, usually in the area of the ligamentum arteriosum. Pregnancy may be well tolerated in patients with both corrected and uncorrected lesions. Epidural or general anesthesia may be executed safely. Goals of management include a thorough understanding of the patients disease process and avoidance of hemodynamic changes. Regardless of anesthetic technique, optimal management requires extensive preparation and effective communication between caregivers and the patient.

Reference:

Weitzel N and Gravlee G. Cardiac disease in the obstetric patient. In: Bucklin, Gambling, & Wlody (Eds). A Practical Approach to Obstetric Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

SOAP 2009