///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Sequential Combined Spinal-Epidural Anesthesia for a Cesarean Delivery in a Parturient with Prosthetic Aortic Valve Stenosis

Abstract Number: 204
Abstract Type: Case Report/Case Series

Ku-Mie Kim M.D.1 ; Michael Hurley M.D.2

INTRODUCTION: Having a prosthetic cardiac valve during pregnancy poses a serious risk to both mother and fetus, including pregnancy loss, premature births, bleeding and, often fatal thromboembolism.1 Especially, in women with mechanical valves, effective anticoagula-tion is a critical part of their management throughout the pregnancy and one of the major anesthetic considerations.2 We report a case of anesthetic management for cesarean delivery(CD) in a parturient who had St. Jude mechanical AV and developed prosthetic valve stenosis. CASE REPORT: A 28 y/o, G4 P2, was admitted for repeat CD at 36 wks of gestation. PMH included mechanical AVR 7 yrs ago secondary to critical AS following bacterial endocarditis. During pregnancy, her anticoagulation had been maintained with enoxaparin 90mg, bid, since 8 wks. Although she remained asymptomatic, serial echocardiography revealed progressive increase of her trans-AV gradient from 30s to >50mmHg and new LV diastolic dysfunction during the third trimester. It was considered this could be from new stenosis, vegetation or high output state. This prompted her obstetrician to schedule her repeat CD at 36 wks. She was admitted the day before the surgery to bridge her anticoagulation to iv heparin. With two IVs and a-line placed, she was taken to the OR, when it had been 38 and 6 hrs off enoxaparin and heparin, respectively. After SBE prophylaxis and 1L of iv fluid given, sequential combined spinal-epidural (CSE) anesthesia was administered with intrathecal hyperbaric spinal bupivacaine 6 mg, fentanyl and PF-morphine. Her initial sensory level was T11. Following test dose, total 10 ml of epidural lidocaine 2% was administered incrementally over 20 min to obtain T4. She remained stable with small doses of phenylephrine. Her epidural catheter was removed at the end. She had an uneventful postoperative course and was discharged on POD #4. On POD #6, however, she returned to the ED with INR of 12, Hgb of 4.6 gm/dL and severe abdominal distension, which required an emergency laparotomy to evacuate 3L of blood. The rest of her course was unremarkable. DISCUSSION: The goals of anesthetic management during CD in paturients with AS are to maintain NSR and HR, adequate preload and afterload, along with avoidance of aortocaval compression and myocardial depression.3 Single-shot spinal anesthesia remains contraindicated in severe AS because of acute reduction in SVR. Epidural anesthesia may be used safely but the quality of the block could be unsatisfactory. Continuous spinal anesthesia has been used with the risk of spinal headache. Sequential CSE is a two-stage technique combining small-dose spinal and gradually titrated epidural anesthesia to avoid precipitous hypotension. It provides a solid, quality block of spinal and hemodynamic stability of epidural anesthesia. It is a suitable regional anesthetic technique for CD in patients with severe AS who may not tolerate sudden changes of afterlaod due to their fixed CO.

SOAP 2010