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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Elective cesarean section of a 29-year-old parturient with congenital ventriculoseptal defect and moderate pulmonary hypertension: a case report.

Abstract Number: 177
Abstract Type: Case Report/Case Series

Dan Ellis MD1 ; Maya Suresh MBBS2

A 29-year-old G3P1011 parturient with a history of a congenital, unrepaired VSD, moderate pulmonary hypertension, and dyspnea (NYHA Class II) presented to the labor and delivery suites at 40 2/7 weeks gestation. The patients past medical and surgical history are otherwise unremarkable. However, her obstetric history was significant for a spontaneous abortion and vaginal delivery in 2005.

The patient, who had been followed by cardiology after her first delivery, was found to have an estimated pulmonary artery pressure on transthoracic echocardiogram of 50-55/5-10 on 10/2007. At this time, her VSD was characterized as small. However, on 7/2009, a repeat transthoracic echocardiogram found her pulmonary artery pressures to be 57-62/10-15, and her VSD was less than 1cm. Both echocardiograms demonstrated an ejection fraction of 60-64%.

A multidisciplinary conference between obstetrics, cardiology, and anesthesiology determined that an elective cesarean section would be preferable to vaginal birth to prevent exacerbation of pulmonary hypertension. Therefore, the patient was scheduled for elective Cesarean section on 10/1/2009.

After arriving in the labor and delivery suites, two 16g peripheral IVs were placed. These angiocatheters were attached to filters to decrease the possibility of air emboli. A 20g angiocatheter was then inserted into the patients left radial artery to ensure tight blood pressure control. Next, a 8-French double lumen central line was then inserted into her right internal jugular vein to allow close monitoring of central venous pressures. Pulmonary artery catheterization was considered. However, the risk of catheter migration across the VSD was deemed to be unacceptable risk.

Next an epidural catheter was placed, and 2% lidocaine with 1 mEq/mL of bicarbonate and 5mcg/mL epinephrine was administered in divided doses of 2-3mL to obtain a T4 level of anesthesia. A total of 17mL of local anesthetic was used. Fluid boluses of 200mL were also administered to maintain a CVP of 6-7 cm H20. A total of 1,000 mL of lactated ringers was administered in the pre-op.

Once an adequate level of anesthesia had been achieved, the patient was transported to the operating room for cesarean section. Over the course of the procedure, the patient received 180 mL of chloroprocaine in her epidural catheter.

The patients operative course was uneventful. Following delivery of a male infant with Apgars of 9 and 9, an infusion of oxytocin 20 units was started. Within minutes, the surgeons reported that the patients uterus was firm. The patients CVP was kept within 6-7, and her MAP was maintained at 65-85.

At the conclusion of the surgery, the patient had received 1,000 mL of fluid, EBL was estimated to be 1,000 mL, and urine output was 400 mL. Before leaving the operating room, 4mg of preservative free morphine and 1mg of stadol were administered through her epidural catheter.

SOAP 2010