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

CASE REPORT: Preeclampsia Superimposed on Insulin-dependent Diabetes, Coronary Artery Disease, Chronic Hypertension, and Heart Failure for Repeat Cesarean Section

Abstract Number: 251
Abstract Type: Case Report/Case Series

Raffi V Chemsian MD1 ; Joseph DeAntonio MD2; Divina J Santos MD3

CASE REPORT: Preeclampsia Superimposed on Insulin-dependent Diabetes, Coronary Artery Disease, Chronic Hypertension, and Heart Failure for Repeat Cesarean Section

Chemsian, R. MD; DeAntonio, J. MD; Santos, D. MD

Albert Einstein College of Medicine/Montefiore Medical Center

Bronx, New York

Anesthetic management of high-risk pregnancy continues to pose a challenge to clinicians, especially in the third trimester, parturition, and postpartum. We present a 32 year-old multigravid with a history of diabetes starting age 12, chronic hypertension, coronary artery disease (CAD) with myocardial infarction and stent in 2002, heart failure, pulmonary hypertension, and renal insufficiency. She was admitted at 32 weeks for preeclampsia superimposed on chronic hypertension.

Aggressive treatment with anti-hypertensives and magnesium sulfate was started. Echocardiography revealed deteriorating ejection fraction (EF) from 40% to 30%. Renal function showed an increase in proteinuria and serum creatinine. Despite aggressive measures, the cardiac and renal functions continued to worsen warranting elective, repeat cesarean section.

We had concern for significant postpartum "autotransfusion" following uterine contraction causing volume overload, heart failure, subsequent pulmonary edema, and ultimately respiratory distress/failure. To avoid this potential scenario, our plan was to induce general anesthesia and secure the airway in a more controlled fashion.

The patient was pre-medicated with Sodium Bicitrate and Metaclopromide. In the operating suite, two large-bore IV's and a radial arterial line were placed prior to induction. General anesthesia was induced with a modified rapid sequence induction (Fentanyl, Lidocaine, Etomidate and Succinylcholine). Induction and intubation of the trachea was uneventful. We preferred transesophageal echocardiography (TEE) versus central venous monitoring as TEE allowed direct and continuous visualization of ventricular function, valvular abnormalities, and volume status during the case. Our TEE exam showed EF 30%, inferior/septal akinesis, with the remaining walls being hypokinetic. The right ventricle was dilated and moderately hypokinetic. The valves were unremarkable. There was minimal change in cardiac function following the delivery and the patient remained hemodynamically stable. The baby was delivered without complication, Apgar scores of 7 and 9. The patient received 1.5 liters of Lactated Ringers, urine output was 150mL, and estimated blood loss was 1000mL.

We elected to leave the patient intubated, while she mobilized some of the volume that she had received, as our concern for postpartum "autotransfusion" remained a priority. The patient was transferred to the ICU for further monitoring and gentle diuresis with Furosemide. She was extubated the following day and closely monitored in the ICU for an additional 2 days. She was subsequently transferred to the floor and discharged home on post-op day #5.

SOAP 2009