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THE ANESTHETIC MANAGEMENT OF A PARTURIENT WITH FONTAN CIRCULATION COMPLICATED BY PULMONARY EMBOLISM: CASE REPORT AND LITERATURE REVIEW
Abstract Number: 173
Abstract Type: Case Report/Case Series
Anesthetic management of parturients with Fontan circulation can be challenging due to the unique physiology where venous blood flows passively into the pulmonary arteries. In these patients, cardiac output is dependent on pulmonary blood flow, therefore, prevention of hypovolemia and avoiding any increase in pulmonary vascular resistance are key factors in maintaining hemodynamic stability.
We describe the anesthetic management of a parturient with Fontan circulation complicated by pulmonary embolism having cesarean delivery.
We also describe a literature review of parturients with Fontan circulation who had cesarean deliveries. For this purpose, we performed a Pubmed search using the words Fontan cesarean section, cesarean delivery and anesthetic management, between 1980- 2008 in English. See table 1.
The patient gave written informed consent for publication of this information. A 26-year-old woman with a known Fontan circulation presented at 26-weeks gestation with premature rupture of membranes and was admitted to our hospital for monitoring. At 30-weeks gestation, she developed shortness of breath and was diagnosed with pulmonary embolism. Anticoagulation therapy was then started. A multidisciplinary case conference was conducted and at 34-weeks gestation, the anticoagulation was stopped and an elective cesarean delivery using slowly titrated epidural anesthesia guided by invasive blood pressure monitoring was performed successfully. The patient remained comfortable and hemodynamically stable. At the end of surgery, preservative-free morphine was administered in the epidural catheter and ultrasound guided bilateral transversus abdominis plane blocks were carried out as part of a multimodal analgesia approach. She was monitored in the step up unit for 24 hours post delivery and discharged home 6 days later. Both patient and her baby did well. Anesthetic concerns included the challenges of her Fontan physiology, which was complicated by pulmonary embolism and anticoagulation therapy.
With a multidisciplinary approach and careful monitoring, a cesarean delivery in a pregnant patient with Fontan circulation complicated by pulmonary embolism was performed successfully under carefully titrated epidural anesthesia.
Fontan circulation, Anesthetic management, Cesarean delivery