Management in a parturient with right ventricular dysfunction and suspected ARVD: what to do when labor gets in the way of the anesthetic plan
Abstract Number: 98
Abstract Type: Case Report/Case Series
Care of parturients with right ventricular (RV) dysfunction requires a well-developed and coordinated plan. However, the unpredictable nature of parturition demands flexibility from caregiving teams. We present the anesthetic management of a parturient with RV dysfunction and suspected arrhythmogenic RV dysplasia (ARVD) who had a precipitous vaginal delivery the day of her planned cesarean delivery (C/D).
A 34 year old G2P0 at 38.9 weeks estimated gestational age (EGA) presented for premature rupture of membranes (PROM) the day of her scheduled C/D. Her past medical history included repair of a ventricular septal defect at 2 years of age causing right bundle branch block, a history of orthostatic hypotension, palpitations, and presumed autoimmune pericarditis. After syncope at 31 weeks EGA, echocardiogram showed RV enlargement and dysfunction concerning for ARVD; definitive testing was planned postpartum (PP). Per her cardiologist, she was a poor candidate for labor and vaginal delivery given her sensitivity to decreases in preload and vagal maneuvers. She was scheduled for elective C/D at 38.9 weeks EGA. At 37 weeks EGA she was dyspneic and tachycardic, and was seen by a faculty anesthesiologist, who developed plans for C/D under either general or epidural anesthesia. Epidural anesthesia was chosen by the scheduled anesthetic team. She was admitted at 1:00 am the day of her C/D due to PROM; blood pressure (BP) was 110/86 mmHg and pulse 86 beats per minute (BPM). Cervical exam was 1 cm dilated/50% effaced/high fetal station; she was not felt to be in labor. The plan remained scheduled C/D. At 5:50 am, she became uncomfortable with contractions every 2 minutes; exam showed full dilation with +2 station. She was rapidly brought to the operating room, and arterial and central venous (CV) access was obtained. BP was 143/56 mmHg, heart rate was 97 BPM, and CV pressure was 23 mmHg. Repeat exam showed the infant at +3 station, so pudendal block was placed for vacuum-assisted vaginal delivery. A total of ketamine 70 mg, midazolam 3 mg, and fentanyl 100 mcg were given to decrease her discomfort, and a male infant was born at 7:29 am. The patient was hemodynamically stable with delivery. She was transferred to the surgical intensive care unit for cardiac monitoring and discharged in stable condition on PP day 2.
Ideal anesthetic management of parturients with RV dysfunction is unknown. Furthermore, ARVD is a rare genetic disease where the RV free wall is largely replaced by fibrous or fibrofatty tissue.1 Although our patient was felt to be a better candidate for scheduled C/D under epidural anesthesia, her precipitous labor and delivery forced a change in plan. In the emergent setting, ketamine, midazolam, and fentanyl sedation reduced maternal discomfort while maintaining hemodynamic stability during vacuum-assisted vaginal delivery in a parturient with suspected ARVD.
1. Anaesthesia 2009;64:73-8.